Estimating Catastrophic Health Expenditures from Household Surveys: Evidence from Living Standard Measurement Surveys (LSMS)-Integrated Surveys on Agriculture (ISA) from Sub-Saharan Africa

Whether or not to enroll, and stay enrolled? A Tanzanian cross-sectional study on voluntary health insurance

Lower-middle income countries (LMICs) have invested significant effort into expanding insurance coverage as a means of improving access to health care. However, it has proven challenging to fulfill these ambitions. This study investigates to what extent variables associated with the enrollment decision (stay never-insured or enroll) differ from variables associated with the dropout decision (stay insured or drop out). A cross-sectional survey that included 722 households from rural districts in Tanzania was conducted and multinomial logistic regressions were performed to determine the associations between independent variables and membership status (never-insured, dropouts, or currently insured). Both the decision to enrollment and the decision to drop out were significantly associated with the presence of chronic disease and perceptions about the quality of services provided, insurance scheme management, and traditional healers. The effect of other variables, such as age, gender and educational level of the household head, household income, and perceptions about premium affordability and benefit-premium ratios, varied across the two groups. To improve voluntary health insurance coverage, policymakers must simultaneously increase the enrollment rate among the never-insured and reduce the dropout rate among the insured. Our conclusions suggest that policies to increase insurance scheme enrollment rates should differ for the two uninsured groups.

Impacts of the COVID-19 Lockdown on Healthcare Inaccessibility and Unaffordability in Uganda

Several studies have reported adverse consequences of the COVID-19 lockdowns on the utilization of healthcare services across Africa. However, little is known about the channels through which lockdowns impacted healthcare utilization. This study focuses on unaffordability as a reason for not utilizing healthcare services. We estimate the causal impacts of the COVID-19 lockdown on healthcare inaccessibility and affordability in Uganda relative to the nonlockdown periods of the pandemic. We use nationally representative longitudinal household data and a household fixed-effects model to identify the impact of the lockdown on whether households could not access medical treatment and whether the reason for not getting care was the lack of money. We find that the lockdown in Uganda was associated with an 8.4% higher likelihood of respondents being unable to access healthcare when treatment was needed relative to the nonlockdown periods. This implies a 122% increase in the share of respondents unable to access healthcare. As lockdown restrictions eased, the likelihood of being unable to access medical treatment decreased. The main reason for the increase in inaccessibility was the lack of money, with a 71% increase in the likelihood of respondents being unable to afford treatment. We find little evidence that the effects of the lockdown differed by wealth status or area of residence. Our results indicate the need for policymakers to consider immediate social support for households as a strategy for balancing the disruptions caused by lockdowns.

Association between women's household decision-making autonomy and health insurance enrollment in sub-saharan Africa

BACKGROUND

Out of pocket payment for healthcare remains a barrier to accessing health care services in sub-Saharan Africa (SSA). Women's decision-making autonomy may be a strategy for healthcare access and utilization in the region. There is a dearth of evidence on the link between women's decision-making autonomy and health insurance enrollment. We, therefore, investigated the association between married women's household decision making autonomy and health insurance enrollment in SSA.

METHODS

Demographic and Health Survey data of 29 countries in SSA conducted between 2010 and 2020 were analyzed. Both bivariate and multilevel logistic regression analyses were carried out to investigate the relationship between women's household decision-making autonomy and health insurance enrollment among married women. The results were presented as an adjusted odds ratio (AOR) and the 95% confidence interval (CI).

RESULTS

The overall coverage of health insurance among married women was 21.3% (95% CI; 19.9-22.7%), with the highest and lowest coverage in Ghana (66.7%) and Burkina Faso (0.5%), respectively. The odds of health insurance enrollment was higher among women who had household decision-making autonomy (AOR = 1.33, 95% CI; 1.03-1.72) compared to women who had no household decision-making autonomy. Other covariates such as women's age, women's educational level, husband's educational level, wealth status, employment status, media exposure, and community socioeconomic status were found to be significantly associated with health insurance enrollment among married women.

CONCLUSION

Health insurance coverage is commonly low among married women in SSA. Women's household decision-making autonomy was found to be significantly associated with health insurance enrollment. Health-related policies to improve health insurance coverage should emphasize socioeconomic empowerment of married women in SSA.

A critical review of literature on health financing reforms in Uganda - progress, challenges and opportunities for achieving UHC

Background

Universal health coverage (UHC) is one of the sustainable development goals (SDG) targets. Progress towards UHC necessitates health financing reforms in many countries. Uganda has had reforms in its health financing, however, there has been no examination of how the reforms align with the principles of financing for UHC.

Objective

This review examines how health financing reforms in Uganda align with UHC principles and contribute to ongoing discussions on financing UHC.

Methods

We conducted a critical review of literature and utilized thematic framework for analysis. Results are presented narratively. The analysis focused on health financing during four health sector strategic plan (HSSP) periods.

Results

In HSSP I, the focus of health financing was on equity, while in HSSP II the focus was on mobilizing more funding. In HSSP III & IV the focus was on financial risk protection and UHC. The changes in focus in health financing objectives have been informed by low per capita expenditures, global level discussions on SDGs and UHC, and the ongoing health financing reform discussions. User fees was abolished in 2001, sector-wide approach was implemented during HSSP I&II, and pilots with results-based financing have occurred. These financing initiatives have not led to significant improvements in financial risk protection as indicated by the high out-of-pocket payments.

Conclusion

Health financing policy intentions were aligned with WHO guidance on reforms towards UHC, however actual outputs and outcomes in terms of improvement in health financing functions and financial risk protections remain far from the intentions.

Ensuring Safety of Patients in Complex Health Systems: A Focus on Primary Healthcare Service Relations in Nigeria

Patient-centered healthcare is a goal for all health systems. However, given the inherent complexities of the health system as one with many nonlinear and dynamic components, the safety of patients could be affected. Therefore, there is the need to study these complexities to manage them toward optimal service delivery. The present study is a qualitative inquiry into the complexities of primary healthcare (PHC) in Nigeria and effects on patients' safety across four PHC facilities in Enugu state in southeast Nigeria. It utilizes a framework that draws on the components of interprofessional collaboration, inclusive of health financing and health workforce satisfaction, to understand the complex PHC system and patient safety. The study findings show that the PHC system in the study area performs suboptimally on the three counts, which implies poor management of the complexities of the system such that patients are highly susceptible to harm. Making a commitment to addressing the shortcomings present in each of the three components will help to decomplexify PHC in line with the World Health Organization agenda of achieving resilient and strong health systems. Importantly, optimizing the psychosocial space in Nigeria's PHC by employing qualified social workers and other psychosocial professionals is crucial for patient safety and a range of psychosocial activities that can enhance job satisfaction of health workers.

Assessment of Strategic Healthcare Purchasing Arrangements and Functions Towards Universal Coverage in Tanzania

BACKGROUND

Strategic health purchasing in low- and middle-income countries has received substantial attention as countries aim to achieve universal health coverage (UHC), by ensuring equitable access to quality health services without the risk of financial hardship. There is little evidence published from Tanzania on purchasing arrangements and what is required for strategic purchasing. This study analyses three purchasing arrangements in Tanzania and gives recommendations to strengthen strategic purchasing in Tanzania.

METHODS

We used the multi-case qualitative study drawing on the National Health Insurance Fund (NHIF), Social Health Insurance Benefit (SHIB), and improved Community Health Fund (iCHF) to explore the three purchasing arrangements with a purchaser-provider split. Data were drawn from document reviews and results were validated with nine key informant (KI) interviews with a range of actors involved in strategic purchasing. A deductive and inductive approach was used to develop the themes and framework analysis to summarize the data.

RESULTS

The findings show that benefit selection for all three schemes was based on the standard treatment guidelines issued by the Ministry of Health. Selection-contracting of the private healthcare providers are based on the location of the provider, the range of services available as stipulated in the scheme guideline, and the willingness of the provider to be contracted. NHF uses fee-for-service to reimburse providers. While SHIB and iCHF use capitation. NHIF has an electronic system to monitor registration, verification, claims processing, and referrals. While SHIB monitoring is done through routine supportive supervision and for the iCHF provider performance is monitored through utilization rates.

CONCLUSION

Enforcing compliance with the contractual agreement between providers-purchasers is crucial for the provision of quality services in an efficient manner. Investment in a routine monitoring system, such as the use of the district health information system which allows effective tracking of healthcare service delivery, and broader population healthcare outcomes.

Catastrophic health expenditure and its determinants among Nigerian households

Health expenditure can be substantial, especially in countries without national health insurance schemes, and it can negatively affect people's welfare. This study uses recent data to evaluate the extent to which Nigerian households suffer from catastrophic health expenditure (CHE) and evaluates its determinants. We used the Living Standards Survey 2018-2019 to estimate the headcount of Nigerian households that experience CHE-the proportion of health expenditures exceeding a certain ratio of such expenditures to non-food expenditures. To evaluate the determinants of CHE, we used ordinary least square regression with state fixed effects. The total sample was 22,110 nationally representative households. Many households, especially poorer ones, do not have any health care expenses; only 60.6% of the poorest households had some health-related expenditure. Even with the limited health-seeking behaviors in this demographic, the percentage of households that suffered from CHE was very high: with a 15% cutoff for CHE thresholds, 34.9 to 44.2% of households experienced CHE. Lower education, higher non-food consumption, and rural residence were correlated with higher amounts of health expenditure and higher odds of CHE. Health-seeking behaviors such as clinic visits for sickness treatment and prevention are limited, especially among the poorer households. Even so, the headcount of households experiencing CHE is very high in Nigeria. Advancing the implementation of national health insurance scheme is important to reduce the burden of health expenditure, especially among the poor, as well as to remove financial barriers to their seeking adequate health services.

Crowding-Out Effect of Out-of-Pocket Health Expenditures on Consumption Among Households in Mongolia

BACKGROUND

High out-of-pocket (OOP) health expenditures are a common problem in developing countries. Studies rarely investigate the crowding-out effect of OOP health expenditures on other areas of household consumption. OOP health costs are a colossal burden on families and can lead to adjustments in other areas of consumption to cope with these costs.

METHODS

This cross-sectional study used self-reported household consumption data from the nationally representative Household Socioeconomic Survey (HSES), collected in 2018 by the National Statistical Office of Mongolia. We estimated a quadratic conditional Engel curves system to determine intrahousehold resource allocation among 12 consumption variables. The 3-stage least squared method was used to deal with heteroscedasticity and endogeneity problems to estimate the causal crowding-out effect of OOP.

RESULTS

The mean monthly OOP health expenditure per household was ₮64 673 (standard deviation [SD]=259 604), representing approximately 6.9% of total household expenditures. OOP health expenditures were associated with crowding out durables, communication, transportation, and rent, and with crowding in education and heating for all households. The crowding-out effect of ₮10 000 in OOP health expenditures was the largest for food (₮5149, 95% CI=-8582; -1695) and crowding-in effect was largest in heating (₮2691, 95% CI=737; 4649) in the lowest-income households. The effect of heating was more than 10 times greater than that in highest-income households (₮261, 95% CI=66; 454); in the highest-income households, food had a crowding-in effect (₮179, 95% CI=-445; 802) in absolute amounts. In terms of absolute amount, the crowding-out effect for food was up to 5 times greater in households without social health insurance (SHI) than in those with SHI.

CONCLUSION

Our findings suggest that Mongolia's OOP health expenses are associated with reduced essential expenditure on items such as durables, communication, transportation, rent, and food. The effect varies by household income level and SHI status, and the lowest-income families were most vulnerable. SHI in Mongolia may not protect households from large OOP health expenditures.

Effects of Public and External Health Spending on Out-of-Pocket Payments for Healthcare in Sub-Saharan Africa

Financing healthcare in Sub-Saharan Africa (SSA) is characterized by high levels of out-of-pocket (OOP) payments for healthcare. This renders many individuals vulnerable to poverty and deviates from the Universal Health Coverage (UHC) goal of providing financial protection for healthcare. We examined the relative effects of public and external health spending on OOP healthcare payment in SSA. We used the system generalised method of moments (GMM) estimator and data from the World Bank's World Development Indicators for 43 SSA countries from 2000 to 2017. The results show reductions in OOP payments are higher with increases in public spending than external spending. This means increases in public health spending, compared to external health spending, will increase the pace towards achieving the financial protection goal of UHC in SSA. But since government spending is limited by fiscal space and parliamentary approval, public health spending through social health insurance might provide a regular means of financing healthcare to speed up achieving the financial protection goal in SSA countries.

A Comparative Cross-Sectional Study of the Prevalence and Determinants of Health Insurance Coverage in Nigeria and South Africa: A Multi-Country Analysis of Demographic Health Surveys

Background: The core Universal Health Coverage (UHC) objectives are to ensure universal access to healthcare services by reducing all forms of inequalities. However, financial constraints are major barriers to accessing healthcare, especially in countries such as Nigeria and South Africa. The findings of this study may aid in informing and communicating health policy to increase financial access to healthcare and its utilization in South Africa and Nigeria. Nigeria-South Africa bilateral relations in terms of politics, economics and trade are demonstrated in the justification of the study setting selection. The objectives were to estimate the prevalence of health insurance coverage, and to explore the socio-demographic factors associated with health insurance in South Africa and Nigeria. Methods: This was a cross-sectional study using the 2018 Nigeria Demographic Health Survey and the 2016 South Africa Demographic Health Survey. The 2018 Nigeria Demographic Health Survey data on 55,132 individuals and the 2016 South Africa Demographic Health Survey on 12,142 individuals were used to investigate the prevalence of health insurance associated with socio-demographic factors. Percentages, frequencies, Chi-square and multivariate logistic regression were e mployed, with a significance level of p < 0.05. Results: About 2.8% of the Nigerian population and 13.3% of the South African population were insured (Nigeria: males-3.4%, females-2.7% vs. South Africa: males-13.9%, females-12.8%). The multivariate logistic regression analyses showed that higher education was significantly more likely to be associated with health insurance, independent of other socio-demographic factors in Nigeria (Model I: OR: 1.43; 95% CI: 0.34-1.54, p < 0.05; Model II: OR: 1.34; 95% CI: 0.28-1.42, p < 0.05) and in South Africa (Model I: OR: 1.33; 95% CI: 0.16-1.66, p < 0.05; Model II: OR: 1.76; 95% CI: 0.34-1.82, p < 0.05). Respondents with a higher wealth index and who were employed were independently associated with health insurance uptake in Nigeria and South Africa (p < 0.001). Females were more likely to be insured (p < 0.001) than males in both countries, and education had a significant impact on the likelihood of health insurance uptake in high wealth index households among both male and females in Nigeria and South Africa. Conclusion: Health insurance coverage was low in both countries and independently associated with socio-demographic factors such as education, wealth and employment. There is a need for continuous sensitization, educational health interventions and employment opportunities for citizens of both countries to participate in the uptake of wide health insurance coverage.

The cost of illness for childhood clinical pneumonia and invasive pneumococcal disease in Nigeria

BACKGROUND

Pneumococcal disease contributes significantly to childhood morbidity and mortality and treatment is costly. Nigeria recently introduced the pneumococcal conjugate vaccine (PCV) to prevent pneumococcal disease. The aim of this study is to estimate health provider and household costs for the treatment of pneumococcal disease in children aged <5 years (U5s), and to assess the impact of these costs on household income.

METHODS

We recruited U5s with clinical pneumonia, pneumococcal meningitis or pneumococcal septicaemia from a tertiary level hospital and a secondary level hospital in Kano, Nigeria. We obtained resource utilisation data from medical records to estimate costs of treatment to provider, and household expenses and income loss data from caregiver interviews to estimate costs of treatment to households. We defined catastrophic health expenditure (CHE) as household costs exceeding 25% of monthly household income and estimated the proportion of households that experienced it. We compared CHE across tertiles of household income (from the poorest to least poor).

RESULTS

Of 480 participants recruited, 244 had outpatient pneumonia, and 236 were hospitalised with pneumonia (117), septicaemia (66) and meningitis (53). Median (IQR) provider costs were US$17 (US$14-22) for outpatients and US$272 (US$271-360) for inpatients. Median household cost was US$51 (US$40-69). Overall, 33% of households experienced CHE, while 53% and 4% of the poorest and least poor households, experienced CHE, respectively. The odds of CHE increased with admission at the secondary hospital, a diagnosis of meningitis or septicaemia, higher provider costs and caregiver having a non-salaried job.

CONCLUSION

Provider costs are substantial, and households incur treatment expenses that considerably impact on their income and this is particularly so for the poorest households. Sustaining the PCV programme and ensuring high and equitable coverage to lower disease burden will reduce the economic burden of pneumococcal disease to the healthcare provider and households.

Formation of public-private model in Russia health care organization

The pandemic of COVID-19, the threat of technogenic and anthropogenic character, brought to the foreground non-market aspects of the general, corporate branch culture and strategy in medicine and health care. Therefore, in many countries, despite differences in state and private property ratios in health infrastructure, the state priority is ensuring cooperation within the national health care system which capable quickly and well-coordinated work in the extremely dangerous epidemics conditions and other emergency situations. The purpose of this article is discussing a problem of public and private models of medical care organization in Russian health care system.Materials and methods. Content analysis methods, economical and statistical analysis, information and analytical materials of the Russian and foreign news agencies, a summary across Russia of Rosstat form No. 62 of the state statistical observation «Data on resource providing and on delivery of health care to the population» (legal entities - the medical organizations which are carrying out activity in the sphere of compulsory health insurance), analytical materials and statistical data of World Health Organization (The European portal of information of health care of WHO: https://gateway.euro.who.int/en/hfa-explorer/), statistical data and metadata on the countries of the Organization for Economic Cooperation and Development (OECD, https://stats.oecd.org/), the materials of monographic researches and periodicals including placed on the Internet were used in this article.Results: the system of compulsory health insurance is an ancestor of the program of the state guarantees of free medical care of in Russian citizens. The length of the text of this Program so far was increased in 130 times in comparison with initial edition of 1998. At the same time, there is still no clear delineation for the bases, volumes and conditions differentiation of free and paid medical care rendering. As a result, the major human right to free medical care remains not completely realized. The numbers of the non-state medical organizations to provide free of charge medical care to the population according to the policy of obligatory medical insurance (i.e. financed from the state sources) in the period of 2011 to 2019 – from 648 to 2423 organizations respectively were increased in Russia four times. This demonstrates the creation of the new, «integrated» model of health care in Russia in the mode of public and private partnership for deciding of social tasks. Although, free medical care for citizens in the private medical organizations is not mentioned in the Constitution of Russian Federation (Main Law). In emergency situations such integration allows private medical structures to involve capacities and also be coordinated with one of the tasks of the Ministry of health target program «Development of the Fundamental, Transmitting and Personalized Medicine».Conclusions. There is a formation of the integrated, public and private (hybrid) model of health care in modern Russia that needs developing of a new partnership and principles of management in the sphere of medical care organization. State policy in the health care financing sphere should be directed not only to the state guarantees of medical care specification, but also to a gap in social and economic inequality reduction. The social protection systems should be focused, first of all, on people who are most in great need of medical care. For the protecting population from catastrophic payments for medical care, it is necessary to bring the concept of the social standards - a number of the general rules, norms and standards which must guarantee the state ensuring constitutional rights of citizens to free medical care in the health care legislation.