Does Community-Based Health Insurance Protect Women from Financial Catastrophe After Cesarean Section? A Prospective Study from a Rural Hospital in Rwanda

BackgroundThe implementation of community-based health insurance in (CBHI) in Rwanda has reduced out of pocket (OOP) spending for the >79% of citizens who enroll in it but the effect for surgical patients is not well described. For all but the poorest citizens who are completely subsidized, the OOP (out of pocket) payment at time of service is 10%. However, 55.5% of the population is below the international poverty line meaning that even this copay can have a significant impact on a family’s financial health. The aim of this study was to estimate the burden of OOP payments for cesarean sections in the context of CBHI and determine if having it reduces catastrophic health expenditure (CHE). MethodsThis study is nested in a larger randomized controlled trial of women undergoing cesarean section at a district hospital in Rwanda. Eligible patients were surveyed at discharge to quantify household income and routine monthly expenditures and direct and indirect spending related to the hospitalization. This was used in conjunction with hospital billing records to calculate the rate of catastrophic expenditure by insurance group. ResultsAbout 94% of the 340 women met the World Bank definition of extreme poverty. Of the 330 (97.1%) with any type of health insurance, the majority (n=310, 91.2%) have CBHI. The average OOP expenditure for a cesarean section and hospitalization was $9.36. The average cost adding transportation to the hospital was $19.29. 164 (48.2%) had to borrow money and 43 (12.7%) had to sell possessions. The hospital bill alone was a CHE for 5.3% of patients. However, when including transportation costs, 15.4% incurred a CHE and including lost wages, 22.6%. ConclusionTo ensure universal health coverage (UHC), essential surgical care must be affordable. Despite enrollment in universal health insurance, cesarean section still impoverishes households in rural Rwanda, the majority of whom already lie below the poverty line. Although CBHI protects against CHE from the cost of healthcare, when adding in the cost of transportation, lost wages and caregivers, cesarean section is still often a catastrophic financial event. Further innovation in financial risk protection is needed to provide equitable UHC.

Changing The Discourse in Ambitions Towards Universal Health Coverage: Lessons From Australian Primary Healthcare; Comment on "Universal Health Coverage for Non-Communicable Diseases and Health Equity: Lessons From Australian Primary Healthcare"

While Australia’s health system has reached universal health coverage (UHC), recent scholarship points to its strengths and identifies ways it could be more effective and equitable, especially for tackling non-communicable diseases (NCDs). Building on the Australian experience, we add to these perspectives and present pertinent lessons for the quest towards UHC, and for policy makers globally with regard to NCDs. Potential lessons include: the need for i) vigilance – UHC requires ongoing monitoring and evaluation of not only financial risk protection but non-financial barriers and impacts such as forgone care; ii) investment and action now on structural determinants of NCDs and related inequalities to avoid potentially higher (fiscal, social and health) costs in the longer term; and iii) the opportunity for policy makers globally and nationally to revisit their ambitions for UHC to include population health policies/programs beyond essential health services that are required for healthier, more equitable and thriving societies.

Impact of public-funded health insurances in India on health care utilisation and financial risk protection: a systematic review

ObjectiveUniversal Health Coverage aims to address the challenges posed by healthcare inequalities and inequities by increasing the accessibility and affordability of healthcare for the entire population. This review provides information related to impact of public-funded health insurance (PFHI) on financial risk protection and utilisation of healthcare.DesignSystematic review.Data sourcesMedline (via PubMed, Web of Science), Scopus, Social Science Research Network and 3ie impact evaluation repository were searched from their inception until 15 July 2020, for English-language publications.Eligibility criteriaStudies giving information about the different PFHI in India, irrespective of population groups (above 18 years), were included. Cross-sectional studies with comparison, impact evaluations, difference-in-difference design based on before and after implementation of the scheme, pre–post, experimental trials and quasi-randomised trials were eligible for inclusion.Data extraction and synthesisData extraction was performed by three reviewers independently. Due to heterogeneity in population and study design, statistical pooling was not possible; therefore, narrative synthesis was performed.OutcomesUtilisation of healthcare, willingness-to-pay (WTP), out-of-pocket expenditure (including outpatient and inpatient), catastrophic health expenditure and impoverishment.ResultsThe impact of PFHI on financial risk protection reports no conclusive evidence to suggest that the schemes had any impact on financial protection. The impact of PFHIs such as Rashtriya Swasthy Bima Yojana, Vajpayee Arogyashree and Pradhan Mantri Jan Arogya Yojana showed increased access and utilisation of healthcare services. There is a lack of evidence to conclude on WTP an additional amount to the existing monthly financial contribution.ConclusionDifferent central and state PFHIs increased the utilisation of healthcare services by the beneficiaries, but there was no conclusive evidence for reduction in financial risk protection of the beneficiaries.RegistrationNot registered.

Alleviating the burden of diabetes with Health Equity Funds: Economic evaluation of the health and financial risk protection benefits in Cambodia

In Cambodia, diabetes caused nearly 3% of the country’s mortality in 2016 and became the fourth highest cause of disability in 2017. Providing sufficient financial risk protection from health care expenditures may be part of the solution towards effectively tackling the diabetes burden and motivating individuals to appropriately seek care to effectively manage their condition. In this study, we aim to estimate the distributional health and financial impacts of strategies providing financial coverage for diabetes services through the Health Equity Funds (HEF) in Cambodia. The trajectory of diabetes was represented using a Markov model to estimate the societal costs, health impacts, and individual out-of-pocket expenditures associated with six strategies of HEF coverage over a time horizon of 45 years. Input parameters for the model were compiled from published literature and publicly available household survey data. Strategies covered different combinations of types of diabetes care costs (i.e., diagnostic services, medications, and management of diabetes-related complications). Health impacts were computed as the number of disability-adjusted life-years (DALYs) averted and financial risk protection was analyzed in terms of cases of catastrophic health expenditure (CHE) averted. Model simulations demonstrated that coverage for medications would be cost-effective, accruing health benefits ($27 per DALY averted) and increases in financial risk protection ($2 per case of CHE averted) for the poorest in Cambodia. Women experienced particular gains in health and financial risk protection. Increasing the number of individuals eligible for financial coverage also improved the value of such investments. For HEF coverage, the government would pay between an estimated $28 and $58 per diabetic patient depending on the extent of coverage and services covered. Efforts to increase the availability of services and capacity of primary care facilities to support diabetes care could have far-reaching impacts on the burden of diabetes and contribute to long-term health system strengthening.

Spatiotemporal variation and socioeconomic factors of financial hardships of out-of-pocket health expenditure in Pakistan

Background: Financial hardships of out-of-pocket health expenditure (OPHE) is a growing concern for health policy makers in many low and middle-income countries. Spatiotemporal variation between Pakistan’s four provinces over 2001-2015 is discussed, which would help comparing existing health services delivery and financial risk protection plans. Aims: In this paper, we estimate financial hardship of OPHE in Pakistan. Methods: We use the data sets of the household integrated economic surveys 2001-02, 2005-06, 2010-11 and 2015-16. We estimate OPHE share in household total and non-subsistence expenditure, catastrophic headcount at the threshold of OPHE ≥ 10% of total expenditure or OPHE ≥ 25% of non-subsistence expenditure. We estimate impoverishment of OPHE using national poverty lines. Finally, we explore socioeconomic factors of financial hardships of OPHE. Results: Over the years, catastrophic headcount and impoverishment of OPHE had decreased at national level (–1.3% points) and in the provinces of Sindh (-7.8% points) and Khyber Pukhtoonkhawa (KPK), (–2.8% points). The province of KPK and the year 2005-06 witnessed the highest incidence of financial catastrophe (26.89% points) and impoverishment (4.8% points) of OPHE. Households in rural areas, in the middle and rich quintiles and those headed by a male were more likely to encounter financial catastrophe and impoverishment due to OPHE. Conclusion: Inter-provincial variation in financial hardships of OPHE provide aide to provincial level priority setting. The high impact of OPHE in the non-poor, in rural areas, and in KPK calls for enhanced targeting of financial risk protection plans.

Perceived effect of financial risk protection by the Urban–Rural Resident Basic Medical Insurance Scheme: a mixed-methods study of rural residents in China

ObjectivesIt is to explore the perceived financial risk protection effect of the Urban–Rural Resident Basic Medical Insurance Scheme (URRBMI) and its influencing factors to provide evidence to further improve the URRBMI.DesignIt is a cross-sectional survey.ParticipantsThis mixed-methods study is conducted in five provinces in rural China. Through stratified cluster random sampling, 1681 rural residents participate in a cross-sectional questionnaire survey (1657 valid questionnaires are retrieved). Thirty rural residents participate in in-depth interviews.Primary and secondary outcome measuresA multivariate logistic regression analysis is adopted to identify factors influencing respondents’ perceptions. Semistructured interviews are used to identify the reasons why some respondents believed the URRBMI to be ineffective.ResultsOverall, 77.5% of respondents believe that the URRBMI is effective. Respondents, who are older, have a higher household income, prefer primary health facilities and provide a higher rating for critical illness compensation and maximum compensatory payouts. They are more likely to give the URRBMI a higher effectiveness rating than their counterparts. Qualitatively, participants who believe the URRBMI to be ineffective list the following reasons: low outpatient service coverage, insufficient or undersupplied drugs and services in the insurance list, problems in the arrangement of deductibles and maximum compensatory payouts, provider-induced behaviour and increased healthcare service price.ConclusionsThis exploration focuses on the reasons why rural residents think the scheme is invalid, which are vital for policy reform. Policies should focus on benefits design and coverage, the assumption of a supervisory role, avoiding financial risk stemming from critical illness and cross-sectoral actions to strengthen the primary healthcare system and comprehensive social security wealth.

Financial Risk Protection for Neurosurgical Care in Indonesia and the Philippines: A Primer on Health Financing for the Global Neurosurgeon

Which conditions treated by neurosurgeons cause the worst economic hardship in low middle-income in countries? How can public health financing be responsive to the inequities in the delivery of neurosurgical care? This review article frames the objectives of equity, quality, and efficiency in health financing to the goals of global neurosurgery. In order to glean provider perspectives on the affordability of neurosurgical care in low-resource settings, we did a survey of neurosurgeons from Indonesia and the Philippines and identified that the care of socioeconomically disadvantaged patients with malignant intracranial tumors were found to incur the highest out-of-pocket expenses. Additionally, the surveyed neurosurgeons also observed that treatment of traumatic brain injury may have to require greater financial subsidies. It is therefore imperative to frame health financing alongside the goals of equity, efficiency, and quality of neurosurgical care for the impoverished. Using principles and perspectives from managerial economics and public health, we conceptualize an implementation framework that addresses both the supply and demand sides of healthcare provision as applied to neurosurgery. For the supply side, strategic purchasing enables a systematic and contractual management of payment arrangements that provide performance-based economic incentives for providers. For the demand side, conditional cash transfers similarly leverages on financial incentives on the part of patients to reward certain health-seeking behaviors that significantly influence clinical outcomes. These health financing strategies are formulated in order to ultimately build neurosurgical capacity in LMICs, improve access to care for patients, and ensure financial risk protection.