Forgone healthcare and financial burden due to out-of-pocket payments in Bangladesh: a multilevel analysis

Background Ensuring access to health services for all is the main goal of universal health coverage (UHC) plan. Out-of-pocket (OOP) payment still remains the main source of funding for healthcare in Bangladesh. The association between barriers to accessing healthcare and over-reliance on OOP payments has not been explored in Bangladesh using nationally representative household survey data. This study is a novel attempt to examine the burden of OOP payment and forgone healthcare in Bangladesh, and further explores the inequalities in catastrophic health expenditures (CHE) and forgone healthcare at the national and sub-national levels. Methods This study used data from the most recent nationally representative cross-sectional survey, Bangladesh Household Income and Expenditure Survey, conducted in 2016–17 (N = 39,124). In order to identify potential determinants of CHE and forgone healthcare, multilevel Poisson regression was used. Inequalities in CHE and forgone healthcare were measured using the slope index of inequality. Results Around 25% of individuals incurred CHE and 14% of the population had forgone healthcare for any reasons. The most common reasons for forgone healthcare were treatment cost (17%), followed by none to accompany or need for permission (5%), and distance to health facility (3%). Multilevel analysis indicated that financial burden and forgone care was higher among households with older populations or chronic illness, and those who utilize either public or private health facilities. Household consumption quintile had a linear negative association with forgone care and positive association with CHE. Conclusion This study calls for incorporation of social safety net in health financing system, increase health facility, and gives priority to the disadvantaged population to ensure access to health services for all.

The Extent of Universal Health Coverage for Maternal Health Services in Eastern Uganda: A Cross Sectional Study

Objective Monitoring essential health services coverage is important to inform resource allocation for the attainment of the Sustainable Development Goal 3. The objective was to assess service, effective and financial coverages of maternal healthcare services and their equity, using health and demographic surveillance site data in eastern Uganda. Methods Between Nov 2018 and Feb 2019, 638 resident women giving birth in 2017 were surveyed. Among them, 386 were randomly sampled in a follow-up survey (Feb 2019) on pregnancy and delivery payments and contents of care. Service coverage (antenatal care visits, skilled birth attendance, institutional delivery and one postnatal visit), effective coverage (antenatal and postnatal care content) and financial coverage (out-of-pocket payments for antenatal and delivery care and health insurance coverage) were measured, stratified by socio-economic status, education level and place of residence. Results Coverage of skilled birth attendance and institutional delivery was both high (88%), while coverage of postnatal visit was low (51%). Effective antenatal care was lower than effective postnatal care (38% vs 76%). Financial coverage was low: 91% of women made out-of-pocket payments for delivery services. Equity analysis showed coverage of institutional delivery was higher for wealthier and peri-urban women and these women made higher out-of-pocket payments. In contrast, coverage of a postnatal visit was higher for rural women and poorest women. Conclusion Maternal health coverage in eastern Uganda is not universal and particularly low for postnatal visit, effective antenatal care and financial coverage. Analysing healthcare payments and quality by healthcare provider sector is potential future research.

The Effect of Health Transformation Plan on Out-of-Pocket Payments of the Hospitalized Patients in Hamedan, Iran

Background: Out-of-Pocket (OOP) payment is categorized among the critical indicators of health system financing. Given the high hospitalization costs of the hospitals, the ministry of health has attempted to implement Health Transformation Plan (HTP) in Iran to reduce OOP. The purpose of this paper is to show the effects of HTP on OOP payments of the hospitalized patients in Hamedan, Iran. Methods: This descriptive-analytical study was carried out on 587 patients in the educational hospitals of Hamedan. The data obtained before and after implementing the HTP was from 2013 to 2015. Data analysis was performed using SPSS16. Results: In this study, each patient's expenditures increased by 32.2 % in 2015, compared to before the implementation of the HTP. Therefore, the health insurance organization's coverage of OOP payments decreased to 8.3 % of the total costs by a 20.2 % reduction in 2015, compared to before the implementation of the plan. Conclusion: According to the study, HTP and government health subsidies were adequate, but the total hospitalization costs had an upward trend in all funds.

Multi-Layered Catastrophic Health Spending of Inpatient Women by Broad Group of Diseases in India

Healthcare for Indian women needs prioritizing, as they continue to face social and economic discrimination over their healthcare, often with high out-of-pocket payments. The study examines the amount inpatient women have to pay for treatment of major diseases, re-classified into four groups as infectious, reproductive, non-communicable diseases (NCDs), and disabilities & injuries, across the country to comprehend the extent of catastrophic health spending (CHS) they experienced. The study is based on India’s 75th round of the National Sample Survey (NSS), i.e., Household Social Consumption: Health (2017-2018), consisting of 26,938 inpatient women aged 12 and above from India's urban and rural areas. We examine the prevalence of the four categories of diseases by individual, household, community, and healthcare characteristics. Expenditure estimates were derived from cross-tabulation, followed by binary logistic regression to assess the association between covariates and inpatient expenditures for the diseases. Indian women are more likely to be hospitalized for infectious diseases (43%), but the burden of CHS (overall) is highest for disabilities and injuries (INR 24,414), followed by NCDs (INR 23,053). Duration of hospitalization and possession of health insurance by women indicate maximum variation with medical spending. Almost 97% of women have incurred out-of-pocket expenditure on hospitalization, from which we identify three layers of CHS. A substantial proportion of women (23 to 50%) experienced CHS, i.e., up to 0-10%, 11-30%, and >30%, which varies distinctively by place of residence and across the six regions. Covariates like age, economic status, and healthcare are highly significant and associated with disease-wise CHS thresholds. Women in India face divergent financial hardships for healthcare. Given the heterogeneity of morbidities and socio-economic characteristics, the need for women-sensitive public health services and interventions are evident.

Equity of health care financing in South Korea: 1990–2016

Background The National Health Insurance in Korea has been in operation for more than 30 years since having achieved universal health coverage in 1989 and has gone through several policy reforms. Despite its achievements, the Korean health insurance has some shortfalls, one of which concerns the fairness of paying for health care. Method Using the population representative Household Income and Expenditure Survey data in Korea, this study examined the yearly changes in the vertical equity of paying for health care between 1990 and 2016 by the source of financing using the Kakwani index, considering health insurance and other related policy reforms in Korea during this period. Results The study results suggest that direct tax was the most progressive mode of health care financing in all years, whereas indirect tax was proportional. The out-of-pocket payments were weakly regressive in all years. The Kakwani index for health insurance contributions was regressive but now is proportional to the ability to pay, whereas the Kakwani index for private health insurance premiums turned from progressive to weakly regressive. The Kakwani index for overall health care financing showed a weak regressivity during the study period. Discussion The overall health care financing in Korea has transformed from a slight regressivity to proportional over time between 1990 and 2016. It is expected that these changes were closely related to the improved equity of health insurance contributions from 1998 to 2008, which was the result of a merger of the health insurance societies and an amendment in the health insurance contribution structure. These results suggest that standardizing insurance managing organizations and financing rules potentially has positive implications for the equity of healthcare financing in a country where the major method of health care financing is social health insurance.

Out-of-pocket payments and catastrophic expenditures due to traffic injuries in Ouagadougou, Burkina Faso

Objective To estimate the out-of-pocket expenditures linked to Road Traffic Injuries in Ouagadougou, Burkina Faso, as well as the prevalence of catastrophic expenditures among those out-of-pocket payments, and to identify the socio-economic determinants of catastrophic expenditures due to Road Traffic Injuries. Methods We surveyed every admission at the only trauma unit of Ouagadougou between January and July 2015 at the time of their admission, 7 days and 30 days later. We estimate a total amount of out-of-pocket expenditures paid by each patient. We considered an expense as catastrophic when it represented 10% at least of the annual global consumption of the patient’s household. We used linear models to determine if socio-economic characteristics were associated to a greater or smaller ratio between out-of-pocket payment and global annual consumption. Findings We surveyed 1323 Road injury victims three times (admission, Days 7 and 30). They paid in average 46,547 FCFA (83.64 US dollars) for their care, which represent a catastrophic expenditure for 19% of them. Less than 5% of the sample was covered by a health insurance scheme. Household economic status is found to be the first determinant of catastrophic health expenditure occurrence, exhibiting a significant and negative on the ratio between road injury expenditures and global consumption. Conclusion Our findings highlight the importance of developing health insurance schemes to protect poor households from the economic burden of road traffic injuries and improve equity in front of health shocks.

Stark choices: exploring health sector costs of policy responses to COVID-19 in low-income and middle-income countries

ObjectivesCOVID-19 has altered health sector capacity in low-income and middle-income countries (LMICs). Cost data to inform evidence-based priority setting are urgently needed. Consequently, in this paper, we calculate the full economic health sector costs of COVID-19 clinical management in 79 LMICs under different epidemiological scenarios.MethodsWe used country-specific epidemiological projections from a dynamic transmission model to determine number of cases, hospitalisations and deaths over 1 year under four mitigation scenarios. We defined the health sector response for three base LMICs through guidelines and expert opinion. We calculated costs through local resource use and price data and extrapolated costs across 79 LMICs. Lastly, we compared cost estimates against gross domestic product (GDP) and total annual health expenditure in 76 LMICs.ResultsCOVID-19 clinical management costs vary greatly by country, ranging between <0.1%–12% of GDP and 0.4%–223% of total annual health expenditure (excluding out-of-pocket payments). Without mitigation policies, COVID-19 clinical management costs per capita range from US$43.39 to US$75.57; in 22 of 76 LMICs, these costs would surpass total annual health expenditure. In a scenario of stringent social distancing, costs per capita fall to US$1.10–US$1.32.ConclusionsWe present the first dataset of COVID-19 clinical management costs across LMICs. These costs can be used to inform decision-making on priority setting. Our results show that COVID-19 clinical management costs in LMICs are substantial, even in scenarios of moderate social distancing. Low-income countries are particularly vulnerable and some will struggle to cope with almost any epidemiological scenario. The choices facing LMICs are likely to remain stark and emergency financial support will be needed.

Social Injustice by Prescription?

Since independence, Tanzania has instituted healthcare reforms in the quest for improving availability, quality, and social equity in access to public medical services. The extent to which the most recent healthcare reforms have impacted the existing patterns of medicinal prescription writing is largely opaque in the literature. This paper relies on data from two hospitals in Dar es Salaam. It emerges that the practice of categorising healthcare seekers into groups depending upon their varied health status and their entitlement to benefits has resulted in differential prescription allocations that might be interpreted as inequitable. The majority of very low income patients finance their healthcare through out-of-pocket payments and support of the Community Health Fund; this group receives a greater ratio of services with zero prescriptions, less poly-pharmacy and fewer prescribed generic medications than the proportion received by well-to-do patients with healthcare insurance. However, the medical and non-medical determinants of this differential in prescription allocation remain unclear, and so too, the ethical implications of such patterns in Tanzania’s out-patient medical service system are inconclusive.

Factors Associated With Off-Label Oncology Prescriptions: The Role of Cost and Financing in a Universal Healthcare System

Purpose: Various solutions have been put forward for prescribing and reimbursing treatments outside their registered indications within universal healthcare systems. However, most off-label oncology prescriptions are not reimbursed by health funds. This study characterized the financing sources of off-label oncology use and the predictors of the decision to forego treatment.Materials and Methods: All 708 off-label oncology requests submitted for approval in a large tertiary cancer center in Israel between 2016 and 2018 were examined for disease and patient sociodemographic characteristics, costs and financing sources, and the factors predicting actual off-label drug administration using multivariate logistic regression analysis.Results: The mean monthly cost of a planned off-label treatment was ILS54,703 (SD = ILS61,487, median = ILS39,928) (approximately US$ 15,500). The main sources of funding were private health insurance (25%) and expanded access pharma company plans (30%). Approximately one third (31%) of the requests did not have a financing source at the time of approval. Of the 708 requests, 583 (or 82%) were filled and treatment was initiated. Predictors for forgoing treatment were the impossibility of out-of-pocket payments or the lack of a financing solution (OR = 0.407; p = 0.005 and OR = 0.400; p &lt; 0.0005).Conclusion: Although off-label recommendations are widespread and institutional approval is often granted, a large proportion of these prescriptions are not filled. In a universal healthcare system, the financing sources for off-label treatments are likely to influence access.