Prevalence and factors associated with catastrophic health expenditure among slum and non-slum dwellers undergoing emergency surgery in a metropolitan area of South Western Nigeria

Epidemiological Predictors of Financial Toxicity in Surgical Burn Injuries: A Multicenter, Longitudinal, Cohort Study

BACKGROUND

Burns constitute a major global health challenge, causing over 11 million injuries and 300,000 deaths annually and surpassing the economic burden of cervical cancer and HIV combined. Despite this, patient-level financial consequences of burn injuries remain poorly quantified, with a significant gap in data from low- and middle-income countries. In this study, we evaluate financial toxicity in burn patients.

METHODS

A prospective, multicenter cohort study was conducted across two tertiary care hospitals in India, assessing 123 adult surgical in-patients undergoing operative interventions for burn injuries. Patient sociodemographic, clinical, and financial data were collected through surveys and electronic records during hospitalization and at 1, 3, and 6 months postoperatively. Out-of-pocket costs (OOPCs) for surgical burn treatment were evaluated during hospitalization. Longitudinal changes in income, employment status, and affordability of basic subsistence needs were assessed at the 1-, 3-, and 6-month postoperative time point. Degree of financial toxicity was calculated using a combination of the metrics catastrophic health expenditure and financial hardship. Development of financial toxicity was compared by sociodemographic and clinical characteristics using logistic regression models.

RESULTS

Of the cohort, 60% experienced financial toxicity. Median OOPCs was US$555.32 with the majority of OOPCs stemming from direct nonmedical costs (US$318.45). Cost of initial hospitalization exceeded monthly annual income by 80%. Following surgical burn care, income decreased by US$318.18 within 6 months, accompanied by a 53% increase in unemployment rates. At least 40% of the cohort consistently reported inability to afford basic subsistence needs within the 6-month perioperative period. Significant predictors of developing financial toxicity included male gender (odds ratio, 4.17; 95% confidence interval, 1.25-14.29; P = 0.02) and hospital stays exceeding 20 days (odds ratio, 11.17; 95% confidence interval, 2.11-59.22; P ≤ 0.01).

CONCLUSIONS

Surgical treatment for burn injuries is associated with substantial financial toxicity. National and local policies must expand their scope beyond direct medical costs to address direct nonmedical and indirect costs. These include burn care insurance, teleconsultation follow-ups, hospital-affiliated subsidized lodging, and resources for occupational support and rehabilitation. These measures are crucial to alleviate the financial burden of burn care, particularly during the perioperative period.

Households Health Care Financing Methods: Social Status Differences, Economic Implications and Clinical Outcomes Among Patients Admitted in a Pediatric Emergency Unit of a Tertiary Hospital in South West Nigeria

Background. The affordability of health care services by households within a country is determined by the health care financing methods used by her citizens. In accordance with World Health Organization (WHO), health services must be delivered equitably and without imposing financial hardship on the citizens. Aim. This study aimed to determine the pattern of households health care financing method and relate it to the social-background, economic implication and clinical outcome of care in pediatric emergency situations. Method: It is a cross-sectional descriptive study. Result. 210 children from different households were recruited. Majority (75.9%) of the children were aged 0 to 5 years, males (61.2%) and belonged to the low socio-economic status (95.7%). The overall median (IQR) cost of care, income and percentage of income spent on care were ₦10 700 (₦7580-₦19 700), ₦ 65000(₦38000-₦110 000) and 17.6% (7.1%-39.7%) respectively. Though 70 (34.8%) of the respondents were aware of health insurance scheme, only 12.8% were enrolled. There were significant differences in the households' health care financing methods with respect to the socioeconomic status (P = .010), paternal level of education (P < .001), maternal occupation (P = .020), paternal occupation (P = .030) and distribution of income (P < .001). Catastrophic spending was experienced by 67.4% of the household, all of whom paid via out-of-pocket payment (OOPP) (P < .001), catastrophic health spending (CHS) was significantly associated with death and discharge against medical advice (DAMA) (P = .023). All cases of mortality and 93% cases of DAMA occurred with paying out of pocket (OOP) (P = .168). Conclusion. health care services were majorly paid for OOP among households in this study and CHS are high among these households. Clinical and financial outcomes were worse when health care services were paid through OOP.

Factors associated with catastrophic health expenditure in sub-Saharan Africa: A systematic review

OBJECTIVE

A non-negligible proportion of sub-Saharan African (SSA) households experience catastrophic costs accessing healthcare. This study aimed to systematically review the existing evidence to identify factors associated with catastrophic health expenditure (CHE) incidence in the region.

METHODS

We searched PubMed, CINAHL, Scopus, CNKI, Africa Journal Online, SciELO, PsycINFO, and Web of Science, and supplemented these with search of grey literature, pre-publication server deposits, Google Scholar®, and citation tracking of included studies. We assessed methodological quality of included studies using the Appraisal tool for Cross-Sectional Studies for quantitative studies and the Critical Appraisal Skills Programme checklist for qualitative studies; and synthesized study findings according to the guidelines of the Economic and Social Research Council.

RESULTS

We identified 82 quantitative, 3 qualitative, and 4 mixed-methods studies involving 3,112,322 individuals in 650,297 households in 29 SSA countries. Overall, we identified 29 population-level and 38 disease-specific factors associated with CHE incidence in the region. Significant population-level CHE-associated factors were rural residence, poor socioeconomic status, absent health insurance, large household size, unemployed household head, advanced age (elderly), hospitalization, chronic illness, utilization of specialist healthcare, and utilization of private healthcare providers. Significant distinct disease-specific factors were disability in a household member for NCDs; severe malaria, blood transfusion, neonatal intensive care, and distant facilities for maternal and child health services; emergency surgery for surgery/trauma patients; and low CD4-count, HIV and TB co-infection, and extra-pulmonary TB for HIV/TB patients.

CONCLUSIONS

Multiple household and health system level factors need to be addressed to improve financial risk protection and healthcare access and utilization in SSA.

PROTOCOL REGISTRATION

PROSPERO CRD42021274830.

The microeconomic impact of out-of-pocket medical expenditure on the households of cardiovascular disease patients in general and specialized heart hospitals in Ibadan, Nigeria

Background

Cardiovascular diseases (CVDs) present a huge threat to population health and in addition impose severe economic burden on individuals and their households. Despite this, there is no research evidence on the microeconomic impact of CVDs in Nigeria. Therefore, this study estimated the incidence and intensity of catastrophic health expenditures (CHE), poverty headcount due to out-of-pocket (OOP) medical spending and the associated factors among the households of a cohort of CVDs patients who accessed healthcare services in public and specialized heart hospitals in Ibadan, Nigeria.

Methods

This study adopts a descriptive cross-sectional study design. A standardized data collection questionnaire developed by the Initiative for Cardiovascular Health Research in Developing Countries was adapted to electronically collect data from all the 744 CVDs patients who accessed healthcare services in public and specialized heart hospitals in Ibadan between 4th November 2019 to the 31st January 2020. A sensitivity analysis, using rank-dependent thresholds of CHE which ranged from 5%-40% of household total expenditures was carried out. The international poverty line of $1.90/day recommended by the World Bank was utilized to ascertain poverty headcounts pre-and post OOP payments for healthcare services. Categorical variables like household socio-demographic and clinical characteristics, CHE and poverty headcounts, were presented using percentages and proportions. Unadjusted and adjusted logistic regression models were used to assess the factors associated with CHE and poverty. Data were analyzed using STATA version 15 and estimates were validated at 5% level of significance.

Results

Catastrophic OOP payment ranged between 3.9%-54.6% and catastrophic overshoot ranged from 1.8% to 12.6%. Health expenditures doubled poverty headcount among households, from 8.13% to 16.4%. Having tertiary education (AOR: 0.49, CI: 0.26–0.93, p = 0.03) and household size (AOR: 0.40, CI: 0.24–0.67, p = 0.001) were significantly associated with CHE. Being female (AOR: 0.41, CI: 0.18–0.92, p = 0.03), household economic status (AOR: 0.003, CI: 0.0003–0.25, p = <0.001) and having 3–4 household members (AOR: 0.30, CI: 0.15–0.61, p = 0.001) were significantly associated with household poverty status post payment for medical services.

Conclusion

OOP medical spending due to CVDs imposed enormous strain on household resources and increased the poverty rates among households. Policies and interventions that supports universal health coverage are highly recommended.

Multimorbidity Among Urban Poor in India: Findings From LASI, Wave-1

Background

Multimorbidity has become a norm in low-and middle-income countries such as India requiring notable health system improvements to combat. Urban population is a heterogeneous group where poor are at a risk of facing inequity in accessing healthcare services which can jeopardize our efforts to attain universal health coverage (UHC). We aimed to estimate the prevalence, assess correlates and patterns of multimorbidity among urban poor. Further, we assessed the outcomes of multimorbidity such as healthcare utilization, expenditure and self-rated health.

Methods

Longitudinal Aging Study in India (LASI), wave-1 is a nationally representative survey conducted amongst participants aged ≥45 years in 2017–18. We included 9,327 participants residing in urban areas, categorized as poor based on monthly per capita expenditure. Descriptive statistics computed prevalence with 95% uncertainty interval. Multivariable logistic regression was executed to assess the association between multimorbidity and various correlates, expressed as adjusted odds ratio. An ordinal regression model was run between self-rated health and number of chronic conditions.

Results

The prevalence of multimorbidity was 45.26% among the urban poor. Hypertension and oral morbidities were the most commonly observed dyad. Respondents who were poorer [AOR: 1.27 (1.06–1.51)] had higher chances of having multimorbidity than the poorest. Respondents with a health insurance [AOR: 1.40 (1.14–1.70)] had a higher risk of having multimorbidity. In-patient admission was significantly higher among participants having multimorbidity. Out of pocket expenditure increased while self-rated health deteriorated with each additional morbid condition.

Conclusion

Multimorbidity is found to be increasingly prevalent among urban poor and individuals having health insurance which demonstrates the need to expand healthcare insurance schemes such as Ayushman Bharat for urban poor to achieve UHC.

Catastrophic health expenditure in sub-Saharan Africa: systematic review and meta-analysis

Objective

To estimate the incidence of, and trends in, catastrophic health expenditure in sub-Saharan Africa.

Methods

We systematically reviewed the scientific and grey literature to identify population-based studies on catastrophic health expenditure in sub-Saharan Africa published between 2000 and 2021. We performed a meta-analysis using two definitions of catastrophic health expenditure: 10% of total household expenditure and 40% of household non-food expenditure. The results of individual studies were pooled by pairwise meta-analysis using the random-effects model.

Findings

We identified 111 publications covering a total of 1 040 620 households across 31 sub-Saharan African countries. Overall, the pooled annual incidence of catastrophic health expenditure was 16.5% (95% confidence interval, CI: 12.9-20.4; 50 datapoints; 462 151 households; I ² = 99.9%) for a threshold of 10% of total household expenditure and 8.7% (95% CI: 7.2-10.3; 84 datapoints; 795 355 households; I ² = 99.8%) for a threshold of 40% of household non-food expenditure. Countries in central and southern sub-Saharan Africa had the highest and lowest incidence, respectively. A trend analysis found that, after initially declining in the 2000s, the incidence of catastrophic health expenditure in sub-Saharan Africa increased between 2010 and 2020. The incidence among people affected by specific diseases, such as noncommunicable diseases, HIV/AIDS and tuberculosis, was generally higher.

Conclusion

Although data on catastrophic health expenditure for some countries were sparse, the data available suggest that a non-negligible share of households in sub-Saharan Africa experienced catastrophic expenditure when accessing health-care services. Stronger financial protection measures are needed.

Exploring dynamics in catastrophic health care expenditure in Nigeria

BACKGROUND

The Nigeria's National Health Insurance Scheme aimed at making health care accessible and affordable since it's became operational in 2005. However, many Nigerians still pay out of pocket for medical expenses, and this drive them to incurring catastrophic health expenditures. Although monitoring progress towards UHC is crucial, one single study exploring the dynamics in catastrophic health expenditure proportion, associated factors, inequality concentration, inequality size, together with decomposition using a longer period Nigeria panel household survey datasets is very scarce.

METHODS

Data was drawn from three rounds of the Nigeria General Household Survey. The fixed percentage and rank-dependent thresholds were used to calculate and compare the proportion of households that incur catastrophic health expenditures. The logistic regression model was employed in analyzing the factors associated with catastrophic health expenditures. The concentration of catastrophic health expenditures inequality was assessed using the concentration curve, whereas the inequality size was determined using the concentration index. The decomposition method was used to decompose the concentration index into determining components.

RESULTS

Relative to the fixed threshold value, the rank-dependent threshold revealed a higher share of households facing catastrophic health expenditures i.e., from 27% in 2010/2011 to 48% in 2015/2016. The two thresholds reveal similar trend, but differ in percentage points. The key factors associated with catastrophic health expenditures were economic status and geopolitical zone. Inequality in catastrophic health expenditures was found to be concentrated among the poor. The household economic status was uncovered as the major positive contributor to catastrophic health expenditures inequality across the sample periods.

CONCLUSION

The findings of the study imply that narrowing economic status gap across households, and increasing the depth of insurance are crucial mechanisms to reduce the probability of incurring catastrophic health expenditures among the poor in Nigeria.