Determinants of individual healthcare expenditure: A cross-sectional analysis in rural Burkina Faso

Drivers of healthcare expenditure growth in West Africa: A panel data investigation

Per capita health expenditure in West African countries appears to have assumed a growing trend over the years. This may not be unconnected with the critical role played by health in economic growth, sustainable development and human capital formation. This study analysed drivers of healthcare expenditure in West Africa, using panel data analysis. Random Effects estimating technique was preferred to pooled Ordinary Least Squares and Fixed Effects techniques based on Hausman and Breusch-Pagan Lagrangian multiplier tests. Data employed were sourced from World Bank's world development indicators. The findings indicated that number of people using at least basic sanitation services, incidence of tuberculosis, malaria incidence, and per capita GDP, significantly increased healthcare expenditure in West Africa within the study period. Infant and under-five mortality (UFM) rates raised healthcare expenditure but insignificantly in the sub-region. The study recommends the need to reduce malaria and tuberculosis incidences as well as UFM rate in West Africa through appropriate policy enactment. Such policies should include adequate investment in education, increased per capita income, development of malaria vaccines, maintenance of hygienic environment and free treatment of tuberculosis patients.

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.

Why did performance-based financing in Burkina Faso fail to achieve the intended equity effects? A process tracing study

In recent years, performance-based financing (PBF) has attracted attention as a means of reforming provider payment mechanisms in low- and middle-income countries. Particularly in combination with demand-side interventions, PBF has been assumed to benefit also the most vulnerable and disadvantaged groups. However, impact evaluations have often found this not to be the case. In Burkina Faso, PBF was coupled with specific equity measures to enhance healthcare utilization among the ultra-poor, but failed to produce the expected effects. Our study used the process tracing methodology to unravel the reasons for the lack of impact produced by the equity measures. We relied on published evidence, secondary data analysis, and findings from a qualitative study to support or invalidate the hypothesized causal mechanism, that is the reconstructed theory of change of the equity measures. Our findings show how various contextual, design, and implementation challenges hindered the causal mechanism from unfolding as planned. These included issues with the identification and exemption of the ultra-poor on the demand side, and with financial issues and considerations on the supply side. In broader terms, our findings underline the difficulty in improving access to care for the ultra-poor, given the multifaceted and complex nature of barriers to care the most vulnerable face. From a methodological point of view, our study demonstrates the value and applicability of process tracing in complementing other forms of evaluation for complex interventions in global health.

Magnitude and determinants of inpatient health expenditure among the elderly in India

As India is experiencing both the epidemiological and demographic transition, the grey population is expected to incur huge expenditure on health care, especially hospitalization expenditure, in the coming decades. The present study, thus, examines the magnitude of different types of inpatient health expenditure (medical, non-medical, total and out-of-pocket expenditure) and factors affecting them among the Indian elderly, using a health expenditure model empirically tested by the World Health Organization. Data were drawn from the 75th Round of the Health Survey conducted by the National Sample Survey Office, Government of India. In addition to basic descriptive statistics, the study employs a two-stage least square and a generalized linear model with log-link and gamma distribution to conduct the econometric analysis. The study finds that higher income, education, and household size, diseases like cancer, treatment involving surgery, poor physical mobility, and the elderly opting for packages involve higher inpatient health spending, while both private and social health insurance tends to reduce the same. So, a thrust on insurance-financed health systems may reduce health spending among the elderly. In this context, the study suggests that a disease-specific policy is required for the elderly along with ensuring state-of-the-art treatment facilities for them in public hospitals for critical ailments.

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.

Does the implementation of UHC reforms foster greater equality in health spending? Evidence from a benefit incidence analysis in Burkina Faso

Introduction

Burkina Faso is one among many countries in sub-Saharan Africa having invested in Universal Health Coverage (UHC) policies, with a number of studies have evaluated their impacts and equity impacts. Still, no evidence exists on how the distributional incidence of health spending has changed in relation to their implementation. Our study assesses changes in the distributional incidence of public and overall health spending in Burkina Faso in relation to the implementation of UHC policies.

Methods

We combined National Health Accounts data and household survey data to conduct a series of Benefit Incidence Analyses. We captured the distribution of public and overall health spending at three time points. We conducted separate analyses for maternal and curative services and estimated the distribution of health spending separately for different care levels.

Results

Inequalities in the distribution of both public and overall spending decreased significantly over time, following the implementation of UHC policies. Pooling data on curative services across all care levels, the concentration index (CI) for public spending decreased from 0.119 (SE 0.013) in 2009 to −0.024 (SE 0.014) in 2017, while the CI for overall spending decreased from 0.222 (SE 0.032) in 2009 to 0.105 (SE 0.025) in 2017. Pooling data on institutional deliveries across all care levels, the CI for public spending decreased from 0.199 (SE 0.029) in 2003 to 0.013 (SE 0.002) in 2017, while the CI for overall spending decreased from 0.242 (SE 0.032) in 2003 to 0.062 (SE 0.016) in 2017. Persistent inequalities were greater at higher care levels for both curative and institutional delivery services.

Conclusion

Our findings suggest that the implementation of UHC in Burkina Faso has favoured a more equitable distribution of health spending. Nonetheless, additional action is urgently needed to overcome remaining barriers to access, especially among the very poor, further enhancing equality.

Case study of the beneficiary group distribution of curative care expenditure based on SHA 2011 in Xinjiang autonomous region, China

BACKGROUND

The System of Health Accounts 2011 (SHA 2011) assists in health policy analysis and health expenditure comparison at the international level. Based on SHA 2011, this study analysed the distribution of beneficiary groups of curative care expenditure (CCE) in Xinjiang, to present suggestions for developing health policies.

METHODS

A total of 160 health institutions were selected using the multistage stratified random sampling method. An analysis of the agewise CCE distribution, institutional flow, and disease distribution was then performed based on the SHA 2011 accounting framework.

RESULTS

In 2016, the CCE in Xinjiang was ¥50.05 billion, accounting for 70.18% of current health expenditure and 6.66% of the gross domestic product. The per capita CCE was ¥2366.56. The CCE was distributed differently across age groups, with the highest spending on people over the age of 65 years. The CCE was highest for diseases of the circulatory, respiratory and digestive systems. Most of the expenditure was incurred in hospitals and, to a lesser extent, in primary healthcare institutions. Family health expenditure, especially on children aged 14 years and below, accounted for a relatively high proportion of the CCE.

CONCLUSION

SHA 2011 was used to capture data, which was then analysed according to the newly added beneficiary dimension. The findings revealed that the use of medical resources is low, the scale of primary medical institutions needs to be significantly expanded and there is a need to optimise the CCE financing scheme. Therefore, the health policymaking department should optimise the relevant policies and improve the efficiency of health services.

Factors related to excessive out-of-pocket expenditures among the ultra-poor after discontinuity of PBF: a cross-sectional study in Burkina Faso

BACKGROUND

Measuring progress towards financial risk protection for the poorest is essential within the framework of Universal Health Coverage. The study assessed the level of out-of-pocket expenditure and factors associated with excessive out-of-pocket expenditure among the ultra-poor who had been targeted and exempted within the context of the performance-based financing intervention in Burkina Faso. Ultra-poor were selected based on a community-based approach and provided with an exemption card allowing them to access healthcare services free of charge.

METHODS

We performed a descriptive analysis of the level of out-of-pocket expenditure on formal healthcare services using data from a cross-sectional study conducted in Diébougou district. Multivariate logistic regression was performed to investigate the factors related to excessive out-of-pocket expenditure among the ultra-poor. The analysis was restricted to individuals who reported formal health service utilisation for an illness-episode within the last six months. Excessive spending was defined as having expenditure greater than or equal to two times the median out-of-pocket expenditure.

RESULTS

Exemption card ownership was reported by 83.64% of the respondents. With an average of FCFA 23051.62 (USD 39.18), the ultra-poor had to supplement a significant amount of out-of-pocket expenditure to receive formal healthcare services at public health facilities which were supposed to be free. The probability of incurring excessive out-of-pocket expenditure was negatively associated with being female (β = - 2.072, p = 0.00, ME = - 0.324; p = 0.000) and having an exemption card (β = - 1.787, p = 0.025; ME = - 0.279, p = 0.014).

CONCLUSIONS

User fee exemptions are associated with reduced out-of-pocket expenditure for the ultra-poor. Our results demonstrate the importance of free care and better implementation of existing exemption policies. The ultra-poor's elevated risk due to multi-morbidities and severity of illness need to be considered when allocating resources to better address existing inequalities and improve financial risk protection.