Porous safety net: catastrophic health expenditure and its determinants among insured households in Togo

Incidence and determinants of out-of-pocket health expenditure in Ethiopia 2012-16

This study assesses the incidence of catastrophic health expenditure (CHE) and identifies the significant factors that expose households to higher levels of out-of-pocket (OOP) health expenditure. Data from the fifth and the sixth Ethiopian National Health Accounts household surveys, which were conducted in 2012-13 and 2015-16, respectively, are used. The incidence of CHE is estimated using both the capacity-to-pay and the budget share approaches. To ensure the robustness of our findings, both unconditional and conditional quantile estimators are adopted as multivariate regression techniques to estimate the impact of socio-economic variables on the distribution of households' OOP expenditure. Our findings show that the incidence of CHE in Ethiopia ranges from 1.7% to 4.7% depending on the approach and the threshold adopted. Larger families, the unemployed, the extremely poor, those who seek care at private-owned providers and families with members affected by chronic illness face higher OOP expenditure. Hence, policy should target those with these identified socio-economic characteristics in the provision of financial risk protection such as fee waiver systems and subsidies.

Do national health insurance schemes guarantee financial risk protection in the drive towards Universal Health Coverage in West Africa? A systematic review of observational studies

To facilitate the drive towards Universal Health Coverage (UHC) several countries in West Africa have adopted National Health Insurance (NHI) schemes to finance health services. However, safeguarding insured populations against catastrophic health expenditure (CHE) and impoverishment due to health spending still remains a challenge. This study aims to describe the extent of financial risk protection among households enrolled under NHI schemes in West Africa and summarize potential learnings. We conducted a systematic review following the PRISMA guidelines. We searched for observational studies published in English between 2005 and 2022 on the following databases: PubMed/Medline, Web of Science, CINAHL, Embase and Google Scholar. We assessed the study quality using the Joanna Briggs Institute (JBI) critical appraisal checklist. Two independent reviewers assessed the studies for inclusion, extracted data and conducted quality assessment. We presented our findings as thematic synthesis for qualitative data and Synthesis Without Meta-analysis (SWiM) for quantitative data. We published the study protocol in PROSPERO with ID CRD42022338574. Nine articles were eligible for inclusion, comprising eight cross-sectional studies and one retrospective cohort study published between 2011 and 2021 in Ghana (n = 8) and Nigeria (n = 1). While two-thirds of the studies reported a positive (protective) effect of NHI enrollment on CHE at different thresholds, almost all of the studies (n = 8) reported some proportion of insured households still encountered CHE with one-third reporting more than 50% incurring CHE. Although insured households seemed better protected against CHE and impoverishment compared to uninsured households, gaps in the current NHI design contributed to financial burden among insured populations. To enhance financial risk protection among insured households and advance the drive towards UHC, West African governments should consider investing more in NHI research, implementing nationwide compulsory NHI programmes and establishing multinational subregional collaborations to co-design sustainable context-specific NHI systems based on solidarity, equity and fair financial contribution.

Perspectives of key decision makers on out-of-pocket payments for medicines in the Ethiopian healthcare system: a qualitative interview study

OBJECTIVE

This study aimed to explore the perspectives of key decision makers on out-of-pocket (OOP) payment for medicines and its implications in the Ethiopian healthcare system.

DESIGN

A qualitative design that employed audiorecorded semistructured in-depth interviews was used in this study. The framework thematic analysis approach was followed in the analysis.

SETTING

Interviewees came from five federal-level institutions engaged in policymaking (three) and tertiary referral-level healthcare service provision (two) in Ethiopia.

PARTICIPANTS

Seven pharmacists, five health officers, one medical doctor and one economist who held key decision-making positions in their respective organisations participated in the study.

RESULT

Three major themes were identified in the areas of the current context of OOP payment for medicines, its aggravating factors and a plan to reduce its burden. Under the current context, participants' overall opinions, circumstances of vulnerability and consequences on households were identified. Factors identified as aggravating the burden of OOP payment were deficiencies in the medicine supply chain and limitations in the health insurance system. Suggested mitigation strategies to be implemented by the health providers, the national medicines supplier, the insurance agency and the Ministry of Health were categorised under plans to reduce OOP payment.

CONCLUSION

The findings of this study indicate that there is widespread OOP payment for medicines in Ethiopia. System level constraints such as weaknesses in the supply system at the national and health facility levels have been identified as critical factors that undermine the protective effects of health insurance in the Ethiopian context. Ensuring steady access to essential medicines requires addressing health system and supply constraints in addition to a well-functioning financial risk protection systems.

Catastrophic health expenditure and household impoverishment in Togo

Background

The main way of financing healthcare in low-income countries continues to be out-of-pocket payments. Despite the efforts of national authorities and international partners to protect households from impoverishment arising from seeking healthcare, the risk of incurring catastrophic healthcare expenses remains very high for households in developing countries. This study aims to analyse catastrophic health expenditures and their effects on household impoverishment in Togo.

Design and methods

Data were obtained from the CWIQ survey, a nationally representative survey conducted in 2015 among 2400 households.We calculated the incidence and the intensity of catastrophic health expenditures in Togo through various thresholds and then estimated the effects of these expenditures on the level of households' impoverishment by determining poverty levels using consumption expenditure before and after making payments for healthcare.

Results

The results indicate that the incidence of catastrophic expenditure varies between 6% and 57% depending on the thresholds used. Households at risk of catastrophic expenditure spend between 19% and 64% of their spending on healthcare. Based on total expenditure and above 20%, the richest households are more prone to catastrophic health expenditures. The findings also show that the incidence of impoverishment caused by health expenditure payments is 8.2% in relative terms and 4.52% in absolute terms. In Togo, 4.52% of households are impoverished by catastrophic health expenditures. This impoverishment effect is greater for male-headed households.

Conclusions

Health system reforms aiming at accessibility to quality care and the development of pre-payment mechanisms will promote the earlier use of healthcare services and thus reduce the higher healthcare costs generated by later attendance at them.

Predicting health services utilization using a score of perceived barriers to medical care: evidence from rural Senegal

BACKGROUND

Ensuring access to healthcare services is a key element to achieving the Sustainable Development Goal 3 of "promoting healthy lives and well-being for all" through Universal Health Coverage (UHC). However, in the context of low- and middle-income countries, most studies focused on financial protection measured through catastrophic health expenditures (CHE), or on health services utilization among specific populations exhibiting health needs (such as pregnancy or recent sickness).

METHODS

This study aims at building an individual score of perceived barriers to medical care (PBMC) in order to predict primary care utilization (or non-utilization). We estimate the score on six items: (1) knowing where to go, (2) getting permission, (3) having money, (4) distance to the facility, (5) finding transport, and (6) not wanting to go alone, using individual data from 1787 adult participants living in rural Senegal. We build the score via a stepwise descendent explanatory factor analysis (EFA), and assess its internal consistency. Finally, we assess the construct validity of the factor-based score by testing its association (univariate regressions) with a wide range of variables on determinants of healthcare-seeking, and evaluate its predictive validity for primary care utilization.

RESULTS

EFA yields a one-dimensional score combining four items with a 0.7 Cronbach's alpha indicating good internal consistency. The score is strongly associated-p-values significant at the 5% level-with determinants of healthcare-seeking (including, but not limited to, sex, education, marital status, poverty, and distance to the health facility). Additionally, the score can predict non-utilization of primary care at the household level, utilization and non-utilization of primary care following an individual's episode of illness, and utilization of primary care during pregnancy and birth. These results are robust to the use of a different dataset.

CONCLUSION

As a valid, sensitive, and easily documented individual-level indicator, the PBMC score can be a complement to regional or national level health services coverage to measure health services access and predict utilization. At the individual or household level, the PBMC score can also be combined with conventional metrics of financial risk protection such as CHE to comprehensively document deficits in, and progress towards UHC.

In Ethiopia's Kutaber district, does community-based health insurance protect households from catastrophic health-care costs? A community- based comparative cross-sectional study

OBJECTIVE

Every health system needs to take action to shield households from the expense of medical costs. The Ethiopian government implemented community-based health insurance (CBHI) to protect households from catastrophic health care expenditure (CHE) and enhance the utilization of health care services. The impact of CBHI on CHE with total household expenditure and non-food expenditure measures hadn't been studied, so the study aimed to evaluate the impact of CBHI on CHE among households in Kutaber district, Ethiopia.

METHODS

A total of 472 households (225 insured and 247 uninsured) were selected by multistage sampling techniques. Households total out-of-pocket (OOP) health payments ≥10% threshold of total household expenditure or ≥40% threshold of household non-food expenditure categorized as CHE. The co-variants for participation in the CBHI scheme were estimated by using a probit regression model. A propensity score matching analysis was used to determine the impact of CBHI on CHE. A Chi-square (χ2) test was computed to compare CHE between insured and uninsured households.

RESULTS

The magnitude of CHE was 39.1% with total household expenditure and 1.8% with non-food expenditure measures among insured households. Insured households were 46.3% protected from CHE when compared to uninsured households with total household expenditure measures and 24.2% to 25% with non-food expenditure measures.

CONCLUSION

The magnitude of CHE was lower among CBHI-enrolled households. CBHI is an effective means of financial protection benefits for households as a share of total household expenditure and non-food expenditure measures. Therefore, increasing the upper limits of benefit packages, minimizing exclusions, and CBHI scale-up to uninsured households is essential.

Mandatory health insurance and health care utilization in Togo

BACKGROUND

Despite the implementation of a mandatory health insurance (MHI) scheme in Togo since 2011, its coverage rate remains low, resulting in a high out-of-pocket payment rate. More than 10 years after its implementation, there are few empirical studies investigating the extent to which Togo's mandatory health insurance has improved beneficiaries' access to health care. Examining how MHI and healthcare use in Togo are related is the goal of this study.

METHODS

We use data from the Harmonized Survey on Living Conditions of Households (EHCVM), conducted in the member states of the West African Economic and Monetary Union (WAEMU) in 2018-2019 and covering 6,171 households in Togo. We employ multinomial logistic regression, given that the dependent variable is polytomous.

RESULTS

The results reveal a high rate of non-utilization of healthcare professionals in the case of illness, even among individuals with MHI coverage. Furthermore, the findings show that the MHI increases the likelihood of seeing a specialist physician and other formal health care professionals when sick. The results also reveal that a household's wealth is positively correlated with the likelihood of seeing formal health care professionals. Urban residents are statistically and significantly more likely than rural residents to see both a specialist physician and a general practitioner. The Grand Lomé region has a statistically and significantly higher likelihood of seeing a specialist physician than the Maritime region.

CONCLUSION

The results support the government's plan to implement universal health insurance. The government should take action to raise the standard of treatment provided to insured patients in health care centers. Additionally, the government should consider waiving medical fees for low-income policyholders. When waiving medical costs for low-income policyholders, the Togolese government should focus on the regions with the worst economic conditions. These interventions should be essential to ensure that no one is left behind. The difference between urban and rural communities should be reduced through supply-side policies that focus on rural areas.

Factors associated with catastrophic health expenditure in sub-Saharan Africa: A systematic review

OBJECTIVE

A non-negligible proportion of sub-Saharan African (SSA) households experience catastrophic costs accessing healthcare. This study aimed to systematically review the existing evidence to identify factors associated with catastrophic health expenditure (CHE) incidence in the region.

METHODS

We searched PubMed, CINAHL, Scopus, CNKI, Africa Journal Online, SciELO, PsycINFO, and Web of Science, and supplemented these with search of grey literature, pre-publication server deposits, Google Scholar®, and citation tracking of included studies. We assessed methodological quality of included studies using the Appraisal tool for Cross-Sectional Studies for quantitative studies and the Critical Appraisal Skills Programme checklist for qualitative studies; and synthesized study findings according to the guidelines of the Economic and Social Research Council.

RESULTS

We identified 82 quantitative, 3 qualitative, and 4 mixed-methods studies involving 3,112,322 individuals in 650,297 households in 29 SSA countries. Overall, we identified 29 population-level and 38 disease-specific factors associated with CHE incidence in the region. Significant population-level CHE-associated factors were rural residence, poor socioeconomic status, absent health insurance, large household size, unemployed household head, advanced age (elderly), hospitalization, chronic illness, utilization of specialist healthcare, and utilization of private healthcare providers. Significant distinct disease-specific factors were disability in a household member for NCDs; severe malaria, blood transfusion, neonatal intensive care, and distant facilities for maternal and child health services; emergency surgery for surgery/trauma patients; and low CD4-count, HIV and TB co-infection, and extra-pulmonary TB for HIV/TB patients.

CONCLUSIONS

Multiple household and health system level factors need to be addressed to improve financial risk protection and healthcare access and utilization in SSA.

PROTOCOL REGISTRATION

PROSPERO CRD42021274830.

Catastrophic health expenditure in sub-Saharan Africa: systematic review and meta-analysis

Objective

To estimate the incidence of, and trends in, catastrophic health expenditure in sub-Saharan Africa.

Methods

We systematically reviewed the scientific and grey literature to identify population-based studies on catastrophic health expenditure in sub-Saharan Africa published between 2000 and 2021. We performed a meta-analysis using two definitions of catastrophic health expenditure: 10% of total household expenditure and 40% of household non-food expenditure. The results of individual studies were pooled by pairwise meta-analysis using the random-effects model.

Findings

We identified 111 publications covering a total of 1 040 620 households across 31 sub-Saharan African countries. Overall, the pooled annual incidence of catastrophic health expenditure was 16.5% (95% confidence interval, CI: 12.9-20.4; 50 datapoints; 462 151 households; I 2 = 99.9%) for a threshold of 10% of total household expenditure and 8.7% (95% CI: 7.2-10.3; 84 datapoints; 795 355 households; I 2 = 99.8%) for a threshold of 40% of household non-food expenditure. Countries in central and southern sub-Saharan Africa had the highest and lowest incidence, respectively. A trend analysis found that, after initially declining in the 2000s, the incidence of catastrophic health expenditure in sub-Saharan Africa increased between 2010 and 2020. The incidence among people affected by specific diseases, such as noncommunicable diseases, HIV/AIDS and tuberculosis, was generally higher.

Conclusion

Although data on catastrophic health expenditure for some countries were sparse, the data available suggest that a non-negligible share of households in sub-Saharan Africa experienced catastrophic expenditure when accessing health-care services. Stronger financial protection measures are needed.

Examining the incidence of catastrophic health expenditures and its determinants using multilevel logistic regression in Malawi

BACKGROUND

Despite a free access to public health services policy in most sub-Saharan African countries, households still contribute to total health expenditures through out-of-pocket expenditures. This reliance on out-of-pocket expenditures places households at a risk of catastrophic health expenditures and impoverishment. This study examined the incidence of catastrophic health expenditures, impoverishing effects of out-of-pocket expenditures on households and factors associated with catastrophic expenditures in Malawi.

METHODS

We conducted a secondary analysis of the most recent nationally representative integrated household survey conducted by the National Statistical Office between April 2016 to 2017 in Malawi with a sample size of 12447 households. Catastrophic health expenditures were estimated based on household annual nonfood expenditures and total household annual expenditures. We estimated incidence of catastrophic health expenditures as the proportion of households whose out-of-pocket expenditures exceed 40% threshold level of non-food expenditures and 10% of total annual expenditures. Impoverishing effect of out-of-pocket health expenditures on households was estimated as the difference between poverty head count before and after accounting for household health payments. We used a multilevel binary logistic regression model to assess factors associated with catastrophic health expenditures.

RESULTS

A total of 167 households (1.37%) incurred catastrophic health expenditures. These households on average spend over 52% of household nonfood expenditures on health care. 1.6% of Malawians are impoverished due to out-of-pocket health expenditures. Visiting a religious health facility (AOR = 2.27,95% CI:1.24-4.15), hospitalization (AOR = 6.03,95% CI:4.08-8.90), larger household size (AOR = 1.20,95% CI:1.24-1.34), higher socioeconomic status (AOR = 2.94,95% CI:1.39-6.19), living in central region (AOR = 3.54,95% CI:1.79-6.97) and rural areas (AOR = 5.13,95% CI:2.14-12.29) increased the odds of incurring catastrophic expenditures.

CONCLUSION

The risk of catastrophic health expenditures and impoverishment persists in Malawi. This calls for government to improve the challenges faced by the free public health services and design better prepayment mechanisms to protect more vulnerable groups of the population from the burden of out-of-pocket payments.

Analysis of the effect of serious illness medical insurance on relieving the economic burden of rural residents in China: a case study in Jinzhai County

Background

In 2003, China established a New Rural Cooperative Medical System (NRCMS) for rural residents to alleviate the burden of medical expenses among rural residents. However, its reimbursement for high medical costs was insufficient. Therefore, China gradually established the Serious Illness Insurance System (SIMIS) based on NRCMS. After receiving payment through NRCMS, patients in rural areas who met the requirements of SIMIS policy would receive a second payment for their high medical expenses. This study aimed to analyze the effect of the implementation of SIMIS on alleviating the economic burden of rural residents in Jinzhai County.

Methods

The study used the inpatient reimbursement data of NRCMS in Jinzhai County, Anhui Province, from 2013 to 2016. We adopted descriptive and regression discontinuity (RD) methods to analyze the payment effect of SIMIS. The RD analysis targeted patients (n = 7353) whose annual serious illness expenses were between CNY 10,000 (1414 USD) and CNY 30,000 (4242 USD), whereas the descriptive analysis was used for data of the patients compensated by SIMIS (n = 2720).

Results

The results of RD showed that the actual medical insurance payment proportion increased by about 2.5% (lwald = 0.025, P < 0.01), inside medical insurance self-payment proportion increased by about 2% (lwald = 0.020, P < 0.10), and outside medical insurance self-payment proportion decreased by about 1.6% (lwald = − 0.016, P < 0.05). The descriptive results showed that patients with serious illnesses mostly chose to go to a hospital outside the county. The annual average number of hospitalizations was 3.64. The reimbursement mainly came from the NRCMS. The payment amount of SIMIS was relatively small, and the out-of-pocket medical expenses were still high.

Conclusion

The medical technology level of Jinzhai County could not meet the needs of patients with seriously illnesses, the number of beneficiaries of SIMIS was small, and the ability to relieve the burden of medical expenses of the rural residents was insufficient. The high out-of-pocket expenses increased the possibility that only people with good economic conditions could benefit from the reimbursement of SIMIS, resulting in inequity.

Does the type of health insurance enrollment affect provider choice, utilization and health care expenditures?

BACKGROUND

Two of the objectives of Universal Health Coverage are equity in access to health services and protection from financial risks. This paper seeks to examine whether the type of health insurance enrollment affects the utilization of health services, choice of provider and financial protection of households in Togo.

METHODS

Data were obtained from a cross-sectional, representative household survey involving 1180 insured households that had reported either illness in the household in the 4 weeks preceding the survey or hospitalization in the 12 months preceding the survey. A nested logit model was used to account for the utilization of health services and provider choice, and methods of assessing catastrophic health care expenditures were used to analyze the level of household financial protection.

RESULTS

Policyholders of private health insurance use private health care facilities more than policyholders of public health insurance. The main reasons for not using health centers among households with public insurance were out-of-pocket payments (49.19%), waiting time (36.80%), and distance to the nearest health center (36.76%). Furthermore, on average, households with public insurance spent a higher proportion of their total monthly nonfood expenditures on health care than those with private insurance. We find that the type of insurance, share of expenditures allocated to food, distance to the nearest health center, and waiting time significantly impact the choice of provider. Regardless of the type of health insurance, elderly individuals avoid using private health centers and referral hospitals due to the high cost.

CONCLUSION

We found that a multiple health insurance system results in a multilevel health system that is not equitable for everyone. The capacity of the health insurance system to provide equitable health care services and protect its members from catastrophic health care expenditures should be at the core of health care reform. This study recommends raising awareness of the criteria for the reimbursement of medical procedures within the framework of public insurance and promoting specific health insurance mechanisms for elderly individuals. Careful attention should be paid to ensuring universal education and literacy as a means of improving access to and the use of health care.

The burden of household out-of-pocket health expenditures in Ethiopia: estimates from a nationally representative survey (2015-16)

In Ethiopia, little is known about the extent of out-of-pocket health expenditures and the associated financial hardships at national and regional levels. We estimated the incidence of both catastrophic and impoverishing health expenditures using data from the 2015/16 Ethiopian household consumption and expenditure and welfare monitoring surveys. We computed incidence of catastrophic health expenditures (CHE) at 10% and 25% thresholds of total household consumption and 40% threshold of household capacity to pay, and impoverishing health expenditures (IHE) using Ethiopia's national poverty line (ETB 7184 per adult per year). Around 2.1% (SE: 0.2, P < 0.001) of households would face CHE with a 10% threshold of total consumption, and 0.9% (SE: 0.1, P < 0.001) of households would encounter IHE, annually in Ethiopia. CHE rates were high in the regions of Afar (5.8%, SE: 1.0, P < 0.001) and Benshangul-Gumuz (4.0%, SE: 0.8, P < 0.001). Oromia (n = 902 000), Amhara (n = 275 000) and Southern Nations Nationalities and Peoples (SNNP) (n = 268 000) regions would have the largest numbers of affected households, due to large population size. The IHE rates would also show similar patterns: high rates in Afar (5.0%, SE: 0.96, P < 0.001), Oromia (1.1%, SE: 0.22, P < 0.001) and Benshangul-Gumuz (0.9%, SE: 0.4, P = 0.02); a large number of households would be impoverished in Oromia (n = 356 000) and Amhara (n = 202 000) regions. In summary, a large number of households is facing financial hardship in Ethiopia, particularly in Afar, Benshangul-Gumuz, Oromia, Amhara and SNNP regions and this number would likely increase with greater health services utilization. We recommend regional-level analyses on services coverage to be conducted as some of the estimated low CHE/IHE regional values might be due to low services coverage. Periodic analyses on the financial hardship status of households could also be monitored to infer progress towards universal health coverage.

Socio-economic inequality in maternal health care utilization in Sub-Saharan Africa: Evidence from Togo

INTRODUCTION

Despite improvements in health care in Togo, the maternal mortality rate remains high, and regional antenatal care and facility-based deliveries are limited. The aim of this study is to measure socioe-conomic inequality in maternal health care (MHC) utilization during pregnancy and delivery.

METHOD

The data were obtained from the last two rounds of the 1998 and 2013 Togo Demographic and Health Survey. Concentration index, concentration curve and logistic regression were used to measure and examine socio-economic inequality in antenatal care and facility-based deliveries.

RESULTS

The concentration indices for antenatal visits and facility-based deliveries were 0.142 and 0.246 in 1998 and 0.129 and 0.159 in 2013, indicating inequality bias towards the rich in both. Household wealth status and women's education were the most significant contributors to inequality in antenatal visits and facility-based deliveries. In 2013, household economic status contributed approximately 75.66% of the inequality in facility-based deliveries, while mothers' education significantly contributed approximately 18.22% to the inequality in antennal visits. Additionally, universal health coverage should be considered as one of the main vehicles for reducing inequalities in the use of MHCs.

CONCLUSION

The results suggest that inequality in MHC utilization during pregnancy and delivery may be effectively reduced by improving the relevant strategies, in particular, those targeted at reducing poverty and illiteracy. School curricula need to be comprehensively addressed for ensuring essential sexual and reproductive education. Our results suggest that the use of MHC can be increased by broadening health insurance to include exemptions for poor and rural households.

Access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya

Background

Access to primary healthcare is crucial for the delivery of Kenya’s universal health coverage policy. However, disparities in healthcare have proved to be the biggest challenge for implementing primary care in poor-urban resource settings. In this study, we assessed the level of access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya.

Methods

The data were drawn from the Lown scholars’ study of 300 randomly selected households in Viwandani slums (Nairobi, Kenya), between June and July 2018. Access to primary care was measured using Penchansky and Thomas’ model. Access index was constructed using principal component analysis and recorded into tertiles with categories labeled as poor, moderate, and highest. Generalized ordinal logistic regression analysis was used to determine the factors associated with access to primary care. The adjusted odds ratios (AOR) and 95% confidence intervals were used to interpret the strength of associations.

Results

The odds of being in the highest access tertile versus the combined categories of lowest and moderate access tertile were three times higher for males than female-headed households (AOR 3.05 [95% CI 1.47–6.37]; p < .05). Households with an average quarterly out-of-pocket healthcare expenditure of ≥USD 30 had significantly lower odds of being in the highest versus combined categories of lowest and moderate access tertile compared to those spending ≤ USD 5 (AOR 0.36 [95% CI 0.18–0.74]; p < .05). Households that sought primary care from private facilities had significantly higher odds of being in the highest versus combined categories of lowest and moderate access tertiles compared to those who sought care from public facilities (AOR 6.64 [95% CI 3.67–12.01]; p < .001).

Conclusion

In Nairobi slums in Kenya, living in a female-headed household, seeking care from a public facility, and paying out-of-pocket for healthcare are significantly associated with low access to primary care. Therefore, the design of the UHC program in this setting should prioritize quality improvement in public health facilities and focus on policies that encourage economic empowerment of female-headed households to improve access to primary healthcare.

Cost-related unmet need for healthcare services in Kenya

Background

The assessment of unmet need is one way to gauge inequities in access to healthcare services. While there are multiple reasons for unmet need, financial barriers are a major reason particularly in low- and middle-income countries where healthcare systems do not offer financial protection. Moreover, accessibility and affordability are paramount in achieving universal health coverage. This study examines the extent of unmet need in Kenya due to financial barriers, the associated determinants, and the influence of regional variations.

Methods

We use data from the 2013 Kenya household health expenditure and utilization (KHHEUS) cross sectional survey. Self-reported unmet need due to lack of money and high costs of care is used to compute the outcome of interest. A multilevel regression model is employed to assess the determinants of cost-related unmet need, confounding for the effect of variations at the regional level.

Results

Cost-related barriers are the main cause of unmet need for outpatient and inpatient services, with wide variations across the counties. A positive association between county poverty rates and cost-related unmet is noted. Results reveal a higher intraclass correlation coefficient (ICC) of 0.359(35.9%) for inpatient services relative to 0.091(9.1%) for outpatient services. Overall, differences between counties accounted for 9.4% (ICC ~ 0.094) of the total variance in cost-related unmet need. Factors that positively influence cost-related unmet need include older household heads, inpatient services, and urban residence. Education of household head, good self-rated health, larger household size, insured households, and higher wealth quintiles are negatively associated with cost-related unmet need.

Conclusion

The findings underscore the important role of cost in enabling access to healthcare services. The county level is seen to have a significant influence on cost-related unmet need. The variations noted in cost-related unmet need across the counties signify the existence of wide disparities within and between counties. Scaling up of health financing mechanisms would fundamentally require a multi-layered approach with a focus on the relatively poor counties to address the variations in access. Further segmentation of the population for better targeting of health financing policies is paramount, to address equity in access for the most vulnerable and marginalized populations.

Effect of Critical Illness Insurance on Household Catastrophic Health Expenditure: The Latest Evidence from the National Health Service Survey in China

BACKGROUND

China fully implemented the critical illness insurance (CII) program in 2016 to alleviate the economic burden of diseases and reduce catastrophic health expenditure (CHE). With an aging society, it is necessary to analyze the extent of CHE among Chinese households and explore the effect of CII and other associated factors on CHE.

METHODS

Data were derived from the Sixth National Health Service Survey (NHSS, 2018) in Jiangsu Province. The incidence and intensity of CHE were calculated with a sample of 3660 households in urban and rural areas in Jiangsu Province, China. Logistic regression and multiple linear regression models were used for estimating the effect of CII and related factors on CHE.

RESULTS

The proportion of households with no one insured by CII was 50.08% (1833). At each given threshold, from 20% to 60%, the incidence and intensity were higher in rural households than in urban ones. CII implementation reduced the incidence of CHE but increased the intensity of CHE. Meanwhile, the number of household members insured by CII did not affect CHE incidence but significantly decreased CHE intensity. Socioeconomic factors, such as marital status, education, employment, registered type of household head, household income and size, chronic disease status, and health service utilization, significantly affected household CHE.

CONCLUSIONS

Policy effort should further focus on appropriate adjustments, such as dynamization of CII lists, medical cost control, increasing the CII coverage rate, and improving the reimbursement level to achieve the ultimate aim of using CII to protect Chinese households against financial risk caused by illness.

Exploring the determinants of distress health financing in Cambodia

Borrowing is a common coping strategy for households to meet healthcare costs in countries where social health protection is limited or non-existent. Borrowing with interest, hereinafter termed distress health financing or distress financing, can push households into heavy indebtedness and exacerbate the financial consequences of healthcare costs. We investigated distress health financing practices and associated factors among Cambodian households, using primary data from a nationally representative household survey of 5000 households. Multivariate logistic regression was used to determine factors associated with distress health financing. Results showed that 28.1% of households consuming healthcare borrowed to pay for that healthcare with 55% of these subjected to distress financing. The median loan was US$125 (US$200 for loans with interest and US$75 for loans without interest). Approximately 50.6% of healthcare-related loans were to pay for the costs of outpatient care in the past month, 45.8% for inpatient care and 3.6% for preventive care in the past 12 months. While the average period to pay off the loan was 8 months, 78% of households were still indebted from loans taken over 12 months before the survey. Distress financing is strongly associated with household poverty-the poorer the household the more likely it is to borrow, fall into debt and unable to pay off the debt-even for members of the health equity funds, a national scheme designed to improve financial access to health services for the poor. Other determinants of distress financing were household size, use of inpatient care and outpatient consultations with private providers or with both private and public providers. In order to ensure effective financial risk protection, Cambodia should establish a more comprehensive and effective social health protection scheme that provides maximum population coverage and prioritizes services for populations at risk of distress financing, especially poorer and larger households.

A review of the incidence and determinants of catastrophic health expenditure in Nigeria: Implications for universal health coverage

BACKGROUND

In the Nigerian context, preconditions for financial catastrophe are operational as there is high out-of-pocket spending (OOPS) on health with low capacity to pay, presence of user fees, and poor prepayment insurance coverage. We reviewed the incidence and determinants of catastrophic health expenditure (CHE) in Nigeria.

METHODS

Databases including PubMed, OVID, EMBASE, CINAHL, and Web of Science were searched for primary research studies on the incidence and determinants of CHE in Nigeria published between 2003 and 2018. Search terms used include household, out-of-pocket expenditure, catastrophic health expenditure, and Nigeria.

RESULTS

Twenty studies that met the inclusion criteria were included in the review. At 10% of total household and nonfood expenditure, the incidence of CHE was 8.2% to 50%, while 3.2% to 100% households incurred CHE at 40% of nonfood expenditure. The incidence of CHE was higher among inpatients and studies with lower threshold definitions. Outpatient CHE was highest for type 2 diabetes and tuberculosis while human immunodeficiency virus (HIV) care incurred the most CHE among inpatients. Determinants of CHE include wealth status, age, gender, place of residence/geographical location, household size/composition, educational status, health insurance status, illness, and health provider types.

CONCLUSION

There is a high incidence of CHE across various common health conditions in Nigeria. CHE was more among the poor, elderly, rural dwellers, private facility utilization, female gender, and noninsured among others. We recommend expansion of the National Health Insurance Scheme via informal social and financing networks platforms. Increased budgetary allocation to health and intersectoral collaboration will also play a significant role in CHE reduction.

Health shocks in sub-Saharan Africa: are the poor and uninsured households more vulnerable?

BACKGROUND

In developing countries, health shock is one of the most common idiosyncratic income shock and the main reason why households fall into poverty. Empirical research has shown that in these countries, households are unable to access formal insurance markets in order to insure their consumption against health shocks. Thus, in this study, are the poor and uninsured households more vulnerable from health shocks? We investigate the factors that lead to welfare loss from health shocks, and how to break the vulnerability from health shocks in three Sub-Saharan Africa (SSA) countries, namely, Burkina Faso, Niger and Togo.

METHODS

This study focusses on 1597 households in Burkina Faso, 1342 households in Niger and 930 households in Togo. A three-step Feasible Generalized Least Squares (FGLS) method was used to estimate vulnerability to poverty and to model the effects of health shocks on vulnerability to poverty.

RESULTS

The estimates of vulnerability show that about 39.04%, 33.69%, and 69.03% of households are vulnerable to poverty, in Burkina Faso, Niger, and Togo respectively. Both interaction variables, 'health shocks and wealth' and 'health shocks and access to health insurance' had a significant negative effect on reducing household's vulnerability to poverty. Poverty is the leading cause of economic loss from health shocks as the poorer cannot afford the purchase of sufficient quantities of quality food, preventive and curative health care, and education. We found that lack of health insurance coverage had a significant effect by increasing the incidence of welfare loss from health shocks. Moreover, household size, type of health care used, gender, education and age of the head of the household as well as the characteristics of housing affect vulnerability to poverty.

CONCLUSION

Our findings suggest that for the poor households, reduction of user fees of health care at the point of service or expansion of health insurance could mitigate vulnerability to poverty. Other challenges-birth control policy, adequate sanitation facilities and a universal basic education program-need to be addressed in order to reduce significantly the effects of health shocks on vulnerability to poverty in SSA.

Extension of mandatory health insurance to informal sector workers in Togo

BACKGROUND

About 90.4% of Togolese workers operate in the informal sector and account for between 20 and 30% of Togo's Gross Domestic Product. Despite their importance in the Togolese economy, informal sector workers (ISW) do not have a health insurance scheme. This paper aims to estimate the willingness-to-pay (WTP) of ISW in order to have access to Mandatory Health Insurance (MHI), and to analyze the main determinants of WTP.

METHODS

This study used data from the Community-Based Monitoring System (CBMS) project implemented in 2015 by the Partnership for Economic Policy (PEP). It focusses on 4,296 ISW (2,374 in urban areas and 1,922 in rural areas, respectively). The contingent valuation method was used to determine the WTP for the MHI while the Tobit model is used to analyze its determinants.

RESULTS AND DISCUSSION

Findings indicate that about 92% of ISW agreed to have access to MHI, like for formal sector workers. Overall, ISW are willing to pay 2,569 FCFA (USD 4.7) per month. ISW in the poorest quintiles are willing to allocate a higher proportion of their income (15%) to the premium than the richest quintiles (2.5%). Generally, women are more interested in MHI than men, although men are willing to pay higher premiums (3,168.9 FCFA or USD 5.8) than women (2,077 FCFA or USD 3.8). Women's lower WTP can be explained by their low levels of education and income, and a lack of employment opportunities compared to men. The gender of the head of the household, the size of the household and the education and income levels are the main determinants of WTP.

CONCLUSION

We conclude that it is possible to extend MHI to ISW as long as their premiums are subsidized. The annual subsidy is estimated at 4.1% of the state current general budget or 96% of the health sector budget. In setting the premium, policy makers should take into account the MHI benefits package, subsidies from the government, and information about the WTP. It is important to emphasize that resource mobilization and management, as well as health services delivery, would be effective only in a context of improved governance.