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Kobashi Y, Sok K, Hayashi Y, Chhay H, Tsubokura M, Chou K, Hokamura N, Ozaki A, Nishikawa Y, Okawada M. Discrepancy of financial burden among elderly visiting a private general hospital in Phnom Penh, Cambodia: A three-year cross-sectional study. PUBLIC HEALTH IN PRACTICE 2022; 4:100306. [PMID: 36570394 PMCID: PMC9773053 DOI: 10.1016/j.puhip.2022.100306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 07/13/2022] [Accepted: 07/28/2022] [Indexed: 12/27/2022] Open
Abstract
Objectives This study aims to clarify the financial burden of health on the elderly. Out-of-pocket payment (OOPP) in a major private general hospital in Phnom Penh was considered an indicator of financial burden. Study design This study is a three-year cross-sectional study. Methods To investigate the characteristics of patients who visited the Sunrise Japan Hospital (SJH), their data were obtained from the electronic reception database. Results A total of 119,938 patients who visited SJH from January 2017 to September 2019 were included. The median age (25th, 75th centiles) was 52 years (36, 66) and 38.31% of patients were aged over 60 years. The OOPP median (25th, 75th centiles was 73.78 USD (32, 161.89). The median OOPP was the lowest in the 20s and highest in the 90s. The OOPP of an emergency patient was the highest in the consultation classifications. Conclusions The need to raise public awareness regarding the financial burden on the elderly is becoming increasingly urgent. It is vital to establish a social system to prevent the medical catastrophes.
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Affiliation(s)
- Yurie Kobashi
- Department of General Internal Medicine, Sunrise Japan Hospital Phnom Penh, Sangkat Chroy Changvar, Phnom Penh, Cambodia,Corresponding author.
| | - Khemvitou Sok
- Department of Radiology, Sunrise Japan Hospital Phnom Penh, Sangkat Chroy Changvar, Phnom Penh, Cambodia
| | - Yoshifumi Hayashi
- Department of Neurosurgery, Sunrise Japan Hospital Phnom Penh, Sangkat Chroy Changvar, Phnom Penh, Cambodia,Department of Neurosurgery, Kitahara International Hospital, Owadamachi, Hachioji, Tokyo, 192-0045, Japan
| | - Hong Chhay
- Department of General Internal Medicine, Sunrise Japan Hospital Phnom Penh, Sangkat Chroy Changvar, Phnom Penh, Cambodia
| | - Masaharu Tsubokura
- Department of Internal Medicine, Soma Central Hospital, Soma, Fukushima, 976-0016, Japan
| | - Kimhab Chou
- Department of Medicine, University of Puthisastra, Sangkat Boeung Raing, Phnom Penh, Cambodia
| | - Nobukazu Hokamura
- Department of Gastroenterology, Sunrise Japan Hospital Phnom Penh, Sangkat Chroy Changvar, Phnom Penh, Cambodia
| | - Akihiko Ozaki
- Department of Breast and Thyroid Surgery, Jyoban Hospital of Tokiwa Foundation, Jyobankamiyunagaya, Iwaki, Fukushima, 972-8322, Japan
| | - Yoshitaka Nishikawa
- Department of Health Informatics, Kyoto University School of Public Health, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Manabu Okawada
- Department of Pediatrics, Sunrise Japan Hospital Phnom Penh, Sangkat Chroy Changvar, Phnom Penh, Cambodia
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Shahabi S, Mojgani P, Shabaninejad H, Teymourlouy AA, Behzadifar M, Lankarani KB. Physical rehabilitation financing in Iran: a policy analysis using Kingdon's multiple streams. BMC Health Serv Res 2021; 21:413. [PMID: 33941180 PMCID: PMC8094566 DOI: 10.1186/s12913-021-06447-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 04/27/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Adequate financing is a crucial function, securing that physical rehabilitation services (i.e., physiotherapy, occupational therapy, prosthetics and orthotics) are available with no financial hardship. Like many other countries, despite the adoption of various policies and strategies in recent decades, Iran enjoys no desirable physical rehabilitation financing (PRF). Accordingly, this qualitative study aimed to explore the PRF-related strategies and issues as well as their impacts on relevant policies in Iran. METHODS An analysis of PRF-related policies was conducted in Iran using semi-structured interviews and policy documents review. Purposive and snowball sampling techniques were employed to select key informants, including health-policy makers, civil society, rehabilitation-policy makers, university professors, and practitioners. Thematic analysis was used to analyze the collected data. The analysis was framed within Kingdon's multiple streams. RESULTS The hindering factors for desirable financing were weak insurance coverage, lack of sustainable financial resources, fragmented financing, lack of split between provider and financer, high-cost of physical rehabilitation services, low engagement of relevant experts in policy-making processes, and corrupt activities. In the policy stream, the following factors were highlighted: involvement of sustainable financial resources, the use of external revenue sources, allocated resources' earmarking, the integration of the current funds to have better pooling, the use of incentive and timely payment mechanisms, the implementation of strategic purchasing principals, and the employment of effective rationing strategies. Moreover, parliament support, changes in administrations, international effects, pressures from interest campaigns and NGOs, and international sanctions were found as factors affecting the politics stream. CONCLUSION The study findings revealed that a variety of national and international factors affect PRF-related issues in Iran. The recently enacted laws indicate that the PRF policies have already been on the national health political agenda. The study reflected the multifaceted nature of barriers to optimal PRF in Iran.
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Affiliation(s)
- Saeed Shahabi
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Parviz Mojgani
- Iran-Helal Institute of Applied Science and Technology, Tehran, Iran
- Research Center for Emergency and Disaster Resilience, Red Crescent Society of The Islamic Republic of Iran, Tehran, Iran
| | | | - Ahmad Ahmadi Teymourlouy
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Masoud Behzadifar
- Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Kamran Bagheri Lankarani
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
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Natarajan N, Brickell K, Guermond V, Lawreniuk S, Parsons L. Challenging the financial inclusion-decent work nexus: evidence from Cambodia’s over-indebted internal migrants. GLOBAL PUBLIC POLICY AND GOVERNANCE 2021; 1:361-381. [PMCID: PMC8490844 DOI: 10.1007/s43508-021-00026-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 09/09/2021] [Indexed: 06/18/2023]
Abstract
In this paper, we question the promotion of financial inclusion, and microfinance specifically, as a means to achieve ‘Decent Work’ (DW) under the International Labor Organization’s (ILO) programme. Drawing upon original research findings from two types of internal migrants in Cambodia, we make a twin contention: first, that excessive levels of microfinance borrowing by garment workers are part-outcome of the failings of the DW programme to engender ‘decent enough work’, and second, that microfinance borrowing is actually eroding rather than contributing to the prospect of decent work for debt-bonded brickmakers in the country. The data presented on two of the largest sectors contributing to Cambodia’s growth in recent decades, enable the paper to show how microfinance and labour precarity are intertwined through the over-indebtedness of workers in both cases. The paper ultimately looks to caution the ILO on its current promotion of financial inclusion and microfinance in particular, stressing the need for significant sectoral reforms before this form of credit can be considered to align with the core principles of the DW programme.
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Affiliation(s)
- Nithya Natarajan
- Department of International Development, King’s College, London, London, UK
| | - Katherine Brickell
- Department of Geography, Royal Holloway, University of London, London, UK
| | - Vincent Guermond
- Department of Geography, Royal Holloway, University of London, London, UK
| | | | - Laurie Parsons
- Department of Geography, Royal Holloway, University of London, London, UK
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Borde MT, Loha E, Johansson KA, Lindtjørn B. Financial risk of seeking maternal and neonatal healthcare in southern Ethiopia: a cohort study of rural households. Int J Equity Health 2020; 19:69. [PMID: 32423409 PMCID: PMC7236117 DOI: 10.1186/s12939-020-01183-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 05/01/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Ethiopian households' out-of-pocket healthcare payments constitute one-third of the national healthcare budget and are higher than the global and low-income countries average, and even the global target. Such out-of-pocket payments pose severe financial risks, can be catastrophic, impoverishing, and one of the causal barriers for low utilisation of healthcare services in Ethiopia. This study aimed to assess the financial risk of seeking maternal and neonatal healthcare in southern Ethiopia. METHODS A population-based cohort study was conducted among 794 pregnant women, 784 postpartum women, and their 772 neonates from 794 households in rural kebeles of the Wonago district, southern Ethiopia. The financial risk was estimated using the incidence of catastrophic healthcare expenditure, impoverishment, and depth of poverty. Annual catastrophic healthcare expenditure was determined if out-of-pocket payments exceeding 10% of total household or 40% of non-food expenditure. Impoverishment was analysed based on total household expenditure and the international poverty line of ≈ $1.9 per capita per day. RESULTS Approximately 93% (735) of pregnant women, 31% (244) of postpartum women, and 48% (369) of their neonates experienced illness. However, only 56 households utilised healthcare services. The median total household expenditure was $527 per year (IQR = 390: 370,760). The median out-of-pocket healthcare payment was $46 per year (IQR = 46: 46, 92) with two episodes per household, and shared 19% of the household's budget. The poorer households paid more than did the richer for healthcare, during pregnancy-related and neonatal illness. However, the richer paid more than did the poorer during postpartum illness. Forty-six percent of households faced catastrophic healthcare expenditure at the threshold of 10% of total household expenditure, or 74% at a 40% non-food expenditure, and associated with neonatal illness (aRR: 2.56, 95%CI: 1.02, 6.44). Moreover, 92% of households were pushed further into extreme poverty and the poverty gap among households was 45 Ethiopian Birr per day. The average household size among study households was 4.7 persons per household. CONCLUSIONS This study demonstrated that health inequity in the household's budget share of total OOP healthcare payments in southern Ethiopia was high. Besides, utilisation of maternal and neonatal healthcare services is very low and seeking such healthcare poses a substantial financial risk during illness among rural households. Therefore, the issue of health inequity should be considered when setting priorities to address the lack of fairness in maternal and neonatal health.
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Affiliation(s)
- Moges Tadesse Borde
- School of Public Health, College of Medicine and Health Sciences, Hawassa University, P.O. Box 1436, Hawassa, Ethiopia.
- Centre for International Health, University of Bergen, Bergen, Norway.
- School of Public Health, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia.
| | - Eskindir Loha
- School of Public Health, College of Medicine and Health Sciences, Hawassa University, P.O. Box 1436, Hawassa, Ethiopia
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Kjell Arne Johansson
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Bernt Lindtjørn
- School of Public Health, College of Medicine and Health Sciences, Hawassa University, P.O. Box 1436, Hawassa, Ethiopia
- Centre for International Health, University of Bergen, Bergen, Norway
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Ir P, Jacobs B, Asante AD, Liverani M, Jan S, Chhim S, Wiseman V. Exploring the determinants of distress health financing in Cambodia. Health Policy Plan 2020; 34:i26-i37. [PMID: 31644799 PMCID: PMC6807511 DOI: 10.1093/heapol/czz006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2019] [Indexed: 11/14/2022] Open
Abstract
Borrowing is a common coping strategy for households to meet healthcare costs in countries where social health protection is limited or non-existent. Borrowing with interest, hereinafter termed distress health financing or distress financing, can push households into heavy indebtedness and exacerbate the financial consequences of healthcare costs. We investigated distress health financing practices and associated factors among Cambodian households, using primary data from a nationally representative household survey of 5000 households. Multivariate logistic regression was used to determine factors associated with distress health financing. Results showed that 28.1% of households consuming healthcare borrowed to pay for that healthcare with 55% of these subjected to distress financing. The median loan was US$125 (US$200 for loans with interest and US$75 for loans without interest). Approximately 50.6% of healthcare-related loans were to pay for the costs of outpatient care in the past month, 45.8% for inpatient care and 3.6% for preventive care in the past 12 months. While the average period to pay off the loan was 8 months, 78% of households were still indebted from loans taken over 12 months before the survey. Distress financing is strongly associated with household poverty-the poorer the household the more likely it is to borrow, fall into debt and unable to pay off the debt-even for members of the health equity funds, a national scheme designed to improve financial access to health services for the poor. Other determinants of distress financing were household size, use of inpatient care and outpatient consultations with private providers or with both private and public providers. In order to ensure effective financial risk protection, Cambodia should establish a more comprehensive and effective social health protection scheme that provides maximum population coverage and prioritizes services for populations at risk of distress financing, especially poorer and larger households.
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Affiliation(s)
- Por Ir
- National Institute of Public Health, Lot No. 80, Street 289, Phnom Penh, Cambodia
| | - Bart Jacobs
- Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GiZ), Lot No. 80, Street 289, Phnom Penh, Cambodia
| | - Augustine D Asante
- School of Public Health & Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Marco Liverani
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Pl, Kings Cross, London, UK
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, 1 King St Newtown, New South Wales, Australia
| | - Srean Chhim
- National Institute of Public Health, Lot No. 80, Street 289, Phnom Penh, Cambodia
| | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Pl, Kings Cross, London, UK.,Kirby Institute, University of New South Wales, Wallace Wurth Building, High St, Kensington NSW, Australia
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Jacobs B, Hui K, Lo V, Thiede M, Appelt B, Flessa S. Costing for universal health coverage: insight into essential economic data from three provinces in Cambodia. HEALTH ECONOMICS REVIEW 2019; 9:29. [PMID: 31667671 PMCID: PMC6822335 DOI: 10.1186/s13561-019-0246-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 10/04/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Knowledge of the costs of health services improves health facility management and aids in health financing for universal health coverage. Because of resource requirements that are often not present in low- and middle-income countries, costing exercises are rare and infrequent. Here we report findings from the initial phase of establishing a routine costing system for health services implemented in three provinces in Cambodia. METHODS Data was collected for the 2016 financial year from 20 health centres (including four with beds) and five hospitals (three district hospitals and two provincial hospitals). The costs to the providers for health centres were calculated using step-down allocations for selected costing units, including preventive and curative services, delivery, and patient contact, while for hospitals this was complemented with bed-day and inpatient day per department. Costs were compared by type of facility and between provinces. RESULTS All required information was not readily available at health facilities and had to be recovered from various sources. Costs per outpatient consultation at health centres varied between provinces (from US$2.33 to US$4.89), as well as within provinces. Generally, costs were inversely correlated with the quantity of service output. Costs per contact were higher at health centres with beds than health centres without beds (US$4.59, compared to US$3.00). Conversely, costs for delivery were lower in health centres with beds (US$128.7, compared to US$413.7), mainly because of low performing health centres without beds. Costs per inpatient-day varied from US$27.61 to US$55.87 and were most expensive at the lowest level hospital. CONCLUSIONS Establishing a routine health service costing system appears feasible if recording and accounting procedures are improved. Information on service costs by health facility level can provide useful information to optimise the use of available financial and human resources.
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Affiliation(s)
- Bart Jacobs
- Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GiZ), c/o NIPH, No.2, Street 289, Khan Toul Kork, P.O. Box 1238, Phnom Penh, Cambodia
- Social Health Protection Network P4H, Phnom Penh, Cambodia
| | - Kelvin Hui
- Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GiZ), c/o NIPH, No.2, Street 289, Khan Toul Kork, P.O. Box 1238, Phnom Penh, Cambodia
| | - Veasnakiry Lo
- Department of Planning and Health Information, Ministry of Health, Phnom Penh, Cambodia
| | | | - Bernd Appelt
- Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GiZ), c/o NIPH, No.2, Street 289, Khan Toul Kork, P.O. Box 1238, Phnom Penh, Cambodia
| | - Steffen Flessa
- Department of General Business Administration and Health Care Management, University of Greifswald, Greifswald, Germany
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Fernandes Antunes A, Jacobs B, de Groot R, Thin K, Hanvoravongchai P, Flessa S. Equality in financial access to healthcare in Cambodia from 2004 to 2014. Health Policy Plan 2018; 33:906-919. [PMID: 30165473 DOI: 10.1093/heapol/czy073] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2018] [Indexed: 12/24/2022] Open
Abstract
Since the end of its internal conflict in 1998, Cambodia has experienced tremendous developments in the social, economic and health sectors, with the government embarking on substantial reforms in health financing. Health equity funds that have improved access to public health services for poor people have gradually been extended to the entire country. Using the World Health Organization's methods for the analysis of healthcare expenditure and household survey data from the 2004, 2009 and 2014 Cambodian Socio-Economic Survey, we assessed trends in reported illness, utilization of healthcare services and associated financial burden on households. The impact of out-of-pocket expenditures for health on catastrophic health expenditures, poverty headcount and depth over the same 10-year period are presented, disaggregated by consumption quintile and place of residence (rural, urban and capital). At the aggregated national level, evolution of these indicators was very positive and correlates with a substantial increase in the capacity-to-pay of households, which reduced the average financial burden on households. However, over time inequalities grew between rural and urban areas. By 2014, the national incidence of catastrophic health expenditure was 4.9%, but four times more likely among rural households than their peers in the capital. For rural households with members seeking medical care, catastrophic health expenditure incidence was 12.3%. The impoverishment rate due to health spending among the lowest consumption quintile was 15.3%; the highest rate in this analysis. These findings suggest that economic and health sector developments have indeed benefited many Cambodian people. However, these gains mainly benefited urban residents; especially those in the capital city. We argue that more resources should be allocated to rural health services to address inequalities and healthcare-related financial hardship, which traps vulnerable people into poverty.
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Affiliation(s)
- Adélio Fernandes Antunes
- Department of General Business Administration and Health Care Management, Faculty of Law and Economics, University of Greifswald, Greifswald, Germany.,SOCIEUX+ EU Expertise on Social Protection, Labour and Employment, Brussels, Belgium
| | - Bart Jacobs
- Cambodian-German Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH; Phnom Penh, Cambodia
| | | | - Kouland Thin
- The Swiss Development Cooperation, Bern, Switzerland
| | | | - Steffen Flessa
- Department of Health Care Management, Faculty of Law and Economics, University of Greifswald, Greifswald, Germany
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