Measuring the value of solidarity: The abem financial assistance program for out-of-pocket payments on pharmacy medicines in Portugal

OBJECTIVE

Out-of-pocket payments for prescribed medicines are still comparatively high in Portugal. The abem program was launched in Portugal in May 2016 to aid vulnerable groups by completely covering out-of-pocket costs of prescribed medicines in community pharmacies. This study assesses the impact of the program on poverty and catastrophic health expenditures.

METHODS

A longitudinal study was carried out with the analysis of several program databases (from the beginning of the program in May 2016 to September 2018) covering the cohorts of beneficiaries, daily data on medicines dispensed, social referencing entities, and solidarity pharmacies. The study provides estimates of standard poverty measures (intensity and severity) as well as the incidence of catastrophic health expenditures.

RESULTS

More than 6000 beneficiaries were supported (56.8% female, 34.7% aged 65 or over), encompassing 127,510 medicines (mainly nervous system and cardiovascular system) with an average 26.9% co-payment (payments totalling €1.5 million). The program achieved substantial reductions in poverty (3.4% in intensity, 5.6% in severity), and eliminated cases with catastrophic health expenditures in medicines that would have affected 7.5% of the beneficiaries.

CONCLUSIONS

Findings confirm a continuous increase in the number of beneficiaries, enabling access to medicines especially for the vulnerable elderly, and a sizable impact on eliminating out-of-pocket payments for medicines in the target population.

Out-of-pocket costs associated with chronic respiratory diseases in Korean adults

OBJECTIVES

Chronic respiratory diseases (CRDs) are a burden on both individuals and society. While previous literature has highlighted the clinical burden and total costs of care, it has not addressed patients' direct payments. This study aimed to estimate the incremental healthcare costs associated with patients with CRDs, specifically out-of-pocket (OOP) costs.

METHODS

We used survey data from the 2019 Korea Health Panel Survey to estimate the total OOP costs of CRDs by comparing the annual hospitalizations, outpatient visits, emergency room visits, and medications of patients with and without CRDs. Generalized linear regression models controlled for differences in other characteristics between groups.

RESULTS

We identified 222 patients with CRDs, of whom 166 were aged 65 years and older. Compared with the non-CRD group, CRD patients spent more on OOP costs (238.3 USD on average). Incremental costs were driven by outpatient visits and medications, which are subject to a coinsurance of 30% or more and may include items not covered by public insurance. Moreover, CRD patients aged 50-64 years incurred the highest incremental costs.

DISCUSSION

The financial burden associated with CRDs is significant, and outpatient visits and medications constitute the largest components of OOP spending. Policymakers should introduce appropriate strategies to reduce CRD-associated burdens.

Financial risk protection in private health insurance: empirical evidence on catastrophic and impoverishing spending from Germany's dual insurance system

Financial risk protection from high costs for care is a main goal of health systems. Health system characteristics typically associated with universal health coverage and financial risk protection, such as financial redistribution between insureds, are inherent to, e.g. social health insurance (SHI) but missing in private health insurance (PHI). This study provides evidence on financial protection in PHI for the case of Germany's dual insurance system of PHI and SHI, where PHI covers 11% of the population. Linked survey and claims data of PHI insureds (n = 3105) and population-wide household budget data (n = 42,226) are used to compute the prevalence of catastrophic health expenditures (CHE), i.e. the share of households whose out-of-pocket payments either exceed 40% of their capacity-to-pay or push them (further) into poverty. Despite comparatively high out-of-pocket payments, CHE is low in German PHI. It only affects the poor. Key to low financial burden seems to be the restriction of PHI to a small, overall wealthy group. Protection for the worse-off is provided through special mandatorily offered tariffs. In sum, Germany's dual health insurance system provides close-to-universal coverage. Future studies should further investigate the effect of premiums on financial burden, especially when linked to utilisation.

Contemporary Universal Health Coverage in India - The Case of Federal State of Odisha (Orissa)

Purpose

The present study assessed the awareness of the public about Biju Swasthya Kalyan Yojana (BSKY), which is a flagship public-funded health insurance scheme of the Government of Odisha. The study also identified its determinants and examined utilisation of the scheme among households in Khordha district of Odisha.

Materials and Methods

Primary data were collected from randomly chosen 150 households using a pretested structured questionnaire from Balipatana block of Khordha district, Odisha. Descriptive statistics and binomial logistic regression were used to substantiate the objectives.

Results

The study found that even though 56.70% of the sample households had heard about BSKY, procedure-specific awareness was low. State government organised BSKY health insurance camp was found to be a major source of knowledge among the sample. The regression model had an R² of 0.414. The Chi² value showed that the model with predictor variables was a good fit. Caste, gender, economic category, health insurance, and awareness about insurance were significant determinants of BSKY awareness. A majority (79.30%) of the sample had the scheme card with them. However, only 12.60% of the cardholders used the card and only 10.67% received benefits. Mean out-of-pocket expenditure (OOPE) faced by the beneficiaries is Rs. 15743.59. Among the beneficiaries, 53.80% financed the OOPE from their savings, 38.50% by borrowing, and 7.70% financed the OOPE by both means.

Conclusion

The study found that even though majority of people had heard about BSKY, they were not aware of its nature, features, and operational procedures. The trend of low benefit received and higher OOPE among the scheme beneficiaries hampers the economic health of the poor. Finally, the study highlighted the need to increase the magnitude of scheme coverage and administrative efficiency.

Healthcare Services Utilisation and Financial Burden among Vietnamese Older People and Their Households

BACKGROUND

This research examined differences in the utilisation of healthcare services and financial burden between and within insured and uninsured older persons and their households under the social health insurance scheme in Vietnam.

METHODS

We used nationally representative data from the Vietnam Household Living Standard Survey (VHLSS) conducted in 2014. We applied the World Health Organization (WHO)'s financial indicators in healthcare to provide cross-tabulations and comparisons for insured and uninsured older persons along with their individual and household characteristics (such as age groups, gender, ethnicity, per-capita household expenditure quintiles, and place of residence).

RESULTS

We found that social health insurance was beneficial to the insured in comparison with the uninsured in terms of utilization of healthcare services and financial burden. However, between and within these two groups, more vulnerable groups (i.e., ethnic minorities and rural persons) had lower utilization rates and higher rates of catastrophic spending than the better groups (i.e., Kinh and urban persons).

CONCLUSION

Given the rapidly ageing population under low middle-income status and the "double burden of diseases", this paper suggested that Vietnam reform the healthcare system and social health insurance so as to provide more equitable utilisation and financial protection to all older persons, including improving the quality of healthcare at the grassroots level and reducing the burden on the provincial/central health level; improving human resources for the grassroots healthcare facilities; encroaching public-private partnerships (PPPs) in the healthcare service provision; and developing a nationwide family doctor network.

Do Out-of-Pocket Payments for Care for Children under 5 Persist Even in a Context of Free Healthcare in Burkina Faso? Evidence from a Cross-Sectional Population-Based Survey

BACKGROUND

In April 2016, Burkina Faso began free healthcare for children aged from 0 to 5 years. However, its implementation faces challenges, and the goal of this study is to estimate the fees paid for this child care and to determine the causes of these direct payments.

METHODS

Data gathering involved 807 children aged from 0 to 5 years who had contact with the public healthcare system. The estimation of the determinants of out-of-pocket health payments involved the application of a two-part regression model.

RESULTS

About 31% of the children made out-of-pocket payments for healthcare (an average of 3407.77 CFA francs per case of illness). Of these, 96% paid for medicines and 24% paid for consultations. The first model showed that out-of-pocket payments were positively associated with hospitalization, urban area of residence, and severity of illness, were made in the East-Central and North-Central regions, and were negatively associated with the 7 to 23 month age range. The second model showed that hospitalization and severity of illness increased the amount of direct health payments.

CONCLUSION

Children targeted by free healthcare still make out-of-pocket payments. The dysfunction of this policy needs to be studied to ensure adequate financial protection for children in Burkina Faso.

A five-year (2017-2021) time series evaluation of patient-reported informal healthcare payments in Romania

Low wages of health professionals are widely recognized as one of the drivers of informal payments in Romania's healthcare system. In January 2018, the government increased wages by an average of 70% to 172% in the public healthcare sector. This study examined the trends in patient-reported informal healthcare payments, discussing the effect of a one-time wage increase in 2018 and the impact of the COVID-19 pandemic in 2020 and 2021. It draws on monthly survey data of patient-reported informal payments collected between January 2017 and December 2021. We analyzed three periods: before the wage rise ("low pay"), between the wage rise and the COVID-19 pandemic ("high pay"), and during the COVID-19 pandemic. We found that patient-reported informal payments decreased between the "low pay" and "high pay" period but with a sharper decline during the COVID-19 pandemic. The share of respondents willing to report informal payments increased during the "high pay" period, indicating a stronger willingness to voice dissatisfaction with health services and informal payments, but slowed down during the first lockdown in 2020. Informal payments were more frequently reported in larger hospitals and the poorest geographical areas. While the 2018 wage increase may have contributed to less prevalent informal payments, survey coverage and design must be improved to draw robust, system-level conclusions to inform tailored policy actions.

Catastrophic health care expenditure and impoverishment in Bhutan

Monitoring financial hardship due to out-of-pocket spending on health care is a critical determinant of progress towards universal health coverage. This study investigates the occurrence, intensity and determinants of catastrophic health expenditure and impoverishment in Bhutan using three rounds of the cross-sectional Bhutan Living Standard Surveys carried out in 2007, 2012 and 2017. We use a composite financial hardship measure defined as households experiencing either catastrophic health expenditure or impoverished/further impoverished due to health spending or both. We calculated concentration indices to examine socio-economic inequalities. We used logistic regression to examine the factors associated with financial hardship. We find that, in the context of a significant increase in living standards, there is a sharp increase in the incidence of catastrophic health expenditure (using 40% of capacity to pay) and impoverishment (based on equivalized average food-share-based poverty line) between 2007 and 2017. In 2017, catastrophic health expenditure was estimated at 0.51%, impoverishment at 0.32% and further impoverishment at 1.93% of the population, cumulating to financial hardship affecting 2.55% of the population. Financial hardship particularly burdened rural dwellers and poorer households. Transportation costs almost doubled the risk of facing financial hardship. Households that were poor, had an unemployed head, were larger and had more elderly members had higher odds of financial hardship. This evidence should prompt policy and programmatic interventions to support Bhutan's progress towards universal health coverage.

Catastrophic Health Expenditure on Private Sector Pharmaceuticals: A Cross-Sectional Analysis from the State of Odisha, India

India has high rates of catastrophic health expenditure (CHE): 16% of Indian households incur CHE. To understand why CHE is so high, we conducted an in-depth analysis in the state of Odisha—a state with high rates of public sector facility use, reported eligibility for public insurance of 80%, and the provision of drugs for free in government-run facilities—yet with the second-highest rates of CHE across India (24%). We collected household data in 2019 representative of the state of Odisha and captured extensive information about healthcare seeking, including the facility type, its sector (private or public), how much was spent out-of-pocket, and where drugs were obtained. We employ Shapley decomposition to attribute variation in CHE and other financial hardship metrics to characteristics of healthcare, controlling for health and social determinants. We find that 36.3% (95% uncertainty interval: 32.7–40.1) of explained variation in CHE is attributed to whether a private sector pharmacy was used and the number of drugs obtained. Of all outpatient visits, 13% are with a private sector chemist, a similar rate as public primary providers (15%). Insurance was used in just 6% of hospitalizations and its use explained just 0.2% (0.1–0.4) of CHE overall. Eighty-six percent of users of outpatient care obtained drugs from the private sector. We estimate that eliminating spending on private drugs would reduce CHE by 56% in Odisha. The private sector for pharmaceuticals fulfills an essential health system function in Odisha—supplying drugs to the vast majority of patients. To improve financial risk protection in Odisha, the role currently fulfilled by private sector pharmacies must be considered alongside existing shortcomings in the public sector provision of drugs and the lack of outpatient care and drug coverage in public insurance programs.

Equity in Out-of-Pocket Payments for Healthcare Services: Evidence from Malaysia

BACKGROUND

Out-of-pocket (OOP) payments are an inequitable mechanism for health financing as their high share of total health expenditures poses a risk of catastrophic healthcare expenditures. This study aimed to assess the distribution and progressivity of OOP payments made by Malaysian households for various group of healthcare services.

METHODS

This study utilized data from the Malaysian Household Expenditure Survey (HES) between 2014 and 2015, which involved 14,473 households. Distribution and progressivity of OOP payments were measured through their proportion of household consumption, a concentration curves plot and the Kakwani Progressivity Index (KPI).

RESULTS

The mean proportion of Malaysian OOP payments for healthcare of household consumption was 1.65%. The proportion increased across households' consumption quintiles, from 1.03% made by the poorest 20% to 1.86% by the richest 20%. The OOP payments in Malaysia were progressive with a positive KPI of 0.0910. The OOP payments made for hospital-based services were the most progressive (KPI 0.1756), followed by medical products, appliances and equipment (KPI 0.1192), pharmaceuticals (0.0925) and outpatient-based services (KPI 0.0394) as the least progressive.

CONCLUSIONS

Overall, the OOP payments for healthcare services in Malaysia were progressive and equitable as they were more concentrated among the richer households.

An Analysis of Catastrophic Out-of-Pocket Health Expenditures in Ghana

Introduction

Ghana implemented a universal health coverage scheme aimed at attaining financial risk protection against catastrophic out-of-pocket health expenditures. The effort has yielded mixed benefits for the different socio-economic profiles of the population. The present study estimates the incidence of catastrophic payments among Ghanaian households.

Methods

The study analyzed the round seven dataset of the Ghana Living Standards Survey collected between 2016 and 2017. We estimated the incidence and intensity of catastrophic payments for total household consumption and non-food consumption for a range of thresholds. The analysis further weighted the measures of catastrophic payments to determine the distribution sensitivity.

Results

As the threshold increased from 10 to 25% of total household consumption, the incidence of catastrophic payments dropped from 1.0 to 0.1%. At the 40% threshold of non-food consumption, the estimated incidence was 0.2%. For both total household consumption and non-food consumption, the concentration indices were negative at all the thresholds. The results were indicative of a higher concentration of financial catastrophe among the poorest households and significant inequalities in the incidence between the poorest and richest households.

Conclusion

The study confirmed the declining trend in the general incidence of catastrophic health expenditures in Ghana. However, the incidence and risk of financial catastrophe remained disproportionately higher among the poorest households, which is instructive of gaps in financial risk protection coverage. The Ghana National Health Insurance Scheme must therefore strengthen its targeting and enrolment of this sub-population group to reduce their vulnerability to catastrophic payments.

Out-of-pocket expenditure and its predictors for illness of under-five children: A cross-sectional study in urban slums of Eastern India

Introduction

Out-of-pocket (OOP) expenditure influences the access to the healthcare of the marginalized and vulnerable population including under-five children (U5C). The aim of the study is to estimate the OOP expenditure and its predictors in Bhubaneswar, a region of eastern India.

Methods

A cross-sectional study was conducted using a semi-structured interview schedule in 20 urban slums of Bhubaneswar. The survey was carried out by using the National Sample Survey Office (NSSO) health consumption schedule 25.0 in which mothers of U5C with illness (n = 530) were interviewed. For data analysis, the nonparametric Wilcoxon rank-sum test and Kruskal-Wallis test were used as tests of significance.

Results

The study revealed that the mean OOP expenditure for outpatient department (OPD) care was ₹375.9 (₹219.48). The mean approximated expenditure was ₹1669.8 (₹1131.9) for inpatient department (IPD) care. In OPD care, doctors' fee and medicine cost constituted 65.01% and 50.46% of OOP expenditure, respectively. In IPD care, medicine cost and doctors' fee contributed to 36.62% and 30.54% of OOP expenditure, respectively. The major significant predictors that contributed to increased OOP were gender and delay in approaching the source of treatment in OPD, whereas in IPD no such predictors were observed.

Conclusions

This study prominently sheds light on the issue of accessibility and affordability of health services without a comprehensive health insurance scheme for U5C illness among the vulnerable urban slum dwellers to achieve universal health coverage.

Factors Associated with Out-of-Pocket Health Expenditure in Polish Regions

Out-of-pocket (OOP) payments are perceived as the most regressive means of health financing. Using the panel-data approach and region-aggregated data from Statistics Poland, this research investigated associations between socio-economic factors and OOP health spending in 16 Polish regions for the period 1999–2019. The dependent variable was real (inflation-adjusted) monthly OOP health expenditure per person in Polish households. Potential independent variables included economic, labour, demographic, educational, health, environmental, and lifestyle measures based on previous research. A set of panel-data estimators was used in regression models. The factors that were positively associated with OOP health spending were disposable income, the proportions of children (aged 0–9) and elderly (70+ years) in the population, healthcare supply (proxied by physicians’ density), air pollution, and tobacco and alcohol expenditure. On the other hand, the increased unemployment rate, life expectancy at age 65, mortality rate, and higher sports participation were all related to lower OOP health spending. The results may guide national strategies to improve health-care allocations and offer additional financial protection for vulnerable groups, such as households with children and elderly members.

A Step towards Understanding and Tackling Health Inequalities: The Use of Secondary Prevention Services and the Need for Health Promotion in a Rural Setting

Poland has recently intensified its health promotion in an effort to extend healthy life expectancy and reduce health inequalities. Our aim was to reach a deprived rural population, increase its health literacy, and explore its use of and barriers to cancer screening and public health care. A CBPR study was conducted in one of the poorest districts in Wielkopolska region, Poland, among 122 beneficiaries of health education workshops. A self-developed questionnaire was used. The reported barriers to participation in cancer screening included: lack of time, lack of need, or feeling healthy (32.8%); long waiting times (17.2%); fear of costs (9%). Physicians seldom recommended screening to their patients. Only 7.4% of respondents had ever received dermatoscopy. Among women, 18.2% did not perform any breast exams and 25% had never had smear tests. Diagnostics was often financed out of pocket (thyroid ultrasound = 58.1%; smear test = 48.5%; breast ultrasound = 36.8%). The health system needs mentioned by participants included better access to physicians (65.6%), promotion of free screening tests (54.9%), and access to public health programmes (22.1%). There is an urgent need to translate national strategies into action. Health promotion and better access to care must become priorities in deprived areas, while primary care providers should become key figures in delivering these services.

Assessing the incidence of catastrophic health expenditure and impoverishment from out-of-pocket payments and their determinants in Bangladesh: evidence from the nationwide Household Income and Expenditure Survey 2016

Background

Out-of-pocket (OOP) payments for healthcare have been increasing steadily in Bangladesh, which deteriorates the financial risk protection of many households.

Methods

We aimed to investigate the incidence of catastrophic health expenditure (CHE) and impoverishment from OOP payments and their determinants. We employed nationally representative Household Income and Expenditure Survey 2016 data with a sample of 46 076 households. A household that made OOP payments of >10% of its total or 40% of its non-food expenditure was considered to be facing CHE. We estimated the impoverishment using both national and international poverty lines. Multiple logistic models were employed to identify the determinants of CHE and impoverishment.

Results

The incidence of CHE was estimated as 24.6% and 10.9% using 10% of the total and 40% of non-food expenditure as thresholds, respectively, and these were concentrated among the poor. About 4.5% of the population (8.61 million) fell into poverty during 2016. Utilization of private facilities, the presence of older people, chronic illness and geographical location were the main determinants of both CHE and impoverishment.

Conclusion

The financial hardship due to OOP payments was high and it should be reduced by regulating the private health sector and covering the care of older people and chronic illness by prepayment-financing mechanisms.

The price of quality care: cross-sectional associations between out-of-pocket payments and quality of care in six low-income countries

OBJECTIVE

To assess the relationship between out-of-pocket (OOP) payments and primary health care quality in six low-income countries: Afghanistan, the Democratic Republic of the Congo (DRC), Haiti, Nepal, Senegal and Tanzania.

METHODS

We examined the association between OOP payments and quality of care during antenatal care and sick child care visits using Service Provision Assessments data. We defined four process quality outcomes from observations of clinical care: visit duration, history-taking items asked, exam items performed, and counselling items delivered. The outcome is the total amount paid for services. We used multilevel models to test the relationship between OOP payments and each quality measure in public, private non-profit and private for-profit facilities controlling for patient, provider, and facility characteristics.

RESULTS

Across the six countries, an average of 42% of the 29 677 observed clients paid for their visit. In the adjusted models, OOP payments were positively associated with the visit duration during sick child visits, with history-taking and exam items during antenatal care visits, and with counselling in private for-profit facilities for both visit types. These associations were strong particularly in Afghanistan, the DRC and Haiti; for example, a high-quality antenatal care visit in the DRC would cost approximately USD 1.12 more than a visit with median quality.

CONCLUSION

Provider effort was associated with higher OOP payments for sick child and antenatal care services in the six countries studied. While many families are already spending high amounts on care, they must often spend even more to receive higher quality care.

Catastrophic Household Expenditure Associated with Out-of-Pocket Healthcare Payments in Spain

Background. The financial effect of households’ out-of-pocket payments (OOP) on access and use of health systems has been extensively studied in the literature, especially in emerging or developing countries. However, it has been the subject of little research in European countries, and is almost nonexistent after the financial crisis of 2008. The aim of the work is to analyze the incidence and intensity of financial catastrophism derived from Spanish households’ out-of-pocket payments associated with health care during the period 2008–2015. Methods. The Household Budget Survey was used and catastrophic measures were estimated, classifying the households into those above the threshold of catastrophe versus below. Three ordered logistic regression models and margins effects were estimated. Results. The results reveal that, in 2008, 4.42% of Spanish households dedicated more than 40% of their income to financing out-of-pocket payments in health, with an average annual gap of EUR 259.84 (DE: EUR 2431.55), which in overall terms amounts to EUR 3939.44 million (0.36% of GDP). Conclusion. The findings of this study reveal the existence of catastrophic households resulting from OOP payments associated with health care in Spain and the need to design financial protection policies against the financial risk derived from facing these types of costs.

Vicious cycle of chronic disease and poverty: a qualitative study in present day Nepal

BACKGROUND

In countries with out-of-pocket (OOP) payment systems for healthcare, the combination of chronic disease and poverty can have damaging socio-economic and health impacts for affected households. Using a life course perspective, this article aims to explore how Nepalese people struggle with, experience and adapt to chronic disease, poverty and their consequences, and how chronic diseases and poverty reinforce each other.

METHODS

In-depth semi-structured interviews were conducted with 21 chronically ill Nepalese people with one or more chronic diseases and/or their caretakers. Data were transcribed and analysed thematically.

RESULTS

The adaptation strategies for the consequences of the huge OOP costs make patients and their households financially disadvantaged. The impoverishment has major social impacts and often persists across generations. The situation forces people to choose between avoiding medical treatment or further impoverishing their families.

CONCLUSIONS

This study explored how chronically ill Nepalese people struggle with socio-economic and health consequences of OOP payments for their disease. The article sheds light on circumstances and adaptation strategies that obstruct every attempt to escape from the vicious cycle of the poverty trap. Hence poverty and health adversities accumulate across generations and contribute to greater health expenditures, worse health outcomes and severely compromised social life.

The Study of Out-of-pocket Payment and the Exposure of Households with Catastrophic Health Expenditures Following the Health Transformation Plan in Iran

Introduction

One of the main objectives of health systems is providing financial protection against out-of-pocket (OOP) health expenditures. According to the 2011 report by the World Health Organization in the Eastern Mediterranean Regional Office (EMRO), a huge portion of health service in Iran is paid OOP, which is around 58% of the total health system expenditure. Furthermore, all over the world, around 25 million households (100 million people) are trapped in poverty as a result of paying health service costs. Therefore, this research was aimed at investigating the OOP and exposure of households with catastrophic health expenditures (CHE) following the implementation of a health transformation plan in Tabriz, Iran.

Methods

A descriptive-analytic study was conducted on a cross-sectional basis. The sample included 400 households, who were interviewed using the World Health Survey questionnaire, and then OOP payment and exposure of households to CHE were estimated, and the effective factors on OOP payment and the determinants of CHE were analyzed using a regression model.

Results

After implementing the health transformation plan, the average share of households’ OOP payments, toward their ability to pay was 13.2%. In addition, 11.25% of the households were exposed to CHE in Tabriz. The key determinants of OOP were income, dental services, pharmaceuticals, radiology, and physiotherapy. The factors affecting CHE were income, insurance status, marital status, dental services, pharmacy, physiotherapy, and radiological services.

Conclusion

Based on the results of the current study and compared to similar research conducted prior to this plan, it is obvious that the transformation plan was able to achieve its goal in “reducing OOP payments”. However, health services such as dental, pharmacy, physiotherapy, and radiology would increase the likelihood of facing OOP payments. These variables should be considered by health policy-makers in order to review and revise the content of recent reform to provide financial protection against OOP for people.

The effect of a community-based health insurance on the out-of-pocket payments for utilizing medically trained providers in Bangladesh

BACKGROUND

We aimed to estimate the effect of the community-based health insurance (CBHI) scheme on the magnitude of out-of-pocket (OOP) payments for the healthcare of the informal workers and their dependents. The CBHI scheme was piloted through a cooperative of informal workers, which covered seven unions in Chandpur Sadar Upazila, Bangladesh.

METHODS

A quasi-experimental study was conducted using a case-comparison design. In total 1292 (646 insured and 646 uninsured) households were surveyed. Propensity score matching was done to minimize the observed baseline differences in the characteristics between the insured and uninsured groups. A two-part regression model was applied using both the probability of OOP spending and magnitude of such spending for healthcare in assessing the association with enrolment status in the CBHI scheme while controlling for other covariates.

RESULTS

The OOP payment was 6.4% (p < 0.001) lower for medically trained provider (MTP) utilization among the insured compared with the uninsured. However, no significant difference was found in the OOP payments for healthcare utilization from all kind of providers, including the non-trained ones.

CONCLUSIONS

The CBHI scheme could reduce OOP payments while providing better quality healthcare through the increased use of MTPs, which consequently could push the country towards universal health coverage.

The COVID-19 Pandemic and the Pathology of the Economic and Political Architecture in Cameroon

This article examines the factors restricting an effective response to the COVID-19 pandemic in Cameroon. It argues that structural adjustment policies in the 1980s and 1990s as well as corruption and limited investment in recent times have severely weakened the country's health system. This article also emphasises the interconnection between poverty, slums, and COVID-19. This interconnection brings to the fore inequality in Cameroon. Arguably, this inequality could facilitate the spread of COVID-19 in the country. This article draws attention to the political forces shaping the response to the pandemic and contends that in some regions in the country, the lack of an effective response to the pandemic may not necessarily be due to a lack of resources. In so doing, it critiques the COVID-19 orthodoxy that focuses exclusively on the pathology of the disease and advocates "technical" solutions to the pandemic, while ignoring the political and socio-economic forces that shape the fight against the pandemic. At times, medical supplies and other forms of assistance may be available, but structural violence impairs access to these resources. Politics must be brought into the COVID-19 discourse, as it shapes the response to the pandemic.

The effects of raising the long-term care insurance co-payment rate on the utilization of long-term care services

AIM

The effect of raising insurance co-payment rates on healthcare service utilization in Japan remains unclear. In this study, we utilized patient-level long-term care (LTC) insurance claims data to analyze these effects.

METHODS

Claims data were obtained on individuals certified as requiring LTC in City A and City B, Fukuoka Prefecture, Japan during August 2014-July 2016. Individuals whose LTC insurance co-payment rate increased from 10% to 20% in August 2015 were regarded as high-income individuals; individuals whose co-payment rate remained at 10% were regarded as non-high-income individuals. We examined the changes in LTC service utilization between high-income individuals and non-high-income individuals during the study period. Monthly LTC insurance charges were analyzed to evaluate service utilization. We created monthly panel data for the study participants, and quantified the differences in LTC service utilization before and after August 2015 between the high-income and non-high-income groups. Care needs levels and age were included as covariates in a fixed-effects model.

RESULTS

The sample comprised 7711 individuals (1000 high-income individuals and 6711 non-high-income individuals) in City A and 647 individuals (84 high-income individuals and 563 non-high-income individuals) in City B. After adjusting for care needs levels and age, the co-payment rate increase was associated with reductions in monthly LTC insurance charges of $34.3 (P < 0.001) in City A and $91.0 (P = 0.022) in City B.

CONCLUSION

The increase in co-payment rate for high-income individuals in August 2015 negatively affected their utilization of LTC services. Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2020; ••: ••-••.

Enrollees' Knowledge and Satisfaction with National Health Insurance Scheme Service Delivery in a Tertiary Hospital, South West Nigeria

Background

Social health insurance scheme provides a platform for mobilizing revenue for health and enhances universal health-care coverage. In addition, knowledge about patients' satisfaction with health care under the scheme will help in identifying gaps and provides evidence toward strengthening the scheme. This study assessed enrollees' knowledge about the National Health Insurance Scheme (NHIS) and satisfaction with health services provided under the scheme.

Materials and Methods

The study was a descriptive cross-sectional survey conducted among the NHIS enrollees accessing health-care services in the University College Hospital, Ibadan. A total of 373 individuals were consecutively recruited for the study, and a semi-structured, pretested interviewer-administered questionnaire was used to obtain information from respondents. Descriptive statistics was used to present results, and Chi-square test was used to test for the association between categorical variables. The level of significance was set at P < 005.

Results

The mean age was 42.5 ± 10.0 years. Of the respondents, 209 (56.0%) were male and 359 (96.2%) were married. About two-thirds, 227 (60.9%), had good knowledge about the NHIS. Majority of the respondents 303 (81.2%) reported paying for some of the costs of service (drugs, laboratory tests, consultation fees, and X-ray) through out-of-pocket and of these, 218 (71.9%) reported that such payments were occasional. Overall, slightly more than half, 197 (52.8%), of the respondents were satisfied with service delivery under the scheme. Female respondents were significantly more satisfied with health-care services (χ² = 3.894,P = 0.048).

Conclusion

There was good knowledge of NHIS, but the level of satisfaction with service delivery was not outstandingly appreciable. There is an urgent need to improve on all areas of quality of service to improve satisfaction with care among enrollees in the scheme.

Financial Catastrophism Inherent with Out-of-Pocket Payments in Long Term Care for Households: A Latent Impoverishment

Background: Out-of-pocket (OOP) payments are configured as an important source of financing long-term care (LTC). However, very few studies have analyzed the risk of impoverishment and catastrophic effects of OOP in LTC. To estimate the contribution of users to the financing of LTC and to analyze the economic consequences for households in terms of impoverishment and catastrophism after financial crisis in Spain.

METHODS

The database that was used is the 2008 Spanish Disability and Dependency Survey, projected to 2012. We analyze the OOP payments effect associated to the impoverishment of households comparing volume and financial situation before and after OOP payment. At the same time, the extent to which OOP payment had led to catastrophism was analyzed using different thresholds.

RESULTS

The results show that contribution of dependent people to the financing of the services they receive exceeds by 50% the costs of these services. This expenditure entails an increase in the number of households that live below the poverty. In terms of catastrophism, more than 80% of households dedicate more than 10% of their income to dependency OOP payments. In annual terms, the catastrophe gap generated by devoting more than 10% of the household income to dependent care OOP payment reached €3955, 1 million (0.38% of GDP).

CONCLUSION

This article informs about consequences of OOP in LCT and supplements previous research that focus on health. Our results should serve to develop strategic for protection against the financial risk resulting from facing the costs of a situation of dependence.

Inequalities in the benefits of national health insurance on financial protection from out-of-pocket payments and access to health services: cross-sectional evidence from Ghana

A central pillar of universal health coverage (UHC) is to achieve financial protection from catastrophic health expenditure. There are concerns, however, that national health insurance programmes with premiums may not benefit impoverished groups. In 2003, Ghana became the first sub-Saharan African country to introduce a National Health Insurance Scheme (NHIS) with progressively structured premium charges. In this study, we test the impact of being insured on utilization and financial risk protection compared with no enrolment, using the 2012-13 Ghana Living Standards Survey (n = 72 372). Consistent with previous studies, we observed that participating in health insurance significantly decreased the probability of unmet medical needs by 15 percentage points (p.p.) and that of incurring catastrophic out-of-pocket (OOP) health payments by 7 p.p. relative to no enrolment in the NHIS. Households living outside a 1-h radius to the nearest hospital had lower reductions in financial risk from excess OOP medical spending relative to households living closer (-5 p.p. vs -9 p.p.). We also find evidence that in Ghana, the scheme was highly pro-poor. Once insured, the poorest 40% of households experienced significantly larger improvements in medical utilization (18 p.p. vs. 8 p.p.) and substantively larger reductions in catastrophic OOP health expenditure (-10 p.p. vs. -6 p.p.) compared with that of the richest households. However, health insurance did not benefit vulnerable persons equally from financial risk. Once insured, poor, low-educated and self-employed households living far from hospitals had significantly lower reductions in catastrophic OOP medical spending compared with their counterparts living closer. Taken together, we show that enrolment in the NHIS is associated with improved financial protection but less so among geographically remote vulnerable groups. Efforts to boost not just insurance uptake but also health service delivery may be needed as a supplement for insurance schemes to accelerate progress towards UHC.

The impact of health reform in Iran on catastrophic health expenditures: Equity and policy implications

PURPOSE

In 2014, the Islamic Republic of Iran launched the Health Transformation Plan (HTP), with the goal of achieving universal health coverage (UHC) through improved financial protection and access to high-quality health services among Iranian households. We aimed to investigate the impact of the HTP on the level and pattern of out-of-pocket (OOP) payments for health care.

METHODS

Using data from two rounds (2013 and 2016) of the Iranian Statistics Centre's Household Expenditure and Income Survey (HEIS), collected before and after implementation of the HTP, we estimate changes in the level and drivers of OOP payments, and the prevalence, intensity, and distribution of catastrophic health expenditures (CHEs) among Iranian households.

FINDINGS

Our results indicate that per capita OOP payments on health remained stable during the observed period, with the largest proportion of OOP payments spent on medicines. Using thresholds of 10% and 25% of total consumption, there was a slight increase in the prevalence of CHE. The prevalence of CHE increased from 3.76% to 3.82% at threshold of 25% of total consumption. Using 40% capacity to pay threshold, prevalence diminished modestly from 2.5% to 2.37% and the intensity decreased from 13.16% to 12.32%. At all thresholds, CHE were more concentrated among wealthier households.

CONCLUSION

These results suggest that while financial protection of the poor in Iran has improved due to the HTP, more work is needed to achieve UHC in Iran. For the next phase of health reforms, more emphasis should be placed on shifting away from OOP co-payments for health financing to progressive prepayment mechanisms to facilitate better sharing of financial risks across population groups.

The impact of out-of-pocket health expenditure on household impoverishment: Evidence from Morocco

Health financing in Morocco relies mainly on out-of-pocket (OoP) payments. World Health Organization (WHO) has shown that these payments can expose households to catastrophic health expenditure (hereinafter CHE) and impoverish them. The study examines the financial burden of OoP health payments on Moroccan households. Two approaches-that developed by Wagstaff and Doeslear and the one advocated by WHO-are adopted to estimate the extent of CHE. These show that 1.77% of households incurred CHE at the 40% threshold for nonfood expenditure. At the 10% threshold for total consumption expenditure, 12.8% of households incurred CHE. We find that these OoP payments have made 1.11% of Moroccan households poorer. In analyzing the determinants of CHE, we estimated an ordered probit model. It appears that any of (a) hospitalization, (b) presence of an elderly person in the household, or (c) the level of poverty increases significantly the likelihood of health expenditure becoming catastrophic. On the other hand, we find that coverage by health insurance protects against CHE.

Coping strategies of cancer patients in Ukraine

This case study explores the coping strategies of oncology patients and their family members in Ukraine. These coping strategies are seen as an individual-level response to the organizational and financial failures of the Ukrainian health care system. Based on semistructured interviews with medical doctors, patients, representatives of charitable foundations, and policy makers, we identify a variety of coping strategies, including personal connections and informal payments. Unequal access to diagnostic and treatment services is observed: coping strategies are developed by patients and their families taking into account the available financial and social capital. Importantly, we could not identify a typical path for cancer patients as cancer patients act in an environment of great uncertainty-in terms of their prognosis and in terms of the cost of treatment. With a weak state and financial uncertainty, patients and physicians perceive coping strategies rather positively as it may contribute to the chance of life.

Medication adherence and cost-related medication non-adherence in patients with rheumatoid arthritis: A cross-sectional study

AIM

First, to assess the clinical characteristics and medication adherence to oral rheumatoid arthritis (RA) medications in patients with RA. Second, to examine adherence determinants with a focus on the effect of medication out-of-pocket (OOP) costs on medication adherence to oral RA medications. Lastly, to examine cost-related medication non-adherence (CRN) in patients with RA.

METHODS

A cross-sectional study of patients with RA was conducted at rheumatology outpatient clinics in Shiraz, Iran. The data collection survey consisted of 5 sections including demographic questions, disease-related questions, Compliance Questionnaire Rheumatology (CQR), CRN questions and an open-ended question. SPSS version 24 was used for analysis.

RESULTS

A total of 308 completed surveys were collected. Adherence to oral RA medications was 40.3%. Just under 20% of participants were biologic disease-modifying antirheumatic drugs (bDMARDs) users and these bDMARDs users were 0.82 times less likely to be adherent to their oral RA medications compared to non-bDMARDs users (P < 0.05). There was no statistically significant association between OOP costs and adherence to oral RA medications (P > 0.05). However, 28.7% of participants reported not refilling, delaying to refill, skipping doses or taking smaller doses due to cost. In findings of the open-ended question, medication costs and affordability were the most commonly mentioned barriers to medication adherence.

CONCLUSION

Non-adherence to oral RA medications was prevalent among Iranian patients with RA and OOP costs were a barrier to medication adherence.

Catastrophic health expenditure of Vietnamese patients with gallstone diseases - a case for health insurance policy revaluation

Purpose

Despite gallstone diseases (GSDs) being a major public health concern with both acute and chronic episodes, none of the studies in Vietnam has been conducted to investigate the household expenditure for the GSD treatment. The objective of this study was to estimate the costs of managing GSD and to explore the prevalence and determinants of catastrophic health expenditure (CHE) among Vietnamese patients.

Materials and methods

A cross-sectional study was conducted from June 2016 to March 2017 in the Department of Hepatobiliary and Pancreatic Surgery, Viet Duc Hospital in Hanoi, Vietnam. A total of 206 patients were enrolled. Demographic and socioeconomic data, household income, and direct and indirect medical costs of patients seeking treatment for GSD were collected through face-to-face interview. Multivariate logistic regression was used to explore factors associated with CHE.

Results

The prevalence of CHE in patients suffering from GSD was 35%. The percentage of patients who were covered by health insurance and at risk for CHE was 41.2%, significantly higher than that of those noninsured (15.8%). Proportions of patients with and without health insurance who sought outpatient treatment were 30.6% and 81.6%, respectively. Patients who were divorced or widowed and had intrahepatic gallstones were significantly more likely to experience CHE. Those who were outpatients, were women, had history of pharmacological treatment to parasitic infection, and belong to middle and highest monthly household income quantile were significantly less likely to experience CHE.

Conclusion

The findings suggested that efforts to re-evaluate health insurance reimbursement capacity, especially for acute diseases and taking into account the varying preferences of people with different disease severity, should be conducted by health authority. Further studies concerning CHE of GSD in the context of ongoing health policy reform should consider utilizing WHO-recommended measures like the fairness in financial contribution index, as well as taking into consideration the behavioral aspects of health care spending.

Financing health care in Bangladesh: Policy responses and challenges towards achieving universal health coverage

Bangladesh has attained notable progress in most of the health indicators, but still, health system of the country is suffering badly from poor funding. Issues like burden of out-of-pocket expenditure, low per capita share in health, inadequate service facilities, and financial barriers in reducing malnutrition are being overlooked due to inadequacy and inappropriate utilization of allocated funds. We aimed to review the current status of health care spending in Bangladesh in response to national health policy (NHP) and determine the future challenges towards achieving universal health coverage (UHC). National health policy suggested a substantial increase in budgetary allocation for health care, although government health care expenditures in proportion to total public spending plummeted down from 6.2% to 4.04% in the past 8 years. Overall, 67% of the health care cost is being paid by people, whereas global standard is below 32%. Only one hospital bed is allocated per 1667 people, and 34% of total posts in health sector are vacant due to scarcity of funds. The country is experiencing demographic dividend with a concurrent rise of aged people, but there seems no financial protection schemes for the aged and working age populations. Such situation results in multiple obstacles in achieving financial risk protection as well as UHC. Policy makers must think effectively to develop and adapt systems in order to achieve UHC and ensure health for all.

The importance of assessing out-of-pocket payments when the financing of antiretroviral therapy is transitioned to domestic funding: findings from Vietnam

OBJECTIVE

To assess out-of-pocket payments and catastrophic health expenditures among antiretroviral therapy (ART) patients in Vietnam, and to model catastrophic payments under different copayment scenarios when the primary financing of ART changes to social health insurance.

METHODS

Cross-sectional facility-based survey of 843 patients at 42 health facilities representative of 87% of ART patients in 2015.

RESULTS

Because of donor and government funding, no payments were made for antiretroviral drugs. Other health expenditures were about $66 per person per year (95% CI: $30-$102), of which $15 ($7-$22) were directly for HIV-related health services, largely laboratory tests. These payments resulted in a 4.9% (95% CI: 3.1-6.8%) catastrophic payment rate and 2.5% (95% CI: 0.9-4.1%) catastrophic payment rate for HIV-related health services. About 32% of respondents reported, they were eligible for SHI without copayments. If patients had to pay 20% of costs of ART under social health insurance, the catastrophic payment rate would increase to 8% (95% CI: 5.5-10.0%), and if patients without health insurance had to pay the full costs of ART, the catastrophic payment rate among all patients would be 24% (95% CI: 21.1-27.4%).

CONCLUSIONS

Health and catastrophic expenditures were substantially lower than in previous studies, although different methods may explain some of the discrepancy. The 20% copayments required by social health insurance would present a financial burden to an additional 0.6% to 5.1% of ART patients. Ensuring access to health insurance for all ART patients will prevent an even higher level of financial hardship.

The proportion of unmet costs considering inpatients billing of selected hospitals, after 2014 Health System reform implementation in Isfahan Province

INTRODUCTION

Since 2013, in Iran's health care, the contribution of direct payments for health-care services was estimated more than 50 % of all expenditures. In May 2014, Iran's health-care reform was established to improve health services quality and reduce patients' out-of-pocket payments <10% in urban and 5% in rural areas. Therefore, the purpose of this study is to investigate unmet costs (those which are not covered either by the insurance companies nor the recent reform coverage mentioned in Sections 1.2.2 and 1.2.1, Article 6 of the Health Minister Reform Guideline) in the inpatient billings within the first 5 months from the reform implementation.

METHODS

This study was conducted as a cross-sectional research in the second half of 2014 on the selected hospitals in Isfahan Province. Data were collected by investigating 97,000 inpatients' billing records issued by 28 hospitals affiliated to Isfahan University of Medical Sciences using census method.

RESULTS

Findings of the study showed that the average of unmet costs paid by the inpatients constituted 21.8% of the total billing costs in 28 hospitals, and the average unmet costs paid by each patient was 1,903,832 Rials.

CONCLUSION

Considering the definition of unmet cost in the context of health-care reform guideline and hospitals' problems in providing some costly services, drugs, and medical equipment (that were not covered by insurance organizations and the reform scheme) within the obligations of the reform, it is necessary to review these obligations and further interact with insurance companies about expanding the coverage to some costly services required by the patients.

Should new health technology be available only for patients able and willing to pay?

New health technology comes on the market at a rapid pace and - sometimes - at a huge cost. Providing access to new health technology is a serious challenge for many countries with mandatory health insurance. This article analyses access to new health technology in Belgium and the Netherlands, using eight concrete examples as a starting point for comparing the two - neighbouring - countries. Contrary to the Netherlands, out-of-pocket payments for new health technology are widely accepted and practiced in Belgium. This difference is largely the result of different regulatory environments. A major difference is the way that entitlements to care are described: closed and explicit in Belgium versus open and non-explicit in the Netherlands. The characteristics of in-kind policies versus reimbursement policies also play a role. Allowing out-of-pocket payments for new health technology has consequences for the patients. It leads to greater access to new health technology (for those who are able and willing to pay), but has a negative effect on equal access to care. Choice and transparency are enhanced by allowing out-of-pocket payments for new health technology. It could be argued that lack of coverage by mandatory health insurance should not render private access to new health technology impossible.

Patterns of informal patient payments in Bulgaria, Hungary and Ukraine: a comparison across countries, years and type of services

Informal payments for health care are a well-known phenomenon in many health care systems around the world. While informal payments could be an important source of health care financing, they have an adverse impact on efficiency and access to care, and are a major impediment to ongoing health care reforms. This paper aims to study the scale and patterns of informal patient payments for out-patient and in-patient services in three former-socialist countries: Bulgaria, Hungary and Ukraine. The data are collected in 2010 and 2011 based on national representative samples and are analysed in pooled models to explain variations in payments. The results of the cross-country comparison suggest a relatively higher prevalence of informal patient payments in Ukraine and Hungary than in Bulgaria, where patients also have to pay formal user charges in the public sector. Nevertheless, informal payments for hospitalization in Bulgaria are quite extensive. We observe some differences in informal payments across the years. Variations in payment size are mainly explained by the nature, type and need for services, fee awareness and, on some occasions, by household income. Interpreted within the context of structural differences (e.g. reform paths, regulations, funding, user fees, anti-corruption policies), the findings of our study have implications on how to address informal payments for health care.

Persistent low adherence to hypertension treatment in Kyrgyzstan: How can we understand the role of drug affordability?

It is well known that cardiovascular diseases (CVD) are a growing cause of mortality and morbidity in low-and middle-income countries (LMIC). While hypertension (HTN), a leading risk factor for CVD, can be easily managed with widely available medicines, there is a huge gap in treatment for HTN in many LMIC. One such country is Kyrgyzstan, where HTN is a major public health concern and adherence to medication is low. The reasons for low adherence in Kyrgyzstan are not well understood, but some evidence suggests that HTN medicines may be unaffordable for low-income families, resulting in inequitable access to HTN treatment. With data from the 2010 Kyrgyzstan Integrated Household Survey, we estimate the prevalence and factors associated with adherence to HTN medication in Kyrgyzstan. We then investigate the hypothesis that affordability may be an important factor in adherence to HTN medication. Using the coarsened exact matching approach, we estimate the economic burden faced by households with at least one member with elevated blood pressure (EBP) in Kyrgyzstan and their risk of catastrophic spending on health care. We find that EBP households have significantly higher total expenditure on health, as well as on medicines, and are more likely to experience catastrophic health spending, suggesting that out-of-pocket expenditure for EBP may be prohibitively expensive for the poorest in Kyrgyzstan. Our findings also reveal a high prevalence of self-medication (i.e. purchasing and using medication without a doctor's prescription), and increased expenditure due to self-medication, among those with EBP. Our research suggests that affordability of HTN medicines may be an important factor in low adherence to treatment in Kyrgyzstan. Low affordability may be due partly to the prescription of medicines that are not reimbursable under the national drug benefit plan, but more research is needed to identify solutions to the affordability problem.

The use of medical care and out-of-pocket payments in Russia

BACKGROUND

Despite the constitutional right of all Russian citizens to free medical care, out-of-pocket payment is a widespread phenomenon for all types of medical treatment. The aims of this paper are twofold: To present new evidence on the use of, and payment for, outpatient and inpatient treatment in Russia; and to compare the motivations behind both official and informal payments for outpatient services provided in public medical institutions.

METHODS

This study uses data from a quantitative household survey conducted in April 2014. The sample comprised 1602 individuals aged ⩾ 18 years, representing the entire adult population of the Russian Federation. We studied three types of medical care: inpatient treatment, outpatient treatment and medicines.

RESULTS

Our study found that 22.2% of patients pay for outpatient services, 37.5% pay for inpatient services and 91.5% pay for outpatient medicinal treatment. The informal payments are almost equally met in both outpatient (13.4%) and inpatient (12.2%) care; while the official payments are more common in inpatient care (25.2%), compared to outpatient care (8.8%). The main reasons for informal payment include: improvements in the quality of care and gratitude for medical staff. The official payments are more frequently motivated by an inability to receive a certain treatment free of charge. CONCLUSIONS THIS STUDY DEMONSTRATES THAT BOTH OFFICIAL AND INFORMAL PAYMENTS FOR MEDICAL TREATMENT ARE WIDESPREAD IN RUSSIA INFORMAL PAYMENTS ARE STRONGLY PREFERRED OVER OFFICIAL PAYMENTS FOR OUTPATIENT CARE, WHILE OFFICIAL PAYMENTS DOMINATE IN INPATIENT CARE.

Methodological Issues to Consider When Collecting Data to Estimate Poverty Impact in Economic Evaluations in Low-income and Middle-income Countries

Out-of-pocket spending is increasingly recognized as an important barrier to accessing health care, particularly in low-income and middle-income countries (LMICs) where a large portion of health expenditure comes from out-of-pocket payments. Emerging universal healthcare policies prioritize reduction of poverty impact such as catastrophic and impoverishing healthcare expenditure. Poverty impact is therefore increasingly evaluated alongside and within economic evaluations to estimate the impact of specific health interventions on poverty. However, data collection for these metrics can be challenging in intervention-based contexts in LMICs because of study design and practical limitations. Using a set of case studies, this letter identifies methodological challenges in collecting patient cost data in LMIC contexts. These components are presented in a framework to encourage researchers to consider the implications of differing approaches in data collection and to report their approach in a standardized and transparent way.

Barriers to universal health coverage in Republic of Moldova: a policy analysis of formal and informal out-of-pocket payments

BACKGROUND

Universal Health Coverage seeks to assure that everyone can obtain the health services they need without financial hardship. Countries which rely heavily on out-of-pocket (OOP) payments, including informal payments (IP), to finance total health expenditures are not likely to achieve universal coverage. The Republic of Moldova is committed to promoting universal coverage, reducing inequities, and expanding financial protection. To achieve these goals, the country must reduce the proportion of total health expenditures paid by households. This study documents the extent of OOP payments and IP in Moldova, analyses trends over time, and identifies factors which may be driving these payments.

METHODS

The study includes analysis of household budget survey data and previous research and policy documents. The team also conducted a review of administrative law intended to control OOP payments and IPs. Focus groups, interviews, and a policy dialogue with key stakeholders were held to validate and discuss findings.

RESULTS

OOP payments account for 45% of total health expenditures. Sixteen percent of outpatients and 30% of inpatients reporting that they made OOP payments when seeking care at a health facility in 2012, more than two-thirds of whom also reported paying for medicines at a pharmacy. Among those who paid anything, 36% of outpatients and 82% of inpatients reported paying informally, with the proportion increasing over time for inpatient care. Although many patients consider these payments to be gifts, around one-third of IPs appear to be forced, posing a threat to health care access. Patients perceive that payments are driven by the limited list of reimbursable medicines, a desire to receive better treatment, and fear or extortion. Providers suggested irrational prescribing and ordering of tests as drivers. Providers may believe that IPs are gifts and do not cause harm for patients and the health system in general.

CONCLUSIONS

Efforts to expand financial protection should focus on reducing household spending on medicines and hospital-based IPs. Reforms should consider ways to reduce medicine prices and promote rational use, strengthen administrative controls, and increase incentives for quality health care provision.

Assessing catastrophic and impoverishing effects of health care payments in Uganda

BACKGROUND

Direct out-of-pocket payments for health care are recognised as limiting access to health care services and also endangering the welfare of households. In Uganda, such payments comprise a large portion of total health financing. This study assesses the catastrophic and impoverishing impact of paying for health care out-of-pocket in Uganda.

METHODS

Using data from the Uganda National Household Surveys 2009/10, the catastrophic impact of out-of-pocket health care payments is defined using thresholds that vary with household income. The impoverishing effect of out-of-pocket health care payments is assessed using the Ugandan national poverty line and the World Bank poverty line ($1.25/day).

RESULTS

A high level and intensity of both financial catastrophe and impoverishment due to out-of-pocket payments are recorded. Using an initial threshold of 10% of household income, about 23% of Ugandan households face financial ruin. Based on both the $1.25/day and the Ugandan poverty lines, about 4% of the population are further impoverished by such payments. This represents a relative increase in poverty head count of 17.1% and 18.1% respectively.

CONCLUSION

The absence of financial protection in Uganda's health system calls for concerted action. Currently, out-of-pocket payments account for a large share of total health financing and there is no pooled prepayment system available. There is therefore a need to move towards mandatory prepayment. In this way, people could access the needed health services without any associated financial consequence.

Forgone care and financial burden due to out-of-pocket payments within the German health care system

BACKGROUND

The amount of out-of-pocket (OOP) payments within the German health care system has risen steadily within the last years. OOP payments aim to strengthen patients' cost awareness and try to restrict the demand on medical necessary treatments. However, besides the intended decline of non-induced health care services there's a risk that people also forgo necessary treatments because the utilization of health care services depends not only on need-factors but also on the ability to pay for it. Therefore, this paper aims to analyze the determinants of the total amount of OOP payments, the financial burden caused by OOP payments and the relinquishment of health care services due to OOP payments.

DATA AND METHODS

The empirical analysis is based on cross-sectional data of the German subsample (n = 2851) of the Survey of Health, Ageing and Retirement in Europe (SHARE). SHARE is a representative panel study among private households with persons above the age of 50 years and covers a wide range of topics, e.g. health behavior, health status and information about the socio-economic status. The analysis of the independent variables "total amount of OOP payments", "financial burden due to OOP payments" and "forgone care" is carried out by the means of descriptive as well as multivariate regression methods.

RESULTS

Individuals with low income as well as people suffering from chronic illnesses face a higher financial burden and forgo health care services more frequently at the same time. E.g. the financial burden of people who belong to the lowest income quintile is about eight times higher compared to individuals who belong to the highest quintile. The probability of forgone care for this group is about 5.6 percentage points higher [95% CI: 5.2 - 6.0].

CONCLUSION

Especially for the group of people with chronic illnesses and low-income earners it cannot be ruled out that they also forgo necessary medical treatments due to the relatively high financial burden they face. Hence, it is required to facilitate the access to necessary care for these groups.

Inputs for universal health coverage: a methodological contribution to finding proxy indicators for financial hardship due to health expenditure

BACKGROUND

Universal health coverage is high on national health agendas of many countries at the moment. Absence of financial hardship is a key component of universal health coverage and should be monitored regularly. However, relevant household survey data, which is traditionally needed for this analysis is not frequently collected in most countries and in some countries, has not been collected at all. As such, proxy indicators for financial hardship would be very useful.

METHODS

We use data from the World Health Survey and use multi-level modeling with national and household level characteristics to see which indicators have a consistent and robust relationship with financial hardship. To strengthen the validity of our findings, we also use different measures of financial hardship.

RESULTS

There are several household level characteristics that seem to have a consistent relationship with financial hardship. However there is only one strong candidate for a proxy indicator at the national level- the share of out-of-pocket payments in total health expenditure. Additionally, the Gini coefficient of total household expenditure was also correlated to financial hardship in most of our models.

CONCLUSION

The national level indicators related only weakly to the risk of financial hardship. Hence, there should not be an over-reliance on them and collecting good quality household survey data is still a superior option for monitoring financial hardship.