Determinants of tuberculosis: an example of high tuberculosis burden in the Saharia tribe

Tuberculosis (TB) is a significant public health problem among the Saharia community, an underprivileged tribal group in the west-central part of India. There are several challenges for India's TB control program to curtail TB in the Saharia tribe. Malnutrition, poor health sector facilities, lower socio-economic status, and substance abuse are interconnected and synergistic factors contributing to a high burden of TB in the Saharia tribe. In this review, efforts are made to collate the findings of previous studies discussing the causes of high burden of TB in the Saharia tribe, social gaps for mitigating these preventable risk factors of TB in the Saharia tribe, and the plausible solutions for closing these gaps. The concept of Health in All Policies and intersectoral co-ordination is needed for the reduction of TB in the Saharia tribe and to make India TB-free by the year 2025.

Trends of Private Drugs' Sales and Costs Incurred by Patients on Anti-tuberculosis Drugs in Selected Districts of Jharkhand (2022): Results From Sub-national TB-Free Certification

BACKGROUND

The government of India is committed to eliminating tuberculosis (TB) by 2025 under the National Tuberculosis Elimination Programme which provides free investigations and treatment as well as incentives for nutritional support during their treatment course. Many TB patients prefer to seek treatment from the private sector which sometimes leads to financial constraints for the patients. Our study aims to find the burden of TB patients in the private sector and the expenses borne by them for their treatment.

METHODOLOGY

Sales data of rifampicin-containing formulation drug consumption in the private sector of six districts of Jharkhand was collected from Clearing and Forwarding agencies. Based on the drug sales data, the total incurring costs of the drugs, total number of patients, and cost per patient seeking treatment from the private sector were calculated for the year 2015-2021. ANOVA and the post hoc test (Tukey honestly significant difference (HSD)) were applied for analysis.

RESULTS

 There was a marked difference amongst all the districts in relation to all the variables namely total costs, cost per patient, and total private patients seeking treatment from the private sector which was statistically significant (p < 0.001). East Singhbhum had the highest out-of-pocket expense and private patients as compared to all six districts. Lohardaga showed the sharpest decline in total private patients from 2015 to 2021. The average cost borne by private patients in 2015 was INR 1821 (95% CI 1086 - 2556) which decreased to INR 1033 (95% CI 507 - 1559) in 2021.

CONCLUSION

From the study, it was concluded that the purchase of medicines for TB treatment from the private sector is one of the essential elements in out-of-pocket expenditure (OOPE) borne by TB patients. Hence, newer initiatives should be explored to foresee the future OOPE borne by the patients and decrease OOPE-induced poverty.

Billing the Insured: An Assessment of Out-of-Pocket Payment by Insured Patients in Ghana

Background

The Ghana National Health Insurance Scheme was introduced in 2003 to provide financial protection to the population. While the Scheme has made strides in improving access to healthcare there have been a few challenges including out of pocket charges to insured patients with weak client power. The study investigated the catastrophic nature of the out-of-pocket charges, the factors affecting the charges and the client power.

Methodology

We used primary data collected in 3 administrative regions: Greater Accra, Ashanti and the Northern regions, within the period April and June 2022 to compute catastrophic expenditure of the out-of-pocket healthcare expenditure on household expenditure on food and non-food. In addition, multivariate logistic regressions and a linear regression were run to examine the incidence of the practice and client power.

Results

The results showed that on average the insured paid out-of-pocket charges with a probability of 66%. The probability was highest (80%) in the Greater Accra, followed by Ashanti region (66.6%) and (52.9%) in the Northern region. The out-of-pocket charges were found to be catastrophic with incidence rate between 48.2% and 26.1% for the 5% and 20% thresholds; the overshoots ranged between 34.1% and 26.9% for the thresholds; the poor were more disadvantaged than the rich. Patients reported the out-of-pocket charges to the NHIA with probability of 1.9%, but the NHIA did not respond to 81% of the reported cases. Knowledge of the benefit list is likely to motivate the insured to report out-of-pocket charges, while cordial relationship between the NHIA staff and the insured deters providers from charging out-of-pocket.

Conclusion

The out-of-pocket charges occur extensively across health facilities and is impoverishing. A close collaboration between the NHIA and the insured is needed to reduce the incidence and hold providers accountable.

Out-of-pocket expenditures and catastrophic expenditures on inpatient care among households of an urban village in Delhi

Background

Out-of-pocket expenditure (OOPE) for inpatient care has been known to cause maximum impoverishment. It can have debilitating consequences for urban poor households. It is necessary to study inpatient care costs and the related factors among the households of an urban village to determine their vulnerability to catastrophic expenditure and to protect them from it.

Objective

The study aimed to calculate the mean OOPE on inpatient care, and catastrophic health expenditure among households of an urban village in Delhi.

Design

This was a cross-sectional study conducted over 18 months among urban village households of Delhi who have been residing for the last 1 year.

Methods

A sample size of 188 was calculated based on another study, and households were selected using systematic random sampling. A pre-designed, pre-tested, semi-structured, and interviewer-administered questionnaire in Hindi was used to elicit and record relevant information. Data were recorded and coded, and analysis was done using licensed SPSS v.26 software. Tables were generated for relevant data, and cross-tables were used to assess statistical association with chi-square or Fisher exact tests, as required. A p-value of 0.05 was considered statistically significant.

Results

The mean annual OOPE borne by a household on inpatient care was INR 6870.3 (SD ± 30,580.6), where 93.3% of OOPE was incurred while seeking treatment from public facilities. The OOPE on inpatient care had a statistically significant association with households having joint family, members from vulnerable population, and belonging to Delhi.

Conclusion

The households of an urban village of Aliganj, Delhi, have high OOPE on inpatient care (60.6%) and catastrophic health expenditure (75.6%).

Multimorbidity, healthcare use and catastrophic health expenditure by households in India: a cross-section analysis of self-reported morbidity from national sample survey data 2017-18

BACKGROUND

The purpose of this research is to generate new evidence on the economic consequences of multimorbidity on households in terms of out-of-pocket (OOP) expenditures and their implications for catastrophic OOP expenditure.

METHODS

We analyzed Social Consumption Health data from National Sample Survey Organization (NSSO) 75th round conducted in the year 2017-2018 in India. The sample included 1,13,823 households (64,552 rural and 49,271 urban) through a multistage stratified random sampling process. Prevalence of multimorbidity and related OOP expenditure were estimated. Using Coarsened Exact Matching (CEM) we estimated the mean OOP expenditure for individuals reporting multimorbidity and single morbidity for each episode of outpatient visits and hospital admission. We also estimated implications in terms of catastrophic OOP expenditure for households.

RESULTS

Results suggest that outpatient OOP expenditure is invariably lower in the presence of multimorbidity as compared with single conditions of the selected Non-Communicable Diseases(NCDs) (overall, INR 720 [USD 11.3] for multimorbidity vs. INR 880 [USD 14.8] for single). In the case of hospitalization, the OOP expenditures were mostly higher for the same NCD conditions in the presence of multimorbidity as compared with single conditions, except for cancers and cardiovascular diseases. For cancers and cardiovascular, OOP expenditures in the presence of multimorbidity were lower by 39% and 14% respectively). Furthermore, around 46.7% (46.674-46.676) households reported incurring catastrophic spending (10% threshold) because of any NCD in the standalone disease scenario which rose to 63.3% (63.359-63.361) under the multimorbidity scenario. The catastrophic implications of cancer among individual diseases was the highest.

CONCLUSIONS

Multimorbidity leads to high and catastrophic OOP payments by households and treatment of high expenditure diseases like cancers and cardiovascular are under-financed by households in the presence of competing multimorbidity conditions. Multimorbidity should be considered as an integrated treatment strategy under the existing financial risk protection measures (Ayushman Bharat) to reduce the burden of household OOP expenditure at the country level.

Catastrophic expenditure rates and barriers for treatment adherence in patients with colorectal cancer in India: The CROCODILE study protocol

AIM

Little is known about the delivery of colorectal cancer treatment in India and its associated costs. The aim of this study is to identify financial and nonfinancial barriers to adherence to colorectal cancer treatment in India.

METHOD

CROCODILE is a mixed-methods study with a quantitative and a qualitative workstream. The quantitative workstream will be a prospective cohort study to assess treatment adherence and catastrophic expenditure rates among patients with colorectal cancer in India. Consecutive newly diagnosed patients with histopathologically proven colorectal cancer from five tertiary hospitals in India will be included. Catastrophic expenditure will be defined as a treatment cost higher than 40% of nonsubsistence annual household income. Treatment costs will include medical, nonmedical and indirect expenses. Income assessment will be compared between three methods: patient-reported income, the International Wealth Index and the Gapminder tool. The qualitative workstream will explore the views and experiences of colorectal cancer patients and professionals about barriers to and facilitators for treatment adherence. Individual semistructured interviews with three to five patients and cancer care professionals in each centre will be performed. An analytical framework will be developed to perform the analysis, through a combined approach (deductive and inductive). The results will be triangulated with the quantitative workstream for mutual knowledge enrichment.

CONCLUSION

The CROCODILE study will identify barriers to and facilitators for colorectal cancer delivery in India, influencing research and policy decisions. It will explore the feasibility of collecting data on patient-level costs and income to inform future economic evaluations in cancer and surgical care.

Economic burden associated with stroke in India: insights from national sample survey 2017-18

Objective: To estimate the out-of-pocket (OOP) expenditure and catastrophic expenditure due to stroke-related hospitalization and determine associated predictors.Methods: Secondary analysis of household-based survey conducted by National Sample Survey Organization from June 2017 to 2018.Results: A total of 1152 and 407 individuals reported stroke-related hospitalization and outpatient care, respectively, in the survey. Stroke-related hospitalization rate in India is 46 per 100,000 persons. The mean and median expenditure per episode of stroke-related hospitalization was INR 40,360 (US$ 539.75) and INR 17,140 (US$ 229.22), respectively, with significant OOP hospitalization expenditure across wealth quintiles (p < 0.001). About 29% (25-34%) of households seeking stroke treatment in public medical institutions experienced catastrophic expenditure. 37% (34-40%) of households resorted to distress health financing due to stroke-related hospitalization. Medicines accounted on an average 38% and 73% of public sector hospitalization and outpatient care, respectively. Patients treated in a private facility, hospitalized for over 7 days, within the poorest wealth quintiles had higher odds of incurring catastrophic expenditure.Conclusion: Economic burden associated with stroke-related hospitalization is substantial in India. The publicly funded health insurance scheme should cover expenses on stroke-related medicines to reduce OOP expenditure of patients seeking treatment in public sector facilities.

The Out-of-Pocket Cost Burden of Cancer Care-A Systematic Literature Review

BACKGROUND

Out-of-pocket costs pose a substantial economic burden to cancer patients and their families. The purpose of this study was to evaluate the literature on out-of-pocket costs of cancer care.

METHODS

A systematic literature review was conducted to identify studies that estimated the out-of-pocket cost burden faced by cancer patients and their caregivers. The average monthly out-of-pocket costs per patient were reported/estimated and converted to 2018 USD. Costs were reported as medical and non-medical costs and were reported across countries or country income levels by cancer site, where possible, and category. The out-of-pocket burden was estimated as the average proportion of income spent as non-reimbursable costs.

RESULTS

Among all cancers, adult patients and caregivers in the U.S. spent between USD 180 and USD 2600 per month, compared to USD 15-400 in Canada, USD 4-609 in Western Europe, and USD 58-438 in Australia. Patients with breast or colorectal cancer spent around USD 200 per month, while pediatric cancer patients spent USD 800. Patients spent USD 288 per month on cancer medications in the U.S. and USD 40 in other high-income countries (HICs). The average costs for medical consultations and in-hospital care were estimated between USD 40-71 in HICs. Cancer patients and caregivers spent 42% and 16% of their annual income on out-of-pocket expenses in low- and middle-income countries and HICs, respectively.

CONCLUSIONS

We found evidence that cancer is associated with high out-of-pocket costs. Healthcare systems have an opportunity to improve the coverage of medical and non-medical costs for cancer patients to help alleviate this burden and ensure equitable access to care.

Rising Catastrophic Expenditure on Households Due to Tuberculosis: Is India Moving Away From the END-TB Goal?

Introduction: One of the targets of the END-TB strategy is to ensure zero catastrophic expenditure on households due to TB. The information about household catastrophic expenditure is limited in India and, therefore difficult to monitor. The objective is to estimate household and catastrophic expenditure for Tuberculosis using national sample survey data. Methods: For arriving at out-of-pocket expenditure due to tuberculosis and its impact on households the study analyzed four rounds of National Sample Survey data (52nd round-1995-1996, 60th round-2004-2005, 71st round-2014-15, and 75th round 2017-2018). The household interview survey data had a recall period of 365 days for inpatient/ hospitalization and 15 days for out-patient care expenditure. Expenditure amounting to >20% of annual household consumption expenditure was termed as catastrophic. Results: A 5-fold increase in median outpatient care cost in 75th round is observed compared to previous rounds and increase has been maximum while accessing public sector. The overall expense ratio of public v/s private is 1:3, 1:4, 1:5, and 1:5, respectively across four rounds for hospitalization. The prevalence of catastrophic expenditure due to hospitalization increased from 16.5% (52nd round) to 43% (71st round), followed by a decline to 18% in the recent 75th round. Conclusion: Despite free diagnostic and treatment services offered under the national program, households are exposed to catastrophic financial expenditure due to tuberculosis. We strongly advocate for risk protection mechanisms such as cash transfer or health insurance schemes targeting the patients of tuberculosis, especially among the poor.

Changes in Catastrophic Health Expenditures Depending on Health Policies in Turkey

Without any financial protection out of pocket health expenses are essential both because their increase causes difficulties in accessing higher quality health services for households and more importantly because it complicates access to most basic health services. As a result of the Health Transformation Program in practice in the Turkish healthcare system since 2003, significant changes have been done in all layers of the health system. Turkish Statistics Institute (TurkStat) publishes the ratio of households that bear catastrophic health expenditures since 2002. According to TurkStat data, the ratio of households with catastrophic expenditure has fallen from 0.81% in 2002 to 0.17% in 2011 with the health transformation project. However, it has started to rise since 2012 and has reached 0.31% in 2014. This study aims to evaluate the expenditure items that may have caused the rise of the ratio of households with catastrophic health expenditures since 2012, which had previously dropped with the Health Transformation Program that has caused fundamental changes in health policies. Methodology and definitions presented in the article named “Distribution of health payments and catastrophic expenditures: Methodology” by Ke Xu published by the World Health Organization in 2005 have been used. Percentages of health expenditure items among the total expenditure of households with positive health expenditure and households with catastrophic health expenditure between 2007 and 2014 have been evaluated using descriptive analysis. Findings have been interpreted in light of the health policies in practice between 2007 and 2014. An overview of the impact of the health policies reveals that medicine expenditures have decreased both for household and public health expenditures. Despite the impact of policies on the pharmaceutical industry was criticized by the industry, the positive impact can be seen by the decrease in the spending on medicine for households spending on health. Hospital service with positive health expenditure is seen to decrease health expenditure. The reasons for the increase in households with catastrophic health expenditure need further research. As a result, the study strives to discuss the possible policy reasons for the observed effects.

'I am on treatment since 5 months but I have not received any money': coverage, delays and implementation challenges of 'Direct Benefit Transfer' for tuberculosis patients - a mixed-methods study from South India

Background: In March 2018, the Government of India launched a direct benefit transfer (DBT) scheme to provide nutritional support for all tuberculosis (TB) patients in line with END TB strategy. Here, the money (@INR 500 [~8 USD] per month) is deposited electronically into the bank accounts of beneficiaries. To avail the benefit, patients are to be notified in NIKSHAY (web-based notification portal of India’s national TB programme) and provide bank account details. Once these details are entered into NIKSHAY, checked and approved by the TB programme officials, it is sent to the public financial management system (PFMS) portal for further processing and payment.

Objectives: To assess the coverage and implementation barriers of DBT among TB patients notified during April–June 2018 and residing in Dakshina Kannada, a district in South India.

Methods: This was a convergent mixed-methods study involving cohort analysis of patient data from NIKSHAY and thematic analysis of in-depth interviews of providers and patients.

Results: Of 417 patients, 208 (49.9%) received approvals for payment by PFMS and 119 (28.7%) got paid by 1 December 2018 (censor date). Reasons for not receiving DBT included (i) not having a bank account especially among migrant labourers in urban areas, (ii) refusal to avail DBT by rich patients and those with confidentiality concerns, (iii) lack of knowledge and (iv) perception that money was too little to meet the needs. The median (IQR) delay from diagnosis to payment was 101 (67–173) days. Delays were related to the complexity of processes requiring multiple layers of approval and paper-based documentation which overburdened the staff, bulk processing once-a-month and technological challenges (poor connectivity and issues related to NIKSHAY and PFMS portals).

Conclusion: DBT coverage was low and there were substantial delays. Implementation barriers need to be addressed urgently to improve uptake and efficiency. The TB programme has begun to take action.

Impoverishment and catastrophic expenditures due to out-of-pocket payments for antenatal and delivery care in Yangon Region, Myanmar: a cross-sectional study

OBJECTIVES

(1) To assess the levels of impoverishment and catastrophic expenditure due to out-of-pocket (OOP) payments for antenatal care (ANC) and delivery care in Yangon Region, Myanmar; and (2) to explore the determinants of impoverishment and catastrophic expenditure.

DESIGN, SETTING AND PARTICIPANTS

A community-based cross-sectional survey among women giving birth within the past 12 months in Yangon, Myanmar, was conducted during October to November 2016 using three-stage cluster sampling procedure.

OUTCOME MEASURES

Poverty headcount ratio, normalised poverty gap and catastrophic expenditure incidence due to OOP payments in the utilisation of ANC and delivery care as well as the determinants of impoverishment and catastrophic expenditure.

RESULTS

Of 759 women, OOP payments were made by 75% of the women for ANC and 99.6% for delivery care. The poverty headcount ratios after payments increased to 4.3% among women using the ANC services, to 1.3% among those using delivery care and to 6.1% among those using both ANC and delivery care. The incidences of catastrophic expenditure after payments were found to be 12% for ANC, 9.1% for delivery care and 20.9% for both ANC and delivery care. The determinants of impoverishment and catastrophic expenditure were women's occupation, number of household members, number of ANC visits and utilisation of skilled health personnel and health facilities. The associations of the outcomes with these variables bear both negative and positive signs.

CONCLUSIONS

OOP payments for all ANC and delivery care services are a challenge to women, as one of fifteen women become impoverished and a further one-fifth incur catastrophic expenditures after visiting facilities that offer these services.

Cost of hemodialysis in a public sector tertiary hospital of India

INTRODUCTION

Nearly 220000 patients are diagnosed with end-stage renal disease (ESRD) every year, which calls for an additional demand of 34 million dialysis sessions in India. The government of India has announced a National Dialysis Programme to provide for free dialysis in public hospitals. In this article we estimate the overall cost of performing hemodialysis (HD) in a tertiary care hospital. Second, we assess the catastrophic impact of out-of-pocket expenditures (OOPEs) for HD on households and its determinants.

METHODS

The economic health system cost of HD was estimated using bottom-up costing methods. All resources, capital and recurrent, utilized for service delivery from April 2015 to March 2016 were identified, measured and valued. Capital costs were annualized after accounting for their useful life and discounting at 3% for future years. Sensitivity analyses were undertaken to determine the effect of variation in the input prices and other assumptions on the annual health system cost. OOPEs were assessed by interviewing 108 patients undergoing HD in the study hospital to account for costs from the patient's perspective. The prevalence of catastrophic health expenditures (CHEs) was computed per threshold of 40% of non-food expenditures.

RESULTS

The overall average cost incurred by the health system per HD session was INR 4148 (US$64). Adjusting for capacity utilization, the health system incurred INR 3025 (US$47) per HD at 100% bed occupancy. The mean OOPE per patient per session was INR 2838 (US$44; 95% confidence interval US$34-55). The major components of this OOPE were medicines and consumables (64.1%). The prevalence of a CHE per HD session was 11.1%.

CONCLUSION

Our study findings would be useful in the context of planning for dialysis services, setting provider payment rates for dialysis under various publicly sponsored health insurance schemes and undertaking future cost-effectiveness analysis to guide resource allocation decisions.

Cost of injury care in India: cross-sectional analysis of National Sample Survey 2014

BACKGROUND

Injuries account for nearly 10% of total deaths in India and this burden is likely to rise. We aimed to estimate the out-of-pocket (OOP) expenditure and catastrophic expenditure due to hospitalisation or outpatient care as a result of any injury and factors associated with incurring catastrophic expenditure.

METHODS

Secondary analysis of nationally representative data for India collected by National Sample Survey Organization in 2014, reporting on health service utilisation and healthcare-related OOP expenditure by income quintiles and by type of health facility (public or private).

RESULTS

The median expenditure per episode of hospitalisation due to any injury was US$156, and it was three times higher among the richest quintile compared with the poorest quintile (p<0.001). There was a significantly higher prevalence (p<0.001) of catastrophic expenditure among the poorest quintile (32%) compared with the richest (21%). Mean private sector OOP hospitalisation expenditure was five times higher than in the public sector (p<0.001). Medicines accounted for 37% and 58% of public sector hospitalisation and outpatient care, respectively. Patients treated in a private facility, hospitalised for over 7 days, in the poorest wealth quintiles and of general caste had higher odds of incurring catastrophic expenditure.

CONCLUSION

People who sustain an injury have a high risk of catastrophic household expenditure, particularly for those in lowest income quartiles. There is a clear need for publicly funded risk protection mechanisms targeting the poor. Promotion of generic medicines and subsidisation for the poorest wealth quintile may also reduce OOP expenditure in public sector facilities.

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.

A cost analysis of road traffic injuries in a tertiary hospital in south-west Nigeria

This study examines the burden of road traffic injuries (RTIs) among road crash victims in a tertiary hospital in Ibadan, Nigeria. The study adopted a purposive sampling method to obtain primary data. Interview was done with 266 RTI victims who were admitted to the University College Hospital, Ibadan and discharged between March and May, 2015, using a structured questionnaire. From the data obtained, the study carried out descriptive statistical analyses. The results showed that the average cost per patient for RTI treatment was ₦ 42,946 ($215.9); on average, the amount expended on surgery was the highest followed by wound dressing and drugs; and the prevalence of catastrophic out-of-pocket (OOP) expenditure was over 86%. It is recommended that given the high burden of OOP hospital expenditure associated with RTI, there is need to implement more effective financial protection mechanisms against the high OOP expenditure faced by crash victims.

Rotavirus vaccines contribute towards universal health coverage in a mixed public-private healthcare system

OBJECTIVES

To evaluate rotavirus vaccination in Malaysia from the household's perspective. The extended cost-effectiveness analysis (ECEA) framework quantifies the broader value of universal vaccination starting with non-health benefits such as financial risk protection and equity. These dimensions better enable decision-makers to evaluate policy on the public finance of health programmes.

METHODS

The incidence, health service utilisation and household expenditure related to rotavirus gastroenteritis according to national income quintiles were obtained from local data sources. Multiple birth cohorts were distributed into income quintiles and followed from birth over the first five years of life in a multicohort, static model.

RESULTS

We found that the rich pay more out of pocket (OOP) than the poor, as the rich use more expensive private care. OOP payments among the poorest although small are high as a proportion of household income. Rotavirus vaccination results in substantial reduction in rotavirus episodes and expenditure and provides financial risk protection to all income groups. Poverty reduction benefits are concentrated amongst the poorest two income quintiles.

CONCLUSION

We propose that universal vaccination complements health financing reforms in strengthening Universal Health Coverage (UHC). ECEA provides an important tool to understand the implications of vaccination for UHC, beyond traditional considerations of economic efficiency.

Economic Burden of Hospitalization Due to Injuries in North India: A Cohort Study

There is little documentation of the potential catastrophic effects of injuries on families due to out of pocket (OOP) expenditure for medical care. Patients who were admitted for at least one night in a tertiary care hospital of Chandigarh city due to injury were recruited and were followed-up at 1, 2 and 12 months after discharge to collect information on OOP expenditure. Out of the total 227 patients, 60% (137/227) had sustained road traffic injuries (RTI). The average OOP expenditure per hospitalisation and up to 12 months post discharge was USD 388 (95% CI: 332–441) and USD 1046 (95% CI: 871–1221) respectively. Mean OOP expenditure for RTI and non-RTI cases during hospitalisation was USD 400 (95% CI: 344–456) and USD 369 (95% CI: 313–425) respectively. The prevalence of catastrophic expenditure was 30%, and was significantly higher among those belonging to the lowest income quartile (OR-26.50, 95% CI: 6.70–105.07, p-value: <0.01) and with an inpatient stay greater than 7 days (OR-10.60, 95% CI: 4.21–26.64, p-value: <0.01). High OOP expenditure for treatment of injury puts a significant economic burden on families. Measures aimed at increasing public health spending for prevention of injury and providing financial risk protection are urgently required in India.

Cost of hospitalisation for non-communicable diseases in India: are we pro-poor?

OBJECTIVES

To estimate out-of-pocket (OOP) expenditure due to hospitalisation from NCDs and its impact on households in India.

METHODS

The study analysed nationwide representative data collected by the National Sample Survey Organisation in 2014 that reported health service utilisation and healthcare-related OOP expenditure by income quintiles and by type of health facility (public or private). The recall period for inpatient hospitalisation expenditure was 365 days. Consumption expenditure was collected for a recall period of 1 month. OOP expenditure amounting to >10% of annual consumption expenditure was termed as catastrophic. Weighted analysis was performed.

RESULTS

The median expenditure per episode of hospitalisation due to NCDs was USD 149 - this was ~3 times higher among the richest quintile compared to poorest quintile. There was a significantly higher prevalence of catastrophic expenditure among the poorest quintile, more so for cancers (85%), psychiatric and neurological disorders (63%) and injuries (63%). Mean private-sector OOP hospitalisation expenditure was nearly five times higher than that in the public sector. Medicines accounted for 40% and 27% of public- and private-sector OOP hospitalisation expenditure, respectively.

CONCLUSION

Strengthening of public health facilities is required at community level for the prevention, control and management of NCDs. Promotion of generic medicines, better availability of essential drugs and possible subsidisation for the poorest quintile will be measures to consider to reduce OOP expenditure in public-sector facilities.

The Effects of Intellectual Property Rights on Access to Medicines and Catastrophic Expenditure

Since the introduction of Trade-Related Aspects of Intellectual Property Rights (TRIPS) in 1995, there has been considerable concern that poor access to essential medicines in developing countries would be exacerbated because strengthening intellectual property rights (IPR) leads to monopoly of pharmaceutical markets and delayed entry of lower-cost generic drugs. However, despite extensive research and disputes regarding this issue, there are few empirical studies on the topic. In this study, we investigated the effect of IPR on access to medicines and catastrophic expenditure for medicines, using data from World Health Surveys 2002-2003. The index of patent rights developed by Ginarte and Park (1997) was used to measure the IPR protection level of each country. Estimates were adjusted for individual and country characteristics. In the results of multilevel logistic regression analyses, higher level of IPR significantly increased the likelihood of nonaccess to prescribed medicines even after controlling for individual socioeconomic status and national characteristics associated with access to medicines. This study's finding on the negative impact of IPR on access to medicines calls for the implementation of more active policy at the supra-national level to improve access in low- and middle-income countries.

The Impact of Community Based Health Insurance in Enhancing Better Accessibility and Lowering the Chance of Having Financial Catastrophe Due to Health Service Utilization: A Case Study of Savannakhet Province, Laos

The Lao population mostly relies on out-of-pocket expenditures for health care services. This study aims to determine the role of community-based health insurance in making health care services accessible and in preventing financial catastrophe resulting from personal payment for inpatient services. A cross-sectional study design was applied. Data collection involved 126 insured and 126 uninsured households in identical study sites. Two logistic regression models were used to predict and compare the probability of hospitalization and financial catastrophe that occurred in both insured and uninsured households within the previous year. The findings show that insurance status does not significantly improve accessibility and financial protection against catastrophic expenditure. The reason is relatively simple, as catastrophic health expenditure refers to a total out-of-pocket payment equal to or more than 40% of household income minus subsistence. When household income declines as a result of inability to work due to illness, the 40% threshold is quickly reached. Despite this, results suggest that insured households are not significantly better off under community-based health insurance. However, compared to uninsured households, insured households do have better accessibility and a lower probability of reaching the financial catastrophe threshold.

Promoting universal financial protection: health insurance for the poor in Georgia--a case study

BACKGROUND

The present study focuses on the program "Medical Insurance for the Poor (MIP)" in Georgia. Under this program, the government purchased coverage from private insurance companies for vulnerable households identified through a means testing system, targeting up to 23% of the total population. The benefit package included outpatient and inpatient services with no co-payments, but had only limited outpatient drug benefits. This paper presents the results of the study on the impact of MIP on access to health services and financial protection of the MIP-targeted and general population.

METHODS

With a holistic case study design, the study employed a range of quantitative and qualitative methods. The methods included document review and secondary analysis of the data obtained through the nationwide household health expenditure and utilisation surveys 2007-2010 using the difference-in-differences method.

RESULTS

The study findings showed that MIP had a positive impact in terms of reduced expenditure for inpatient services and total household health care costs, and there was a higher probability of receiving free outpatient benefits among the MIP-insured. However, MIP insurance had almost no effect on health services utilisation and the households' expenditure on outpatient drugs, including for those with MIP insurance, due to limited drug benefits in the package and a low claims ratio. In summary, the extended MIP coverage and increased financial access provided by the program, most likely due to the exclusion of outpatient drug coverage from the benefit package and possibly due to improper utilisation management by private insurance companies, were not able to reverse adverse effects of economic slow-down and escalating health expenditure. MIP has only cushioned the negative impact for the poorest by decreasing the poor/rich gradient in the rates of catastrophic health expenditure.

CONCLUSIONS

The recent governmental decision on major expansion of MIP coverage and inclusion of additional drug benefit will most likely significantly enhance the overall MIP impact and its potential as a viable policy instrument for achieving universal coverage. The Georgian experience presented in this paper may be useful for other low- and middle-income countries that are contemplating ways to ensure universal coverage for their populations.