Distribution of out of pocket health expenditures in a sub-Saharan Africa country: evidence from the national survey of household standard of living, Côte d'Ivoire

Persistency of catastrophic out-of-pocket health expenditures: Measurement with evidence from three African countries - Malawi, Tanzania, and Uganda

Catastrophic out-of-pocket health expenditure (CHE) remain high in Sub-Saharan Africa and may not conform to the sporadic random pattern of acute illnesses that shapes insurance arrangements intended to avoid the risk of financial loss. The persistency of CHE remains a largely unexplored issue due to the lack of relevant methods and scarcity of panel data. This paper addresses the first shortcoming by presenting three different approaches to incorporating the timeframes into the analysis, considering dynamics between two periods, average over time and the recurrence of CHE incidence. Through the application of the complementary approaches, we identify (i) those at risk of persistent CHE in the short-term; (ii) those facing transient versus persistent CHE in the long-term; and (iii) those facing multiple CHE spells. The methods are applied to different definitions of CHE using panel data from three sub-Saharan countries: Malawi (3 waves: 2010, 2013, and 2016) with 4983 observations; Tanzania (3 waves: 2008, 2010, and 2012) with 8715 observations; and Uganda (5 waves: 2009, 2010, 2011, 2013, and 2015) with 6475 observations. All datasets are balanced panels. Additionally, we employ empirical strategies to identify the underlying factors contributing to these persistent and relatively high OOP. Across the three countries, we find that at least 27% of the people facing CHE in one period, because they spent more than 5% of their household budget on health out-of-pocket, will face it again in the next period. The lower-bound risk for those spending more than 10% of their household budget is 9% and for those spending more than 25% of their household capacity to pay is 13%. Between 11% and 45% of the population incurred CHE at least twice during the observation period when using the 5% budget definition of CHE. The double recurrence rate ranges between 7% and 13% when using the 25% capacity-to-pay definition and between 3% and 20% when using the 10% budgetshare definition. Between 22% and 32% of the population experienced chronic CHE at the 5% of the budgetshare definition (6%-10% at the 10% of the budgetshare definition of CHE; 2%-11% at 25% of capacity-to-pay). Our panel regression analysis consistently highlights the susceptibility of certain groups to face persistence CHE, notably those residing in rural areas, individuals with lower levels of education, the elderly, and those who have undergone hospitalizations.

The economics of healthcare access: a scoping review on the economic impact of healthcare access for vulnerable urban populations in low- and middle-income countries

BACKGROUND

The growing urban population imposes additional challenges for health systems in low- and middle-income countries (LMICs). We explored the economic burden and inequities in healthcare utilisation across slum, non-slum and levels of wealth among urban residents in LMICs.

METHODS

This scoping review presents a narrative synthesis and descriptive analysis of studies conducted in urban areas of LMICs. We categorised studies as conducted only in slums, city-wide studies with measures of wealth and conducted in both slums and non-slums settlements. We estimated the mean costs of accessing healthcare, the incidence of catastrophic health expenditures (CHE) and the progressiveness and equity of health expenditures. The definitions of slums used in the studies were mapped against the 2018 UN-Habitat definition. We developed an evidence map to identify research gaps on the economics of healthcare access in LMICs.

RESULTS

We identified 64 studies for inclusion, the majority of which were from South-East Asia (59%) and classified as city-wide (58%). We found severe economic burden across health conditions, wealth quintiles and study types. Compared with city-wide studies, slum studies reported higher direct costs of accessing health care for acute conditions and lower costs for chronic and unspecified health conditions. Healthcare expenditures for chronic conditions were highest amongst the richest wealth quintiles for slum studies and more equally distributed across all wealth quintiles for city-wide studies. The incidence of CHE was similar across all wealth quintiles in slum studies and concentrated among the poorest residents in city-wide studies. None of the definitions of slums used covered all characteristics proposed by UN-Habitat. The evidence map showed that city-wide studies, studies conducted in India and studies on unspecified health conditions dominated the current evidence on the economics of healthcare access. Most of the evidence was classified as poor quality.

CONCLUSIONS

Our findings indicated that city-wide and slums residents have different expenditure patterns when accessing healthcare. Financial protection schemes must consider the complexity of healthcare provision in the urban context. Further research is needed to understand the causes of inequities in healthcare expenditure in rapidly expanding and evolving cities in LMICs.

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.

Factors Associated with the Implementation of an Improved Community Health Fund in the Ubungo Municipality Area, Dar es Salaam Region, Tanzania

Community-based health insurance schemes help households to afford healthcare services. This paper describes healthcare facilities and community factors that are associated with the Improved Community Health Fund (iCHF) scheme in the Ubungo district of Tanzania. A cross-sectional descriptive study was conducted using online questionnaires that were completed by healthcare providers and community members in public-owned healthcare facilities in the Ubungo Municipal Council district of Dar es Salaam, Tanzania, between October and November 2021. The data were analyzed using descriptive statistics and the chi-squared test of association. We found a statistically significant relationship between income level and satisfaction with the iCHF scheme. For community-related factors, income level was statistically significant in the level of involvement in iCHF implementation among local leaders. Further, income level was statistically significant in relation to community behavior/culture toward the iCHF. Occupation was statistically significant in iCHF implementation, iCHF premiums, and iCHF membership size. A statistically significant relationship was also found between income, iCHF membership size, and iCHF premiums. Moreover, people would be willing to pay the required premiums if the quality of the healthcare services under the iCHF scheme improves. Therefore, the government should allocate resources to reduce the challenges that are facing iCHF implementation, such as the preference for a user fee scheme over the iCHF, the issues that are faced by enrollment officers, and inadequate iCHF premiums and membership size.

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.

Universal health insurance in Africa: a narrative review of the literature on institutional models

Introduction

Several African countries have introduced universal health insurance (UHI) programmes. These programmes aim to extend health insurance to groups that are usually excluded, namely informal workers and the indigent. Countries use different approaches. The purpose of this article is to study their institutional characteristics and their contribution to the achievement of universal health coverage (UHC) goals.

Method

This study is a narrative review. It focused on African countries with a UHI programme for at least 4 years. We identified 16 countries. We then compared how these UHI schemes mobilise, pool and use funds to purchase healthcare. Finally, we synthesised how all these aspects contribute to achieving the main objectives of UHC (access to care and financial protection).

Results

Ninety-two studies were selected. They found that government-run health insurance was the dominant model in Africa and that it produced better results than community-based health insurance (CBHI). They also showed that private health insurance was marginal. In a context with a large informal sector and a substantial number of people with low contributory capacity, the review also confirmed the limitations of contribution-based financing and the need to strengthen tax-based financing. It also showed that high fragmentation and voluntary enrolment, which are considered irreconcilable with universal insurance, characterise most UHI systems in Africa.

Conclusion

Public health insurance is more likely to contribute to the achievement of UHC goals than CBHI, as it ensures better management and promotes the pooling of resources on a larger scale.

Determinants of Turkish households' out-of-pocket expenditures on three categories of health care services: A multivariate probit approach

This study identifies the driving forces that contribute to the probabilities of incidence of out-of-pocket (OOP) expenditures by households in Turkey. Factors affecting the probability of OOP expenditures on medical products/devices/supplies (MP), outpatient services (OTS), and inpatient services (ITS) are examined using the Household Budget Survey data gathered by the Turkish Statistical Institute in 2018. The study applies the multivariate probit model. The incidence of OOP spending varied with 48.9% of the households reporting OOP expenditure on MP, 22.4% on OTS, and 25.4% on ITS. The largest probability changes were associated with household disposable annual income, household type and size, age category, and having private health insurance. Gender and marital status also influenced expenditures in some categories. Lifestyle choices had small and mixed effects, with smoking and alcohol consumption lowering the probability of OOP spending. From a policy standpoint, households with the lowest incomes, large households, and those where the household head was 'others' (retiree, student, housewife, not actively working, etc.) or had a condition preventing employment seemed to report OOP expenditures less frequently and may have chosen not to receive healthcare services, leading to the need for more healthcare services later.

Healthcare utilisation, cancer screening and potential barriers to accessing cancer care in rural South West Nigeria: a cross-sectional study

BACKGROUND/AIMS

Cancer burden is predicted to double by 2030 in sub-Saharan Africa; access to healthcare services for cancer management is a priority in the region. In Nigeria, National Cancer Control Plan aims to ensure >50% cancer screening of eligible populations by 2022 for all Nigerians. We describe healthcare utilisation, cancer screening activities and potential barriers to accessing cancer care within an understudied rural community-based adult population in South West Nigeria.

METHODS

In April 2018, we conducted a cross-sectional study of community-based adults (>18 years) ~130 km east of Ibadan, 250 km from Lagos in Osun State, South West Nigeria. Participants completed a face-to-face survey in local dialect. We used a questionnaire to assess demographics, health status, income, medical expenditures, doctor visits and cancer screening history.

RESULTS

We enrolled 346 individuals: with median age of 52 years and 75% women. Of the entire cohort, 4% had medical insurance. 46% reported a major medical cost in the last year. Cancer screening activities were infrequent in eligible participants: 1.5% reported having had cervical cancer screening, 3.3% mammogram and 5% colonoscopy screening. Cancer screening assessment was less frequent in those with less income and lower education levels. Using a multivariable logistic regression model including personal income, insurance status and education, higher personal income was associated with more cancer screening activity (OR 2.7, 95% CI 1.3 to 5.7, p<0.01). Despite this, most individuals had contact with a primary healthcare doctor (52% in the last year), and over 70% access to radio and TV suggesting the opportunity to expand community-based screening interventions and awareness exists.

CONCLUSIONS

Despite national increases in cancer cases, we highlight a deficiency in cancer screening and universal healthcare coverage within a community-based adult Nigerian population. Subject to availability of governmental resources, increasing financial risk protection, awareness and targeted resource allocation may help expand access in Nigeria.

A Narrative Synthesis Review of Out-of-Pocket Payments for Health Services Under Insurance Regimes: A Policy Implementation Gap Hindering Universal Health Coverage in Sub-Saharan Africa

BACKGROUND

"Achieve universal health coverage (UHC), including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all" is the Sustainable Development Goal (SDG) 3.8 target. Although most high-income countries have achieved or are very close to this target, low- and middle-income countries (LMICs) especially those in sub-Saharan Africa (SSA) are still struggling with its achievement. One of the observed challenges in SSA is that even where services are supposed to be "free" at point-of-use because they are covered by a health insurance scheme, out-of-pocket fees are sometimes being made by clients. This represents a policy implementation gap. This study sought to synthesise the known evidence from the published literature on the 'what' and 'why' of this policy implementation gap in SSA.

METHODS

The study drew on Lipsky's street level bureaucracy (SLB) theory, the concept of practical norms, and Taryn Vian's framework of corruption in the health sector to explore this policy implementation gap through a narrative synthesis review. The data from selected literature were extracted and synthesized iteratively using a thematic content analysis approach.

RESULTS

Insured clients paid out-of-pocket for a wide range of services covered by insurance policies. They made formal and informal cash and in-kind payments. The reasons for the payments were complex and multifactorial, potentially explained in many but not all instances, by coping strategies of street level bureaucrats to conflicting health sector policy objectives and resource constraints. In other instances, these payments appeared to be related to structural violence and the 'corruption complex' governed by practical norms.

CONCLUSION

A continued top-down approach to health financing reforms and UHC policy is likely to face implementation gaps. It is important to explore bottom-up approaches - recognizing issues related to coping behaviour and practical norms in the face of unrealistic, conflicting policy dictates.

Inequalities in out-of-pocket health expenditure among women of reproductive age: after-effects of national health insurance scheme initiation in Ghana

Background

Improvement in maternal healthcare is a public health priority. Unfortunately, in spite of the efforts made over time regarding universal coverage, there remain issues with accessibility and use of healthcare services up to now. In this study, we examined inequalities in out-of-pocket health expenditure among women of reproductive age in Ghana. We analyzed secondary data collected in Ghana Demographic and Health Survey (GDHS) - 2014. A total of 9,002 women of reproductive age were included in this study. Lorenz curves and the concentration index were used to examine neighborhood socioeconomic disadvantage inequalities in out-of-pocket expenditure for maternal healthcare utilization

Results

About two thirds (66.0%) of women of reproductive age in Ghana were covered by health insurance. In sum, women of high neighborhood socioeconomic disadvantage status had the least out-of-pocket expenditure for total healthcare utilization, laboratory investigations, antenatal care visits, post-natal care visits, care for new born for up to 3 months, and other healthcare services. The converse was however true for family planning service utilization. Using Concentration Index, we quantified the degree of neighborhood socioeconomic disadvantage inequalities in healthcare service utilizations.

Conclusion

This study showed a gap in health insurance coverage among women of reproductive age. There were also inequalities in out-of-pocket expenditure for healthcare services utilization. It is expedient for stakeholders in the healthcare system to make policies targeted at bridging the neighborhood socioeconomic differences in maternal healthcare use and develop programs to improve women’s financial protection. Moreover, enlightenment on health insurance availability and coverage should focus on women at risk of out-of-pocket expenditure.

Predictors of three-month mortality among hospitalized older adults in Togo

Background

Assessing hospital mortality and its predictors is important as some of these can be prevented through appropriate interventions. Few studies have reported hospital mortality data among older adults in sub-Saharan Africa. The objective of this study was to assess the mortality and associated factors among hospitalized older adults in Togo.

Methods

We conducted a prospective cohort study from February 2018 to September 2019 among patients ≥50 years admitted in medical and surgical services of six hospitals in Togo. Data were recorded during hospitalization and through telephone follow-up survey within 90 days after admission. The main outcome was all-cause mortality at 3 months. Survival curves were estimated using the Kaplan-Meier method and Cox regression analyses were performed to assess predictors of mortality.

Results

The median age of the 650 older adults included in the study period was 61 years, IQR: [55–70] and at least one comorbidity was identified in 59.7% of them. The all-cause mortality rate of 17.2% (95%CI: 14.4–20.4) and the majority of death (93.7%) occurred in hospital. Overall survival rate was 85.5 and 82.8% after 30 and 90 days of follow-up, respectively. Factors associated with 3-month mortality were the hospital level in the health pyramid, hospitalization service, length of stay, functional impairment, depression and malignant diseases.

Conclusion

Togolese health system needs to adjust its response to an aging population in order to provide the most effective care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-020-01907-y.

[Human resource density and inequality in health care spending in the Americas]

OBJECTIVE

To determine the existence of inequality and gradient in out-of-pocket expenses, public spending and private spending, among countries from the Americas stratified according to their human resources for health (HRH) density.

METHODS

Analytical and transversal study of health inequalities for out-of-pocket spending (percentage of total health spending), public spending and private spending (percentage of GDP), applying the human resource density (medicine and nursing) as a stratifier. Based on data from the Pan American Health Organization and the World Bank, 32 countries from the Americas were categorized according to their density, and weighted rates, descriptors, differences, correlations, and simple and complex indicators of inequality were calculated.

RESULTS

There is high variability in HRH density (3.8 to 171.3; mean 43.97, SD 37.08) with significant differences between high and low density categories. The first quartile concentrates 9% of the population and 4.45% of the HRH; the first 3 quartiles concentrate 48.4% of the population and 17% of the HRH. The stratification showed a gradient and inequalities in expenditure indicators, higher in the out-of-pocket expenditure, with which the HRH density presented a negative correlation.

CONCLUSIONS

HRH density shows high variability among countries and categorized groups; it is unevenly concentrated in the population, and is greater in countries with higher public spending. As a stratifier of the sample, it showed inequalities and gradients in health spending; the strata with lower density showed higher out-of-pocket spending, lower public spending and higher private spending.