Health seeking behaviour and the related household out-of-pocket expenditure for chronic non-communicable diseases in rural Malawi

Current curative expenditure of non-communicable diseases changed in Dalian, China from 2017 to 2019: a study based on 'System of Health Accounts 2011'

OBJECTIVES

To analyse the current curative expenditure (CCE) of NCDs in China from 2017 to 2019.

DESIGN

A cross-sectional study. Medical institutions were collected by multistage stratified random sampling from 2017 to 2019.

SETTING

Dalian, China PARTICIPANTS: 408 institutions and 8 104 233 valid items were included in the study. NCDs patients were selected according to International Classification of Diseases-10.

PRIMARY AND SECONDARY OUTCOME MEASURES

CCE for NCDs was measured based on the System of Health Accounts 2011. Influenced factors were analysed by linear regression. All analyses and calculations were performed by STATA V.15.0.

RESULTS

The CCE of NCDs was ¥14.929 billion in 2017, ¥16.377 billion in 2018 and ¥18.055 billion in 2019, which accounted for more than 65% of total expenditure spent each year. More than 60% came from public financing. The proportion of family health financing continued to decline, reaching 31.16% in 2019. The expenditures were mainly in general hospitals, above 70%. Elderly patients account for the majority. Diseases of the circulatory system, diseases of the digestive system and neoplasms were the main NCDs. Year, age, gender, length of stay, surgery, insurance and institution level affected hospitalisation expenses.

CONCLUSIONS

NCDs are the main CCE of diseases in China, and their resources are not allocated reasonably. To reduce the CCE of NCDs, the government needs to optimise resource allocation and rationalise institutional flows and functions.

How equitable is health spending on curative services and institutional delivery in Malawi? Evidence from a quasi-longitudinal benefit incidence analysis

Background

Malawi is one of a handful of countries that had resisted the implementation of user fees, showing a commitment to providing free healthcare to its population even before the concept of Universal Health Coverage (UHC) acquired global popularity. Several evaluations have investigated the effects of key policies, such as the essential health package or performance-based financing, in sustaining and expanding access to quality health services in the country. Understanding the distributional impact of health spending over time due to these policies has received limited attention. Our study fills this knowledge gap by assessing the distributional incidence of public and overall health spending between 2004 and 2016.

Methods

We relied on a Benefit Incidence Analysis (BIA) to measure the socioeconomic inequality of public and overall health spending on curative services and institutional delivery across different health facility typologies. We used data from household surveys and National Health Accounts. We used a concentration index (CI) to determine the health benefits accrued by each socioeconomic group.

Results

Socioeconomic inequality in both public and overall health spending substantially decreased over time, with higher inequality observed in overall spending, non-public health facilities, curative health services, and at higher levels of care. Between 2004 and 2016, the inequality in public spending on curative services decreased from a CI of 0.037 (SE 0.013) to a CI of 0.004 (SE 0.011). Whiles, it decreased from a CI of 0.084 (SE 0.014) to a CI of 0.068 (SE 0.015) for overall spending in the same period. For institutional delivery, inequality in public and overall spending decreased between 2004 and 2016 from a CI of 0.032 (SE 0.028) to a CI of -0.057 (SE 0.014) and from a CI of 0.036 (SE 0.022) to a CI of 0.028 (SE 0.018), respectively.

Conclusions

Through its free healthcare policy, Malawi has reduced socioeconomic inequality in health spending over time, but some challenges still need to be addressed to achieve a truly egalitarian health system. Our findings indicate a need to increase public funding for the health sector to ensure access to care and financial protection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01624-5.

Exploring health-seeking behavior for non-communicable chronic conditions in northern Bangladesh

Non-communicable Diseases (NCDs) account for 67% of total deaths in Bangladesh. However, the Bangladeshi health system is inadequately prepared to tackle NCDs. Evidence on NCD-specific health-seeking behavior can help appropriately address the needs of people affected by NCDs in Bangladesh. Our study aims to explore health-seeking behavior for people affected by NCDs in northern Bangladesh. We conducted a qualitative study in Mithapukur, Rangpur, during 2015-2016. We purposely selected respondents and carried out 25 in-depth interviews with individuals affected by non-communicable diseases and 21 healthcare providers. Additionally, we held six focus group discussions in the wider community. We verbatim transcribed all interviews and analyzed the content using thematic analysis, according to the following thematic areas: individual, household, and contextual factors that influence health-seeking behavior for NCDs within the context of the broader socio-economic environment. Study findings indicate that people seek care only when symptoms disrupt their daily lifestyle. Henceforth, people's health beliefs, religious beliefs, and relations with local providers direct their actions, keeping provider accessibility, cost anticipation, and satisfying provider-encounters in mind. Health-seeking is predominantly delayed and fragmented. Semi-qualified providers represent a popular first choice. Gender roles dominate health-seeking behavior as women need their guardian's permission to avail care. Our findings indicate the need to sensitize people about the importance of early health-seeking for NCDs, and continuing life-long NCD treatment. Our findings also highlight the need for people-centered care, making preventive and curative NCD services accessible at grassroots level, along with relevant provider training. Furthermore, special provisions, such as financial support and outreach programs are needed to enable access to NCD care for women and the poor.

Integrated healthcare services for HIV, diabetes mellitus and hypertension in selected health facilities in Kampala and Wakiso districts, Uganda: A qualitative methods study

Health policies in Africa are shifting towards integrated care services for chronic conditions, but in parts of Africa robust evidence on effectiveness is limited. We assessed the integration of vertical health services for HIV, diabetes and hypertension provided in a feasibility study within five health facilities in Uganda. From November 2018 to January 2020, we conducted a series of three in-depth interviews with 31, 29 and 24 service users attending the integrated clinics within Kampala and Wakiso districts. Ten healthcare workers were interviewed twice during the same period. Interviews were conducted in Luganda, translated into English, and analysed thematically using the concepts of availability, affordability and acceptability. All participants reported shortages of diabetes and hypertension drugs and diagnostic equipment prior to the establishment of the integrated clinics. These shortages were mostly addressed in the integrated clinics through a drugs buffer. Integration did not affect the already good provision of anti-retroviral therapy. The cost of transport reduced because of fewer clinic visits after integration. Healthcare workers reported that the main cause of non-adherence among users with diabetes and hypertension was poverty. Participants with diabetes and hypertension reported they could not afford private clinical investigations or purchase drugs prior to the establishment of the integrated clinics. The strengthening of drug supply for non-communicable conditions in the integrated clinics was welcomed. Most participants observed that the integrated clinic reduced feelings of stigma for those living with HIV. Sharing the clinic afforded privacy about an individual's condition, and users were comfortable with the waiting room sitting arrangement. We found that integrating non-communicable disease and HIV care had benefits for all users. Integrated care could be an effective model of care if service users have access to a reliable supply of basic medicines for both HIV and non-communicable disease conditions.

Uneven economic burden of non-communicable diseases among Indian households: A comparative analysis

BACKGROUND

Non-communicable diseases (NCDs) are the leading global cause of death and disproportionately concentrate among those living in low-income and middle-income countries. However, its economic impact on households remains less well known in the Indian context. This study aims to assess the economic impact of NCDs in terms of out-of-pocket expenditure (OOPE) and its catastrophic impact on NCDs affected households in India.

MATERIALS AND METHODS

Data were collected from the 75th round of the National Sample Survey Office, Government of India, conducted in the year 2017-18. This is the latest round of data available on health, which constitutes a sample of 113,823 households. The collection of data is based on a stratified multi-stage sampling method. Generalised Linear Regression model was employed to identify the socio-economic covariates associated with the catastrophic health expenditure (CHE) on hospitalisation.

RESULTS

The result shows a higher burden of OOPE on NCDs affected households. The mean expenditure by NCDs households in public hospitals is INR 13,170 which is more than twice as compared to the non-NCDs households INR 6,245. Particularly, the proportion of total medical expenditure incurred on medicines (0.39) and diagnostics (0.15) is troublesome for households with NCDs, treated in public hospitals. Moreover, results from the generalised linear regression model confirm the significant relationship between CHE with residence, caste, religion, household size, and economic status of households. The intensity of CHE is more for the households who are poor, drinking unsafe water, using firewood as cooking fuel, and household size of 1-5 members.

CONCLUSION

Therefore, an urgent need for a prevention strategy should be made by the government to protect households from the economic burden of NCDs. Specifically, to reduce the burden of CHE associated with NCDs, a customised disease-specific health insurance package should be introduced by the government of India in both public and private facilities.

Patterns of healthcare seeking among people reporting chronic conditions in rural sub-Saharan Africa: findings from a population-based study in Burkina Faso

OBJECTIVE

Non-communicable diseases are rapidly becoming one of the leading causes of morbidity and mortality in sub-Saharan Africa. Yet, little is known about patterns of healthcare seeking among people with chronic conditions in these settings. We aimed to explore determinants of healthcare seeking among people who reported at least one chronic condition in rural Burkina Faso.

METHODS

Data were drawn from a cross-sectional population-based survey conducted across 24 districts on 52 562 individuals from March to June 2017. We used multinomial logistic regression to assess factors associated with seeking care at a formal provider (facility-based care) or at an informal provider (home and traditional treatment) compared to no care.

RESULTS

1124 individuals (2% of all respondents) reported at least one chronic condition. Among those, 22.8% reported formal care use, 10.6% informal care use, and 66.6% no care. The presence of other household members reporting a chronic condition (RRR = 0.57, 95%-CI [0.39, 0.82]) was negatively associated with seeking formal care. Wealthier households (RRR = 2.14, 95%-CI [1.26, 3.64]), perceived illness severity (RRR = 3.23, 95%-CI [2.22, 4.70]) and suffering from major chronic conditions (RRR = 1.54, 95%-CI [1.13, 2.11]) were positively associated with seeking formal care.

CONCLUSION

Only a minority of individuals with chronic conditions sought formal care, with important differences due to socio-economic status. Policies and interventions aimed at increasing the availability and affordability of services for early detection and management in peripheral settings should be prioritised.

Determinants of healthcare seeking and out-of-pocket expenditures in a "free" healthcare system: evidence from rural Malawi

BACKGROUND

Monitoring financial protection is a key component in achieving Universal Health Coverage, even for health systems that grant their citizens access to care free-of-charge. Our study investigated out-of-pocket expenditure (OOPE) on curative healthcare services and their determinants in rural Malawi, a country that has consistently aimed at providing free healthcare services.

METHODS

Our study used data from two consecutive rounds of a household survey conducted in 2012 and 2013 among 1639 households in three districts in rural Malawi. Given our explicit focus on OOPE for curative healthcare services, we relied on a Heckman selection model to account for the fact that relevant OOPE could only be observed for those who had sought care in the first place.

RESULTS

Our sample included a total of 2740 illness episodes. Among the 1884 (68.75%) that had made use of curative healthcare services, 494 (26.22%) had incurred a positive healthcare expenditure, whose mean amounted to 678.45 MWK (equivalent to 2.72 USD). Our analysis revealed a significant positive association between the magnitude of OOPE and age 15-39 years (p = 0.022), household head (p = 0.037), suffering from a chronic illness (p = 0.019), illness duration (p = 0.014), hospitalization (p = 0.002), number of accompanying persons (p = 0.019), wealth quartiles (p₂ = 0.018; p₃ = 0.001; p₄ = 0.002), and urban residency (p = 0.001).

CONCLUSION

Our findings indicate that a formal policy commitment to providing free healthcare services is not sufficient to guarantee widespread financial protection and that additional measures are needed to protect particularly vulnerable population groups.

At what cost is performance-based financing implemented? Novel evidence from Malawi

Our study estimated the full economic cost of implementing performance-based financing [PBF, the Support for Service Delivery Integration Performance-Based Incentives (SSDI-PBI) programme], as a means of first introducing strategic purchasing in a low-income setting, Malawi. Our analysis distinguished design from implementation costs and traces costs across personnel and non-personnel cost categories over the 2012-15 period. The full cost of the SSDI-PBI programme amounted to USD 3 402 187, equivalent to USD 6.46 per targeted beneficiary. The design phase accounted for about one-third (USD 1 161 332) of the total costs, while the incentives (USD 1 140 436) represented about one-third of the total cost of the intervention and about half the cost of the implementation phase. With a cost of USD 1 605 178, personnel costs represented the dominant cost category. Our study indicated that the introduction of PBF entailed consumption of a substantial amount of resources, hence representing an important opportunity cost for the health system.

Determinants of health seeking behavior for chronic non-communicable diseases and related out-of-pocket expenditure: results from a cross-sectional survey in northern Bangladesh

BACKGROUND

In spite of high prevalence rates, little is known about health seeking and related expenditure for chronic non-communicable diseases in low-income countries. We assessed relevant patterns of health seeking and related out-of-pocket expenditure in Bangladesh.

METHODS

We used data from a household survey of 2500 households conducted in 2013 in Rangpur district. We employed multinomial logistic regression to assess factors associated with health seeking choices (no care or self-care, semi-qualified professional care, and qualified professional care). We used descriptive statistics (5% trimmed mean and range, median) to assess related patterns of out-of-pocket expenditure (including only direct costs).

RESULTS

Eight hundred sixty-six (12.5%) out of 6958 individuals reported at least one chronic non-communicable disease. Of these 866 individuals, 139 (16%) sought no care or self-care, 364 (42%) sought semi-qualified care, and 363 (42%) sought qualified care. Multivariate analysis confirmed that the following factors increased the likelihood of seeking qualified care: a higher education, a major chronic non-communicable disease, a higher socio-economic status, a lower proportion of chronic household patients, and a shorter distance between a household and a sub-district public referral health facility. Seven hundred fifty-four (87 %) individuals reported out-of-pocket expenditure, with drugs absorbing the largest portion (85%) of total expenditure. On average, qualified care seekers encountered the highest out-of-pocket expenditure, followed by those who sought semi-qualified care and no care, or self-care.

CONCLUSION

Our study reveals insufficiencies in health provision for chronic conditions, with more than half of all affected people still not seeking qualified care, and the majority still encountering considerable out-of-pocket expenditure. This calls for urgent measures to secure better access to care and financial protection.

Health Service Utilization Among People With Noncommunicable Diseases in Rural Vietnam

CONTEXT

Chronic noncommunicable diseases (NCDs) have been shown to be major causes of morbidity and mortality in hospitals for the whole country.

OBJECTIVE

This study aims to describe the situation of health service utilization among people with NCDs in a rural area and identify association between the situation of health service utilization among people with chronic diseases and their socioeconomic status.

DESIGN

This was a cross-sectional study.

SETTING

A rural district located in the North of Vietnam.

PARTICIPANTS

People 15 years of age and older. Health service utilization was analyzed only among people who reported having NCD.

MAIN OUTCOME MEASURES

Data were collected through a personal household interview conducted by 12 trained field workers. The dependent variable is health care service utilization among people with chronic NCDs. The explanatory variables include both household attributes such as household economic conditions, and so forth, and individual characteristics.

RESULTS

Eighteen percent of the adults and 51% of the elderly respondents reported having at least 1 of the NCDs. The proportions of people with NCDs who used at least 1 outpatient service and used at least 1 inpatient health service during the last 12 months were 68.1% and 10.7%, respectively (the nonutilization rates of 31.9% and 89.3%, respectively). The statistically significant correlates of health care service utilization among people with NCDs were ethnicity (ethnic minority was significantly associated with a lower odds of health care service utilization) and health insurance (no health insurance was significantly associated with lower odds of health care service utilization).

CONCLUSION

Given the evidence from this study, actions to improve access to health care services among people with NCDs are clearly needed. The capacity of primary health care system for the prevention and control of NCDs should be ranked a top priority.

The costs of seeking healthcare: Illness, treatment seeking and out of pocket expenditures among the urban poor in Delhi, India

The poor often experience illness and the treatment costs are high and even catastrophic for the poor. This paper reports the extent of illness, treatment-seeking behaviour and out of pocket healthcare expenditures and the determinants of treatment-seeking behaviour and healthcare expenditures among the urban poor living in Delhi. A total of 2,998 households participated in the study. Socio-demographic details, illness experiences (episodic illness in the past 3 months, hospitalisation in the past 1 year and any chronic illness), treatment seeking and healthcare expenditures were collected for all household members through a pretested, interviewer-administered questionnaire. Logistic regressions were carried out for factors associated with treatment-seeking choices. Multiple linear regressions were carried for factors associated with out of pocket expenditures (OOPE). Of the total 15,218 household members (of the 2,998 households), 4,052 (26.6%) experienced episodic illness (mainly fever, respiratory illnesses, food- and waterborne diseases and eye infections) in the past 3 months, 230 (1.5%) were hospitalised and 976 (6.4%) have chronic illness (mainly hypertension, diabetes, arthritis and respiratory problems). Of the 2,998 households, 2,225 (74.2%) households reported at least one event of illness. Unqualified practitioners were the main source of care for episodic illnesses. Perceived seriousness of the illness, having Employees State Insurance Scheme (ESIS) benefit, higher educational status of the head of the household, higher monthly household incomes, belonging other backward castes and settled-migrant status led to seeking formal care. Dengue was the main reason for hospitalisation. Government including ESIS hospitals were mainly utilised for hospitalisation. Healthcare expenditures were higher for private healthcare. Possession of mandatory health insurance was protective against OOPEs. OOPEs were more for the men/boys and for the young. Improving access to government healthcare services is important. Extending the ESIS to the unorganised workers including urban poor migrants should be considered so as to bring them under mandatory social protection.

'Blood pressure can kill you tomorrow, but HIV gives you time': illness perceptions and treatment experiences among Malawian individuals living with HIV and hypertension

Non-communicable diseases like hypertension are increasingly common among individuals living with HIV in low-resource settings. The prevalence of hypertension among people with HIV in Malawi, e.g. has been estimated to be as high as 46%. However, few qualitative studies have explored the patient experience with comorbid chronic disease. Our study aimed to address this gap by using the health belief model (HBM) to examine how comparative perceptions of illness and treatment among participants with both HIV and hypertension may affect medication adherence behaviours. We conducted semi-structured interviews with 75 adults with HIV and hypertension at an urban clinic in Lilongwe, Malawi. Questions addressed participants' experiences with antiretroviral and antihypertensive medications, as well as their perspectives on HIV and hypertension as illnesses. Interviews were performed in Chichewa, transcribed, translated into English and analysed using ATLAS.ti. Deductive codes were drawn from the HBM and interview guide, with inductive codes added as they emerged from the data. Self-reported medication adherence was much poorer for hypertension than HIV, but participants saw hypertension as a disease at least as concerning as HIV-primarily due to the perceived severity of hypertension's consequences and participants' limited ability to anticipate them compared with HIV. Differences in medication adherence were attributed to the high costs of antihypertensive medications relative to the free availability of antiretroviral therapy, with other factors like lifestyle changes and self-efficacy also influencing adherence practices. These findings demonstrate how participants draw on past experiences with HIV to make sense of hypertension in the present, and suggest that although patients are motivated to control their hypertension, they face individual- and system-level obstacles in adhering to treatment. Thus, health policies and systems seeking to provide integrated care for HIV and hypertension should be attentive to the complex illness experiences of individuals living with these diseases.

Is Health Insurance Associated with Health Service Utilization and Economic Burden of Non-Communicable Diseases on Households in Vietnam?

The rising burden of Non-Communicable Diseases (NCDs) in developing countries has caused high out-of-pocket (OOP) health spending leading to many households suffering Catastrophic Health Expenditure (CHE). This study examined the association between health insurance (HI) on health-care utilization and the burden of OOP expenditure among people with reported NCDs and on their households in Vietnam.The study draws on a cross-sectional household survey of accessibility and utilization of health services in Vietnam. Data were obtained from three provinces to represent urban, rural and mountainous areas of the country. The study used a sample of 2,038 individuals with reported NCD aged over 18 years from 1,642 households having at least one person with reported NCD.The results show that people with reported NCD who had HI were twice as likely to use outpatient care compared with those without HI. Having more than one member with reported NCD resulted in double the odds of a household suffering CHE. Households in the three lowest wealth quintiles were more likely to encounter CHE and financial distress than economically better-off households. HI did not provide a protective effect to households, as there was no significant association between the HI status of household members with reported NCD and CHE or financial distress. Seeking care at higher-level facilities was significantly associated with CHE.This study highlights the need for evidence to design future HI-based interventions targeting susceptible populations to narrow the gaps in health service utilization among the population and mitigate financial catastrophe associated with NCDs.Abbreviations: NCD: Noncommunicable diseases; UHC: Universal Health Coverage; HI: Health insurance; CHE: Catastrophic health expenditure; OOP: Out of Pocket.

Care-Seeking Dynamics among Patients with Diabetes Mellitus and Hypertension in Selected Rural Settings in Kenya

Diabetes mellitus and hypertension are two common non-communicable diseases (NCDs) that often coexist in patients. However, health-seeking behaviour in patients with diabetes mellitus or hypertension has not been extensively studied especially in low- and middle-income countries. This study aimed to examine care-seeking dynamics among participants diagnosed with diabetes and/or hypertension across nine counties in rural Kenya. We conducted a cross-sectional study among adults diagnosed with diabetes and/or hypertension through face-to-face interviews. Of the 1100 participants, 69.9% had hypertension, 15.5% diabetes while 14.7% had both. The mean age of the respondents was 64 years. The majority of the respondents (86%) were on allopathic treatment. Hospital admission, having a good self-rated health status and having social support for illness, were positively associated with appropriate health-seeking behaviour while use of alcohol and pharmacy or chemist as source of treatment were negatively associated with appropriate health-seeking behaviour. Our study found a high prevalence of appropriate health-seeking behaviour among respondents with the majority obtaining care from government facilities. The results are evidence that improving public health care services can promote appropriate health-seeking behaviour for non-communicable diseases and thus improve health outcomes.

Effect of a typical systemic hospital reform on inpatient expenditure for rural population: the Sanming model in China

Background

Considering catastrophic health expenses in rural households with hospitalised members were unproportionally high, in 2013, China developed a model of systemic reform in Sanming by adjusting payment method, pharmaceutical system, and medical services price. The reform was expected to control the excessive growth of hospital expenditures by reducing inefficiency and waste in health system or shortening the length of stay. This study analyzed the systemic reform’s impact on the financial burden and length of stay for the rural population in Sanming.

Methods

A total of 1,113,615 inpatient records for the rural population were extracted from the rural new cooperative medical scheme (NCMS) database in Sanming from 2007 to 2012 (before the reform) and from 2013 to 2016 (after the reform). We calculated the average growth rate of total inpatient expenditures and costs of different medical service categories (medications, diagnostic testing, physician services and therapeutic services) in these two periods. Generalized linear models (GLM) were employed to examine the effect of reform on out-of-pocket (OOP) expenditures and length of stay, controlling for some covariates. Furthermore, we controlled the fixed effects of the year and hospitals, and included cluster standard errors by hospital to assess the robustness of the findings in the GLM analysis.

Results

The typical systemic reform decreased the average growth rate of total inpatient expenditures by 1.34%, compared with the period before the reform. The OOP expenditures as a share of total expenditures showed a downward trend after the reform (42.34% in 2013). Holding all else constant, individuals after the reform spent ¥308.42 less on OOP expenditures (p < 0.001) than they did before the reform. Moreover, length of stay had a decrease of 0.67 days after the reform (p < 0.001).

Conclusions

These results suggested that the typical systemic hospital reform of the Sanming model had some positive effects on cost control and reducing financial burden for the rural population. Considering the OOP expenditures as a share of total expenditures was still high, China still has a long way to go to improve the benefits rural people have enjoyed from the NCMS.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4048-7) contains supplementary material, which is available to authorized users.

How have researchers defined and used the concept of 'continuity of care' for chronic conditions in the context of resource-constrained settings? A scoping review of existing literature and a proposed conceptual framework

Background

Within the context of the growing burden of non-communicable diseases (NCDs) globally, there is limited evidence on how researchers have explored the response to chronic health needs in the context of health policy and systems in low- and middle-income countries. Continuity of care (CoC) is one concept that represents several elements of a long-term model of care. This scoping review aims to map and describe the state of knowledge regarding how researchers in resource-constrained settings have defined and used the concept of CoC for chronic conditions in primary healthcare.

Methods

This scoping review adopted the modified framework for interpretive scoping literature reviews. A systematic literature search in PubMed was performed, followed by a study selection process and data extraction, analysis and synthesis. Extracted data regarding the context of using CoC and the definition of CoC were analysed inductively to identify similar patterns; based on this, articles were divided into groups. MaxQDA was then used to re-code each article with themes according to the CoC definition to perform a cross-case synthesis under each identified group.

Results

A total of 55 peer-reviewed articles, comprising reviews or commentaries and qualitative or quantitative studies, were included. The number of articles has increased over the years. Five groups were identified as those (1) reflecting a change across stages or systems of care, (2) mentioning continuity or lack of continuity without a detailed definition, (3) researching CoC in HIV/AIDS programmes and its scaling up to support management of NCDs, (4) researching CoC in NCD management, and (5) measuring CoC with validated questionnaires.

Conclusion

Research or policy documents need to provide an explicit definition of CoC when this terminology is used. A framework for CoC is suggested, acknowledging three components for CoC (i.e. longitudinal care, the nature of the patient–provider relationship and coordinated care) while considering relevant contextual factors, particularly access and quality.

Electronic supplementary material

The online version of this article (10.1186/s12961-019-0426-1) contains supplementary material, which is available to authorized users.

Health seeking for chronic lung disease in central Malawi: Adapting existing models using insights from a qualitative study

BACKGROUND

Chronic lung diseases contribute to the growing non-communicable disease (NCD) burden and are increasing, particularly in many low and middle-income countries (LMIC) in sub-Saharan African. Early engagement with health systems in chronic lung disease management is critical to maintain quality of life and prevent further damage. Our study sought to understand health seeking behaviour in relation to chronic lung disease and TB in a rural district in Malawi.

METHODS

Qualitative data was collected between March-May 2015, exploring patterns of health seeking for lung disease amongst residents of two districts in rural Malawi. Participants included those with and without lung disease, health workers and village leaders. Participants with a history of TB were included in the sample due to similarities in clinical presentation and in view of potential to cause long-term damage to lung tissue.

RESULTS

Our findings are ordered around a specific model of health seeking devised by adapting previous models. The model and findings span three broad areas that were found to influence health seeking: understandings of health and disease which shaped whether, when and where to seek care; the care seeking decision which was influenced by social and structural factors; and the care seeking experience which impacted future care decisions creating 'feedback loops'.

DISCUSSION

Efforts to improve effective and accessible healthcare provision for chronic lung disease need to address all the determinants of health seeking behaviour identified. This may include: enhancing the structural and financial accessibility of health services, through the strengthening of community linkages; improving communication between formal health providers, patients and communities around symptoms, diagnosis and management of chronic lung diseases; and improving the quality of diagnostic and management services through the strengthening of health systems 'hardware' (equipment availability) and 'software' (development of trusting and respectful relationships between providers and patients).

Health financing at district level in Malawi: an analysis of the distribution of funds at two points in time

There is growing attention to tracking country level resource flows to health, but limited evidence on the sub-national allocation of funds. We examined district health financing in Malawi in 2006 and 2011, and equity in the allocation of funding, together with the association between financing and under five and neonatal mortality. We explored the process for receiving and allocating different funding sources at district level. We obtained domestic and external financing data from the Integrated Financial Management Information System (2006–11) and AidData (2000–12) databases. Out-of-pocket payment data came from two rounds of integrated household budget surveys (2005; 2010). Mortality data came from the Multiple Indicator Cluster Survey (2006) and Demographic and Health Survey (2010). We described district level health funding by source, ran correlations between funding and outcomes and generated concentration curves and indices. 41 semi-structured interviews were conducted at the national level and in 10 districts with finance and health managers. Per capita spending from all sources varied substantially across districts and doubled between 2006 and 2011 from 7181 Kwacha to 15 312 Kwacha. In 2011, external funding accounted for 74% of funds, with domestic funding accounting for 19% of expenditure, and out of pocket (OOP) funding accounting for 7%. All funding sources were concentrated among wealthier districts, with OOP being the most pro-rich, followed by domestic expenditure and external funding. Districts with higher levels of domestic and external funding had lower levels of post-neonatal mortality, and those with higher levels of out-of-pocket payments had higher levels of 1–59 month mortality in 2006. There was no association between changes in financing and outcomes. Districts reported delayed receipt of lower-than-budgeted funds, forcing them to scale-down activities and rely on external funding. Governments need to track how resources are allocated sub-nationally to maximize equity and ensure allocations are commensurate to health need.

Underlying determinants of health provider choice in urban slums: results from a discrete choice experiment in Ahmedabad, India

Background

Severe underutilization of healthcare facilities and lack of timely, affordable and effective access to healthcare services in resource-constrained, bottom of pyramid (BoP) settings are well-known issues, which foster a negative cycle of poor health outcomes, catastrophic health expenditures and poverty. Understanding BoP patients’ healthcare choices is vital to inform policymakers’ effective resource allocation and improve population health and livelihood in these areas. This paper examines the factors affecting the choice of health care provider in low-income settings, specifically the urban slums in India.

Method

A discrete choice experiment was carried out to elicit stated preferences of BoP populations. A total of 100 respondents were sampled using a multi-stage systemic random sampling of urban slums. Attributes were selected based on previous studies in developing countries, findings of a previous exploratory study in the study setting and qualitative interviews. Provider type and cost, distance to the facility, attitude of doctor and staff, appropriateness of care and familiarity with doctor were the attributes included in the study. A random effects logit regression was used to perform the analysis. Interaction effects were included to control for individual characteristics.

Results

The relatively most valued attribute is appropriateness of care (β=3.4213, p = 0.00), followed by familiarity with the doctor (β=2.8497, p = 0.00) and attitude of the doctor and staff towards the patient (β=1.8132, p = 0.00). As expected, respondents prefer shorter distance (β= − 0.0722, p = 0.00) but the relatively low importance of the attribute distance to the facility indicate that respondents are willing to travel longer if any of the other statistically significant attributes are present. Also, significant socioeconomic differences in preferences were observed, especially with regard to the type of provider.

Conclusion

The analyses did not reveal universal preferences for a provider type, but overall the traditional provider type is not well accepted. It also became evident that respondents valued appropriateness of care above other attributes. Despite the study limitations, the results have broader policy implications in the context of Indian government’s attempts to reduce high healthcare out-of-pocket expenditures and provide universal health coverage for its population. The government’s attempt to emphasize the focus on traditional providers should be carefully reconsidered.

Social determinants of adult mortality from non-communicable diseases in northern Ethiopia, 2009-2015: Evidence from health and demographic surveillance site

INTRODUCTION

In developing countries, mortality and disability from non-communicable diseases (NCDs) is rising considerably. The effect of social determinants of NCDs-attributed mortality, from the context of developing countries, is poorly understood. This study examines the burden and socio-economic determinants of adult mortality attributed to NCDs in eastern Tigray, Ethiopia.

METHODS

We followed 45,982 adults implementing a community based dynamic cohort design recording mortality events from September 2009 to April 2015. A physician review based Verbal autopsy was used to identify the most probable causes of death. Multivariable Cox proportional hazards regression was performed to identify social determinants of NCD mortality.

RESULTS

Across the 193,758.7 person-years, we recorded 1,091 adult deaths. Compared to communicable diseases, NCDs accounted for a slightly higher proportion of adult deaths; 33% vs 34.5% respectively. The incidence density rate (IDR) of NCD attributed mortality was 194.1 deaths (IDR = 194.1; 95% CI = 175.4, 214.7) per 100,000 person-years. One hundred fifty-seven (41.8%), 68 (18.1%) and 34 (9%) of the 376 NCD deaths were due to cardiovascular disease, cancer and renal failure, respectively. In the multivariable analysis, age per 5-year increase (HR = 1.35; 95% CI: 1.30, 1.41), and extended family and non-family household members (HR = 2.86; 95% CI: 2.05, 3.98) compared to household heads were associated with a significantly increased hazard of NCD mortality. Although the difference was not statistically significant, compared to poor adults, those who were wealthy had a 15% (HR = 0.85; 95% CI: 0.65, 1.11) lower hazard of mortality from NCDs. On the other hand, literate adults (HR = 0.35; 95% CI: 0.13, 0.9) had a significantly decreased hazard of NCD attributed mortality compared to those adults who were unable to read and write. The effect of literacy was modified by age and its effect reduced by 18% for every 5-year increase of age among literate adults.

CONCLUSION

In summary, the study indicates that double mortality burden from both NCDs and communicable diseases was evident in northern rural Ethiopia. Public health intervention measures that prioritise disadvantaged NCD patients such as those who are unable to read and write, the elders, the extended family and non-family household co-residents could significantly reduce NCD mortality among the adult population.

Poverty-related diseases (PRDs): unravelling complexities in disease responses in Cameroon

BACKGROUND

In Cameroon, poverty-related diseases (PRDs) are a major public health concern. Research and policies addressing PRDs are based on a particular understanding of the interaction between poverty and disease, usually an association between poverty indicators and health indicators for a specific country or region. Such indicators are useful but fail to explain the nature of the linkages between poverty and disease or poverty and health. This paper presents results of a study among university students, unravelling how they perceive diseases, the linkages with poverty, their responses to diseases and the motivations behind reported responses. Based on the health belief model, this cross-sectional study was carried out among 272 students at the universities of Buea and Yaoundé in Cameroon. Data were collected using questionnaires containing items matching the research objectives. The questionnaires were self-completed.

RESULTS

Malaria was considered as the most common disease perceived and also a major PRD. Contrary to official rankings of HIV/AIDS and TB, cholera and diarrhoea were considered as other major PRDs. Also, typhoid fever was perceived to be more common and a PRD than HIV/AIDS and TB combined. The most prominently attributed cause for disease was (lack of) hygiene. In response, students deployed formal and/or informal healthcare strategies, depending on factors like available money, perceived severity of the disease and disease type. Discrepancies were observed in respondents' response to diseases generally and to malaria in particular. Even though, overall, respondents pre-dominantly reported a formal healthcare response toward diseases in general, for malaria, informal responses dominated. There was an overall strong awareness and (pro)activity among students for dealing with diseases.

CONCLUSIONS

Although the high use of informal facilities and medication for malaria may well be a reason why eradication is problematic, this seems to be a deliberate strategy linked to an awareness of the limitations of the formal health system. In any intervention intended to foster health, it is therefore vital to consider people's perceptions toward diseases and their response strategies. Our results give important leads to health promotion interventions to develop group-specific programs.

The economic burden of chronic non-communicable diseases in rural Malawi: an observational study

Background

Evidence from population-based studies on the economic burden imposed by chronic non-communicable diseases (CNCDs) is still sparse in Sub-Saharan Africa. Our study aimed to fill this existing gap in knowledge by estimating both the household direct, indirect, and total costs incurred due to CNCDs and the economic burden households bear as a result of these costs in Malawi.

Methods

The study used data from the first round of a longitudinal household health survey conducted in 2012 in three rural districts in Malawi. A cost-of-illness method was applied to estimate the economic burden of CNCDs. Indicators of catastrophic spending and impoverishment were used to estimate the economic burden imposed by CNCDs on households.

Results

A total 475 out of 5643 interviewed individuals reported suffering from CNCDs. Mean total costs of all reported CNCDs were 1,040.82 MWK, of which 56.8 % was contributed by direct costs. Individuals affected by chronic cardiovascular conditions and chronic neuropsychiatric conditions bore the highest levels of direct, indirect, and total costs. Using a threshold of 10 % of household non-food expenditure, 21.3 % of all households with at least one household member reporting a CNCD and seeking care for such a condition incurred catastrophic spending due to CNCDs. The poorest households were more likely to incur catastrophic spending due to CNCDs. An additional 1.7 % of households reporting a CNCD fell under the international poverty line once considering direct costs due to CNCDs.

Conclusion

Our study showed that the economic burden of CNCDs is high, causes catastrophic spending, and aggravates poverty in rural Malawi, a country where in principle basic care for CNCDs should be offered free of charge at point of use through the provision of an Essential Health Package (EHP). Our findings further indicated that particularly high direct, indirect, and total costs were linked to specific diagnoses, although costs were high even for conditions targeted by the EHP. Our findings point at clear gaps in coverage in the current Malawian health system and call for further investments to ensure adequate affordable care for people suffering from CNCDs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1716-8) contains supplementary material, which is available to authorized users.

Evaluating complex health financing interventions: using mixed methods to inform further implementation of a novel PBI intervention in rural Malawi

Background

Gaps remain in understanding how performance-based incentive (PBI) programs affect quality of care and service quantity, whether programs are cost effective and how programs could be tailored to meet client and provider needs while remaining operationally viable. In 2014, Malawi’s Ministry of Health launched the Service Delivery Integration-PBI (SSDI-PBI) program. The program is unique in that no portion of performance bonuses are paid to individual health workers, and it shifts responsibility for infrastructure and equipment procurement from facility staff to implementing partners. This protocol outlines an approach that analyzes processes and outcomes, considers expected and unexpected consequences of the program and frames the program’s outputs relative to its costs. Findings from this evaluation will inform the intended future scale-up of PBI in Malawi.

Methods/design

This study employs a prospective controlled before-and-after triangulation design to assess effects of the PBI program by analyzing quantitative and qualitative data from intervention and control facilities. Guided by a theoretical framework, the evaluation consists of four main components: service provision, health worker motivation, implementation processes and costing. Quality and access outcomes are assessed along four dimensions: (1) structural elements (related to equipment, drugs, staff); (2) process elements (providers’ compliance with standards); (3) outputs (service utilization); (4) experiential elements (experiences of service delivery). The costing component includes costs related to start-up, ongoing management, and the cost of incentives themselves. The cost analysis considers costs incurred within the Ministry of Health, funders, and the implementing agency. The evaluation relies on primary data (including interviews and surveys) and secondary data (including costing and health management information system data).

Discussion

Through the lens of a PBI program, we illustrate how complex interventions can be evaluated via not only primary, mixed-methods data collection, but also through a wealth of secondary data from program implementers (including monitoring, evaluation and financial data), and the health system (including service utilization and service readiness data). We also highlight the importance of crafting a theory and using theory to inform the nature of data collected. Finally, we highlight the need to be responsive to stakeholders in order to enhance a study’s relevance.

A household perspective on access to health care in the context of HIV and disability: a qualitative case study from Malawi

BACKGROUND

Equitable access to health care is a challenge in many low-income countries. The most vulnerable segments of any population face increased challenges, as their vulnerability amplifies problems of the general population. This implies a heavy burden on informal care-givers in their immediate and extended households. However, research falls short of explaining the particular challenges experienced by these individuals and households. To build an evidence base from the ground, we present a single case study to explore and understand the individual experience, to honour what is distinctive about the story, but also to use the individual story to raise questions about the larger context.

METHODS

We use a single qualitative case study approach to provide an in-depth, contextual and household perspective on barriers, facilitators, and consequences of care provided to persons with disability and HIV.

RESULTS

The results from this study emphasise the burden that caring for an HIV positive and disabled family member places on an already impoverished household, and the need for support, not just for the HIV positive and disabled person, but for the entire household.

CONCLUSIONS

Disability and HIV do not only affect the individual, but the whole household, immediate and extended. It is crucial to consider the interconnectedness of the challenges faced by an individual and a household. Issues of health (physical and mental), disability, employment, education, infrastructure (transport/terrain) and poverty are all related and interconnected, and should be addressed as a whole in order to secure equity in health.

Access to Treatment for Diabetes and Hypertension in Rural Cambodia: Performance of Existing Social Health Protection Schemes

Background

Non-communicable diseases (NCD) pose challenges to Cambodia’s health system. Medicines for NCD are on the National Essential Medicines List but no clinical guidelines support their utilization. Two social health protection schemes aimed at the informal sector population exist (Health Equity Funds and Insurance) together with two disease-specific interventions (a Peer Educator Network and Chronic Diseases Clinics) targeted at NCD patients. This study examines performance of these various schemes in relation to NCD.

Methods

Cross-sectional household survey among 709 individuals self-reporting diabetes and/or hypertension in three geographical locations in rural Cambodia using a structured questionnaire investigating diagnostic and treatment pathways, health seeking behaviour, health expenditures, and financial coping mechanisms.

Results

Two third of respondents with NCD were female and 55% did not belong to any scheme. The majority (59%) were diagnosed in the private sector and only 56% were on allopathic treatment that was mainly sought in the private sector (49%). Outpatient treatment cost was higher in the private sector and when using multiple providers of care. The majority were indebted, 11% due to health-related expenses. Contrary to social health protection schemes, disease-specific interventions offered better access to allopathic treatment and provided medicines in accordance with NEML.

Conclusion

The benefit packages of existing social health protection schemes and services in the public health sector should be adjusted to cater for the needs of people living with NCD in rural Cambodia. Initiatives that offer active disease management strategies and promote patients and community participation appear more successful in increasing treatment adherence and decreasing the risk of financial hardship.

Out-of-pocket expenditure and its determinants in the context of private healthcare sector expansion in sub-Saharan Africa urban cities: evidence from household survey in Ouagadougou, Burkina Faso

Background

Conventional wisdom suggests that out-of-pocket (OOP) expenditure reduces healthcare utilization. However, little is known about the expenditure borne in urban settings with the current development of the private health sector in sub-Saharan Africa. In an effort to update knowledge on medical expenditure, this study investigated the level and determinants of OOP among individuals reporting illness or injury in Ouagadougou, Burkina Faso and who either self-treated or received healthcare in either a private or public facility.

Methods

A cross-sectional study was conducted with a representative sample of 1017 households (5638 individuals) between August and November 2011. Descriptive statistics and multivariate techniques including generalized estimating equations were used to analyze the data.

Results

Among the surveyed sample, 29.6 % (n = 1666) persons reported a sickness or injury. Public providers were the single most important providers of care (36.3 %), whereas private and informal providers (i.e.: self-treatment, traditional healers) accounted for 29.8 and 34.0 %, respectively. Almost universally (96 %), households paid directly for care OOP. The average expenditure per episode of illness was 8404XOF (17.4USD) (median 3750XOF (7.8USD). The total expenditure was higher for those receiving care in private facilities compared to public ones [14,613.3XOF (30.3USD) vs. 8544.1XOF (17.7USD); p < 0.001], and the insured patients’ bill almost tripled uninsured (p < 0.001). Finally, medication was the most expensive component of expenditure in both public and private facilities with a mean of 8022.1XOF (16.7USD) and 12,270.5 (25.5USD), respectively.

Conclusion

OOP was the principal payment mechanism of households. A significant difference in OOP was found between public and private provider users. Considering the importance of private healthcare in Burkina Faso, regulatory oversight is necessary. Furthermore, an extensive protection policy to shield households from catastrophic health expenditure is required.

Investigating parents/caregivers financial burden of care for children with non-communicable diseases in Ghana

Background

The introduction of the Ghana national health insurance scheme (NHIS) has led to progressive and significant increase in utilization of health services. However, the financial burden of caring for children with non-communicable diseases (NCDs) under the dispensation of the NHIS, especially during hospitalization, is less researched. This paper therefore sought to assess the financial burden parents/caregivers face in caring for children hospitalized with NCDs in Ghana, in the era of the Ghana NHIS.

Methods

We conducted a cross-sectional survey of 225 parents or caregivers of children with NCDS hospitalized in three hospitals. Convenience sampling was used to select those whose children were discharged from hospital after hospitalization. Descriptive statistics such as frequencies and chi-square and logistic regression were used in data analysis. The main outcome variable was financial burden of care, proxied by cost of hospitalization. The independent variable included socio-economic and other indicators such as age, sex, income levels and financial difficulties faced by parents/caregivers.

Results

The study found that over 30 % of parents/caregivers spend more than Gh¢50 (25$) as cost of treatment of children hospitalized with NCDs; and over 40 % of parents/caregivers also face financial difficulties in providing health care to their wards. It was also found that even though many children hospitalized with NCDs have been covered by the NHIS, and that the NHIS indeed, provides significant financial relief to parents in the care of children with NCDs, children who are insured still pay out-of-pocket for health care, in spite of their insurance status. It was also found that there is less support from relatives and friends in the care of children hospitalized with NCDs, thus exacerbating parents/caregivers financial burden of caring for the children.

Conclusions

Even though health insurance has proven to be of significant relief to the financial burden of caring for children with NCDs, parents/caregivers still face significant financial burden in the care of their wards. Stakeholders in health care delivery should therefore ensure that all children with NCDs including those excluded from the NHIS should be covered by NHIS. A special effort focusing on identifying children with NCDs within the lower income groups, especially from rural areas, in order to exempt them from any form of payment for their health care is recommended.

Factors Affecting the Uptake of HIV Testing among Men: A Mixed-Methods Study in Rural Burkina Faso

Background

This study aimed to explore factors shaping the decision to undergo Human Immunodeficiency Virus (HIV) testing among men in rural Burkina Faso.

Methods

The study took place in 2009 in the Nouna Health District and adopted a triangulation mixed methods design. The quantitative component relied on data collected through a structured survey on a representative sample of 1130 households. The qualitative component relied on 38 in-depth interviews, with men purposely selected to represent variation in testing decision, age, and place of residence. A two-part model was conducted, with two distinct outcome variables, i.e. “being offered an HIV test” and “having done an HIV test”. The qualitative data analysis relied on inductive coding conducted by three independent analysts.

Result

Of the 937 men, 357 had been offered an HIV test and 97 had taken the test. Younger age, household wealth, living in a village under demographic surveillance, and knowing that HIV testing is available at primary health facilities were all positively associated with the probability of being offered an HIV test. Household wealth and literacy were found to be positively associated, and distance was found to be negatively associated with the probability of having taken an HIV test. Qualitative findings indicated that the limited uptake of HIV testing was linked to poor knowledge on service availability and to low risk perceptions.

Conclusion

With only 10% of the total sample ever having tested for HIV, our study confirmed that male HIV testing remains unacceptably low in Sub-Saharan Africa. This results from a combination of health system factors, indicating general barriers to access, and motivational factors, such as one’s own knowledge of service availability and risk perceptions. Our findings suggested that using antenatal care and curative services as the exclusive entry points into HIV testing may not be sufficient to reach large portions of the male population. Thus, additional strategies are urgently needed to increase service uptake.

Out-of-pocket expenditure on chronic non-communicable diseases in sub-Saharan Africa: the case of rural Malawi

In Sub-Saharan Africa (SSA) the disease burden of chronic non-communicable diseases (CNCDs) is rising considerably. Given weaknesses in existing financial arrangements across SSA, expenditure on CNCDs is often borne directly by patients through out-of-pocket (OOP) payments. This study explored patterns and determinants of OOP expenditure on CNCDs in Malawi. We used data from the first round of a longitudinal household health survey conducted in 2012 on a sample of 1199 households in three rural districts in Malawi. We used a two-part model to analyze determinants of OOP expenditure on CNCDs. 475 respondents reported at least one CNCD. More than 60% of the 298 individuals who reported seeking care incurred OOP expenditure. The amount of OOP expenditure on CNCDs comprised 22% of their monthly per capita household expenditure. The poorer the household, the higher proportion of their monthly per capita household expenditure was spent on CNCDs. Higher severity of disease was significantly associated with an increased likelihood of incurring OOP expenditure. Use of formal care was negatively associated with the possibility of incurring OOP expenditure. The following factors were positively associated with the amount of OOP expenditure: being female, Alomwe and household head, longer duration of disease, CNCDs targeted through active screening programs, higher socio-economic status, household head being literate, using formal care, and fewer household members living with a CNCD within a household. Our study showed that, in spite of a context where care for CNCDs should in principle be available free of charge at point of use, OOP payments impose a considerable financial burden on rural households, especially among the poorest. This suggests the existence of important gaps in financial protection in the current coverage policy.