Out-of-pocket expenditure and catastrophic health expenditure for hospitalization due to injuries in public sector hospitals in North India

Measurements of Impoverishing and Catastrophic Surgical Health Expenditures in Low- and Middle-Income Countries and Reduction Interventions in the Last 30 Years: A Systematic Review

INTRODUCTION

Approximately 33 million people suffer catastrophic health expenditure (CHE) from surgery and/or anesthesia costs. The aim of this systematic review is to evaluate catastrophic and impoverishing expenditure associated with surgery and anesthesia in low- and middle-income countries (LMICs).

METHODS

We performed a systematic review of all studies from 1990 to 2021 that reported CHE in LMICs for treatment of a condition requiring surgical intervention, including cesarean section, trauma care, and other surgery.

RESULTS

77 studies met inclusion criteria. Tertiary facilities (23.4%) were the most frequently studied facility type. Only 11.7% of studies were conducted in exclusively rural health-care settings. Almost 60% of studies were retrospective in nature. The cost of procedures ranged widely, from $26 USD for a cesarean section in Mauritania in 2020 to $74,420 for a pancreaticoduodenectomy in India in 2018. GDP per capita had a narrower range from $315 USD in Malawi in 2019 to $9955 USD in Malaysia in 2015 (Median = $1605.50, interquartile range = $1208.74). 35 studies discussed interventions to reduce cost and catastrophic expenditure. Four of those studies stated that their intervention was not successful, 18 had an unknown or equivocal effect on cost and CHE, and 13 concluded that their intervention did help reduce cost and CHE.

CONCLUSIONS

CHE from surgery is a worldwide problem that most acutely affects vulnerable patients in LMICs. Existing efforts are insufficient to meet the true need for affordable surgical care unless assistance for ancillary costs is given to patients and families most at risk from CHE.

Exploring the similarities and differences of burn registers globally: Results from a data dictionary comparison study

INTRODUCTION

Pooling and comparing data from the existing global network of burn registers represents a powerful, yet untapped, opportunity to improve burn prevention and care. There have been no studies investigating whether registers are sufficiently similar to allow data comparisons. It is also not known what differences exist that could bias analyses. Understanding this information is essential prior to any future data sharing. The aim of this project was to compare the variables collected in countrywide and intercountry burn registers to understand their similarities and differences.

METHODS

Register custodians were invited to participate and share their data dictionaries. Inclusion and exclusion criteria were compared to understand each register population. Descriptive statistics were calculated for the number of unique variables. Variables were classified into themes. Definition, method, timing of measurement, and response options were compared for a sample of register concepts.

RESULTS

13 burn registries participated in the study. Inclusion criteria varied between registers. Median number of variables per register was 94 (range 28 - 890), of which 24% (range 4.8 - 100%) were required to be collected. Six themes (patient information, admission details, injury, inpatient, outpatient, other) and 41 subthemes were identified. Register concepts of age and timing of injury show similarities in data collection. Intent, mechanism, inhalational injury, infection, and patient death show greater variation in measurement.

CONCLUSIONS

We found some commonalities between registers and some differences. Commonalities would assist in any future efforts to pool and compare data between registers. Differences between registers could introduce selection and measurement bias, which needs to be addressed in any strategy aiming to facilitate burn register data sharing. We recommend the development of common data elements used in an international minimum data set for burn injuries, including standard definitions and methods of measurement, as the next step in achieving burn register data sharing.

Epidemiological Predictors of Financial Toxicity in Surgical Burn Injuries: A Multicenter, Longitudinal, Cohort Study

BACKGROUND

Burns constitute a major global health challenge, causing over 11 million injuries and 300,000 deaths annually and surpassing the economic burden of cervical cancer and HIV combined. Despite this, patient-level financial consequences of burn injuries remain poorly quantified, with a significant gap in data from low- and middle-income countries. In this study, we evaluate financial toxicity in burn patients.

METHODS

A prospective, multicenter cohort study was conducted across two tertiary care hospitals in India, assessing 123 adult surgical in-patients undergoing operative interventions for burn injuries. Patient sociodemographic, clinical, and financial data were collected through surveys and electronic records during hospitalization and at 1, 3, and 6 months postoperatively. Out-of-pocket costs (OOPCs) for surgical burn treatment were evaluated during hospitalization. Longitudinal changes in income, employment status, and affordability of basic subsistence needs were assessed at the 1-, 3-, and 6-month postoperative time point. Degree of financial toxicity was calculated using a combination of the metrics catastrophic health expenditure and financial hardship. Development of financial toxicity was compared by sociodemographic and clinical characteristics using logistic regression models.

RESULTS

Of the cohort, 60% experienced financial toxicity. Median OOPCs was US$555.32 with the majority of OOPCs stemming from direct nonmedical costs (US$318.45). Cost of initial hospitalization exceeded monthly annual income by 80%. Following surgical burn care, income decreased by US$318.18 within 6 months, accompanied by a 53% increase in unemployment rates. At least 40% of the cohort consistently reported inability to afford basic subsistence needs within the 6-month perioperative period. Significant predictors of developing financial toxicity included male gender (odds ratio, 4.17; 95% confidence interval, 1.25-14.29; P = 0.02) and hospital stays exceeding 20 days (odds ratio, 11.17; 95% confidence interval, 2.11-59.22; P ≤ 0.01).

CONCLUSIONS

Surgical treatment for burn injuries is associated with substantial financial toxicity. National and local policies must expand their scope beyond direct medical costs to address direct nonmedical and indirect costs. These include burn care insurance, teleconsultation follow-ups, hospital-affiliated subsidized lodging, and resources for occupational support and rehabilitation. These measures are crucial to alleviate the financial burden of burn care, particularly during the perioperative period.

Examining the factors contributing to a reduction in hardship financing among inpatient households in India

In India, the rising double burden of diseases and the low fiscal capacity of the government forces people to resort to hardship financing. This study aimed to examine the factors contributing to the reduction in hardship financing among inpatient households in India. The study relies on two rounds of National Sample Surveys with a sample of 34,478 households from the 71st round (2014) and 56,681 households from the 75th round (2018). We employed multivariable logistic regression and multivariate decomposition analyses to explore the factors associated with hardship financing in Indian households with hospitalized member(s) and assess the contributing factors to the reduction in hardship financing between 2014 and 2018. Notably, though hardship financing for inpatient households has decreased between 2014 and 2018, households with catastrophic health expenditure (CHE) had higher odds of hardship financing than those without CHE. While factors such as CHE, prolonged hospitalization, and private hospitals had impoverishing effects on hardship financing in 2014 and 2018, the decomposition model showed the potential of CHE (32%), length of hospitalization (32%), and private hospitals (24%) to slow down this negative impact over time. The findings showed the potential for further improvements in financial health protection for inpatient care over time, and underscore the need for continuing efforts to strengthen the implementation of public programs and schemes in India such as Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY).

Do hospitalizations push households into poverty in India: evidence from national data

Introduction

High percentage of OOP (Out-of-Pocket) costs can lead to poverty and exacerbate existing poverty, with 21.9% of India's 1.324 billion people living below the poverty line. Factors such as increased patient cost-sharing, high-deductible health plans, and expensive medications contribute to high OOP costs. Understanding the poverty-inducing impact of healthcare payments is essential for formulating effective measures to alleviate it.

Methods

The study used data from the 75th round of the National Sample Survey Organization (Household Social Consumption in India: Health) from July 2017-June 2018, focusing on demographic-socio-economic characteristics, morbidity status, healthcare utilization, and expenditure. The analysis included 66,237 hospitalized individuals in the last 365 days. Logistic regression model was used to examine the impact of OOP expenditures on impoverishment.

Results

Logistic regression analysis shows that there is 0.2868 lower odds of experiencing poverty due to OOP expenditures in households where there is the presence of at least one child aged 5 years and less present in the household compared to households who do not have any children. There is 0.601 higher odds of experiencing poverty due to OOP expenditures in urban areas compared to households in rural areas. With an increasing duration of stay in the hospital, there is a higher odds of experiencing poverty due to OOP health expenditures. There is 1.9013 higher odds of experiencing poverty due to OOP expenditures if at least one member in the household used private healthcare facility compared to households who never used private healthcare facilities.

Conclusion

In order to transfer demand from private to public hospitals and reduce OOPHE, policymakers should restructure the current inefficient public hospitals. More crucially, there needs to be significant investment in rural areas, where more than 70% of the poorest people reside and who are more vulnerable to OOP expenditures because they lack coping skills.

Economic Burden of Accidents and Injuries in India: What Does 75th Round of National Sample Survey Imply?

Background

Accidents and injuries constitute a sizable share of mortality and morbidity in low- and middle-income countries. This affects the most productive age group and increases disability-adjusted life years (DALYs). It results in a substantial financial burden on the households. To explore the economic burden of accidents and Injuries on Indian households and to find how the catastrophic health expenditure (CHE) from accidents and injuries affects the population. Another objective is to explore Catastrophic out-of-pocket expenditures (OOPE) patterns and distressed financing of households in India.

Materials and Methods

The study used data from the 75th round of nationally representative surveys, that is, the National Sample Survey (NSS). Authors have analyzed the data using descriptive binary logistic regression analysis to estimate the rate and average days of hospitalization, average OOPE, and share of the population experiencing the catastrophic impact from the health expenditure separately from the public and private healthcare institutions.

Results

The study observed that hospitalization in the private sector imposes 72% of households incur CHE at more than 10% cut-off and 41% at more than 25% cut-off. In comparison, it is less in the public sector, with 22% of households incurring CHE at more than 10% of annual per capita household income and 9% at more than 25%.

Conclusion

The increasing incidence of road traffic accidents (RTA) is a concern for the overstretched health system. The government should provide better healthcare facilities and universal health insurance coverage to ensure patients' speedy recovery and financial security.

Navigating health systems for burn care: Patient journeys and delays in Uttar Pradesh, India

BACKGROUND

India has one of the highest burden of burns. The health systems response to burn care is sometimes patchy and highly influenced by social determinants. Delay in access to acute care and rehabilitation adversely affects recovery outcomes. Evidence on underlying factors for delays in care are limited. In this study, we aim to explore patients' journeys to analyse their experiences in accessing burn care in Uttar Pradesh, India.

METHODS

We conducted qualitative inquiry using the patient journey mapping approach and in-depth interviews (IDI). We purposively selected a referral burn centre in Uttar Pradesh, India and included a diverse group of patients. A chronological plot of the patient's journey was drawn and confirmed with respondents at the end of the interview. A detailed patient journey map was drawn for each patient based on interview transcripts and notes. Further analysis was done in NVivo 12 using a combination of inductive and deductive coding. Similar codes were categorised into sub-themes, which were distributed to one of the major themes of the 'three delays' framework.

RESULTS

Six major burns patients (4 female and 2 males) aged between 2 and 43 years were included in the study. Two patients had flame burns, and one had chemical, electric, hot liquid, and blast injury, respectively. Delay in seeking care (delay 1) was less common for acute care but was a concern for rehabilitation. Accessibility and availability of services, costs of care and lack of financial support influenced delay (1) for rehabilitation. Delay in reaching an appropriate facility (delay 2) was common due to multiple referrals before reaching an appropriate burn facility. Lack of clarity on referral systems and proper triaging influenced this delay. Delay in getting adequate care (delay 3) was mainly due to inadequate infrastructure at various levels of health facilities, shortage of skilled health providers, and high costs of care. COVID-19-related protocols and restrictions influenced all three delays.

CONCLUSIONS

Burn care pathways are adversely affected by barriers to timely access. We propose using the modified 3-delays framework to analyse delays in burns care. There is a need to strengthen referral linkage systems, ensure financial risk protection, and integrate burn care at all levels of health care delivery systems.

A comprehensive examination of the economic impact of out-of-pocket health expenditures in India

More than 50% of health expenditure is financed through out-of-pocket payments in India, imposing a colossal financial burden on households. Amidst the rising incidence of non-communicable diseases, injuries, and an unfinished agenda of infectious diseases, this study examines comprehensively the economic impact of out-of-pocket health expenditure (OOPE) across 17 disease categories in India. Data from the latest round of the National Sample Survey (2017-18), titled 'Household Social Consumption: Health', were employed. Outcomes, namely, catastrophic health expenditure (CHE), poverty headcount ratio, distressed financing, foregone care, and loss of household earnings, were estimated. Results showed that 49% of households that sought hospitalization and/or outpatient care experienced CHE and 15% of households fell below the poverty line due to OOPE. Notably, outpatient care was more burdensome (CHE: 47.8% and impoverishment: 15.0%) than hospitalization (CHE: 43.1% and impoverishment: 10.7%). Nearly 16% of households used distressed sources to finance hospitalization-related OOPE. Cancer, genitourinary disorders, psychiatric and neurological disorders, obstetric conditions, and injuries imposed a substantial economic burden on households. OOPE and associated financial burden were higher among households where members sought care in private healthcare facilities compared with those treated in public facilities across most disease categories. The high burden of OOPE necessitates the need to increase health insurance uptake and consider outpatient services under the purview of health insurance. Concerted efforts to strengthen the public health sector, improved regulation of private healthcare providers, and prioritizing health promotion and disease prevention strategies are crucial to augment financial risk protection.

Financial toxicity of cancer treatment in India: towards closing the cancer care gap

Background

The rising economic burden of cancer on patients is an important determinant of access to treatment initiation and adherence in India. Several publicly financed health insurance (PFHI) schemes have been launched in India, with treatment for cancer as an explicit inclusion in the health benefit packages (HBPs). Although, financial toxicity is widely acknowledged to be a potential consequence of costly cancer treatment, little is known about its prevalence and determinants among the Indian population. There is a need to determine the optimal strategy for clinicians and cancer care centers to address the issue of high costs of care in order to minimize the financial toxicity, promote access to high value care and reduce health disparities.

Methods

A total of 12,148 cancer patients were recruited at seven purposively selected cancer centres in India, to assess the out-of-pocket expenditure (OOPE) and financial toxicity among cancer patients. Mean OOPE incurred for outpatient treatment and hospitalization, was estimated by cancer site, stage, type of treatment and socio-demographic characteristics. Economic impact of cancer care on household financial risk protection was assessed using standard indicators of catastrophic health expenditures (CHE) and impoverishment, along with the determinants using logistic regression.

Results

Mean direct OOPE per outpatient consultation and per episode of hospitalization was estimated as ₹8,053 (US$ 101) and ₹39,085 (US$ 492) respectively. Per patient annual direct OOPE incurred on cancer treatment was estimated as ₹331,177 (US$ 4,171). Diagnostics (36.4%) and medicines (45%) are major contributors of OOPE for outpatient treatment and hospitalization, respectively. The overall prevalence of CHE and impoverishment was higher among patients seeking outpatient treatment (80.4% and 67%, respectively) than hospitalization (29.8% and 17.2%, respectively). The odds of incurring CHE was 7.4 times higher among poorer patients [Adjusted Odds Ratio (AOR): 7.414] than richest. Enrolment in PM-JAY (CHE AOR = 0.426, and impoverishment AOR = 0.395) or a state sponsored scheme (CHE AOR = 0.304 and impoverishment AOR = 0.371) resulted in a significant reduction in CHE and impoverishment for an episode of hospitalization. The prevalence of CHE and impoverishment was significantly higher with hospitalization in private hospitals and longer duration of hospital stay (p < 0.001). The extent of CHE and impoverishment due to direct costs incurred on outpatient treatment increased from 83% to 99.7% and, 63.9% to 97.1% after considering both direct and indirect costs borne by the patient and caregivers, respectively. In case of hospitalization, the extent of CHE increased from 23.6% (direct cost) to 59.4% (direct+ indirect costs) and impoverishment increased from 14.1% (direct cost) to 27% due to both direct and indirect cost of cancer treatment.

Conclusion

There is high economic burden on patients and their families due to cancer treatment. The increase in population and cancer services coverage of PFHI schemes, creating prepayment mechanisms like E-RUPI for outpatient diagnostic and staging services, and strengthening public hospitals can potentially reduce the financial burden among cancer patients in India. The disaggregated OOPE estimates could be useful input for future health technology analyses to determine cost-effective treatment strategies.

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.

Out-of-pocket cost for medical care of injured patients presenting to emergency department of national hospital in Tanzania: a prospective cohort study

OBJECTIVE

We aimed to determine the out-of-pocket (OOP) costs for medical care of injured patients and the proportion of patients encountering catastrophic costs.

DESIGN

Prospective cohort study SETTING: Emergency department (ED) of a tertiary-level hospital in Dar es Salaam, Tanzania.

PARTICIPANTS

Injured adult patients seen at the ED of Muhimbili National Hospital from August 2019 to March 2020.

METHODS

During alternating 12-hour shifts, consecutive trauma patients were approached in the ED after stabilisation. A case report form was used to collect social-demographics and patient clinical profile. Total charges billed for ED and in-hospital care and OOP payments were obtained from the hospital billing system. Patients were interviewed by phone to determine the measures they took to pay their bills.

PRIMARY OUTCOME MEASURE

The primary outcome was the proportion of patients with catastrophic health expenditure (CHE), using the WHO definition of OOP expenditures ≥40% of monthly income.

RESULTS

We enrolled 355 trauma patients of whom 51 (14.4%) were insured. The median age was 32 years (IQR 25-40), 238 (83.2%) were male, 162 (56.6%) were married and 87.8% had ≥2 household dependents. The majority 224 (78.3%) had informal employment with a median monthly income of US$86. Overall, 286 (80.6%) had OOP expenses for their care. 95.1% of all patients had an Injury Severity Score <16 among whom OOP payments were US$176.98 (IQR 62.33-311.97). Chest injury and spinal injury incurred the highest OOP payments of US$282.63 (84.71-369.33) and 277.71 (191.02-874.47), respectively. Overall, 85.3% had a CHE. 203 patients (70.9%) were interviewed after discharge. In this group, 13.8% borrowed money from family, and 12.3% sold personal items of value to pay for their hospital bills.

CONCLUSION

OOP costs place a significant economic burden on individuals and families. Measures to reduce injury and financial risk are needed in Tanzania.

Out-of-pocket health expenditure and associated factors among patients with hypertension in Debre-Tabor Comphrensive Specialized Hospital, South Gondar zone, Northwest Ethiopia, 2020

Introduction

Hypertension is a non-communicable chronic disease that has a wide financial effect at the individual and household levels especially in developing countries due to its complexity and chronicity. Nevertheless, there are limited studies in Ethiopia. Therefore the aim of this study was to assess out-of pocket health expenditure and associated factors among adult patients with hypertension in Debre-Tabor Comphrensive Specialized Hospital.

Methods

A facility-based cross-sectional study was conducted in total of 357 adult hypertensive patients from March to April 2020 using a systematic random sampling technique. Descriptive stastics were used to estimate the magnitude of out-of-pocket health expenditure, while after checking the assumptions linear regression model was fitted for identifying the factors associated with the outcome variable at a significance level of value of p < 0.05 and 95% confidence interval.

Result

A total of 346 study participants interviewed with a response rate of 96.92%. Annual mean out of pocket health expenditure of the participant was $113.40 ± $10.18 with 95% CI = (102.63, 124.16) per patient. The direct medical mean out of pocket health expenditure of the participant was $68.86 per patient per year and the median of non-medical components of the out of pocket health expenditure of the participant was $3.53. Sex, wealth status, distance from hospital, comorbidity, health insurance and number of visit are factors significantly associated to out-of-pocket expenditure.

Conclusion

This study revealed that out of pocket health expenditure among adult patients with hypertension was found high compared to the national per capita health expenditure. Sex, wealth index, distance away from hospital, frequency of visit, comorbidities, and health insurance coverage were factors significantly associated with high out-of-pocket health expenditure. Ministry of health together with regional health bureaus and other concerned stakeholders work on strengthening early detection and prevention strategies of chronic comorbidities of hypertensive patients,promote health insurance coverage and better to subsidize medication costs for the poors.

Exploring Barriers to, and Enablers of, Evidence-Informed Hip Fracture Care in Five Low- Middle-Income Countries: China, India, Thailand, the Philippines and Vietnam

Globally, populations are ageing and the estimated number of hip fractures will increase from 1.7 million in 1990 to more than 6 million in 2050. The greatest increase in hip fractures is predicted in Low- and Middle‑Income Countries (LMICs), largely in the Asia-Pacific region where direct costs are expected to exceed $US15 billion by 2050. The aims of this qualitative study are to identify barriers to, and enablers of, evidence informed hip fracture care in LMICs, and to determine if the Blue Book standards, developed by the British Orthopaedic Association and British Geriatrics Society to facilitate evidence informed care of patients with fragility fractures, are applicable to these settings. This study utilised semi-structured interviews with clinical and administrative hospital staff to explore current hip fracture care in LMICs. Transcribed interviews were imported into NVivo 12 and analysed thematically. Interviews were conducted with 35 participants from eleven hospitals in five countries. We identified five themes-costs of care and the capacity of patients to pay, timely hospital presentation, competing demands on limited resources, delegation and defined responsibility, and utilisation of available data-and within each theme, barriers and enablers were distinguished. We found a mismatch between patient needs and provision of recommended hip fracture care, which in LMICs must commence at the time of injury. This study describes clinician and administrator perspectives of the barriers to, and enablers of, high quality hip fracture care in LMICs; results indicate that initiatives to overcome barriers (in particular, delays to definitive treatment) are required. While the Blue Book offers a starting point for clinicians and administrators looking to provide high quality hip fracture care to older people in LMICs, locally developed interventions are likely to provide the most successful solutions to improving hip fracture care.

Financing Pediatric Surgery: A Provider's Perspective from the Global Initiative for Children's Surgery

BACKGROUND

Half the world's population is at risk of catastrophic health expenditure (CHE, out-of-pocket spending of more than 10% of annual expenditure) should they require surgery. Protection against CHE is a key indicator of successful health care delivery and has been identified as a priority area by the Global Initiative for Children's Surgery (GICS). Data specific to pediatric surgical patients is limited. This study examines the financial risks for pediatric surgical patients and their families from a provider's perspective.

METHODS

We surveyed GICS members about the existing financial protection mechanisms and estimated expenditures for their patients. Questions were structured based on the National Surgical, Obstetric and Anesthesia Planning Surgical Indicators and finalized based on multi-institutional consensus between high-income country and low-and middle-income country (LMIC) providers. Chi-squared test, Fisher's exact test and student's t-test were used as appropriate.

RESULTS

Among 107 respondents, 72.4% were from low income or lower-middle income (LIC/LMIC) countries, and 55.1% were attending or consultant physicians. Families were most likely to decline surgery in LIC/LMIC due to inability to afford treatment (mean Likert = 3.77 ± 1.06). The odds of incurring CHE after children's surgery are up to 17 times greater in LIC/LMIC (P = 0.001, unadjusted OR 17.28, 95%CI 2.13-140.02). Over 50% of families of children undergoing major surgery in these settings face CHE. An estimated 5.1% of providers in LIC/LMIC and 56.2% (P < 0.001) of providers in UMIC/HIC reported that families are able to pay for their direct medical costs with the assistance available to them and were more likely to sell assets (74.4% vs. 33.3%, P = 0.005).

CONCLUSION

Patients in LMICs are at greater risk for CHE and have less financial risk protection than their HIC counterparts. Given this disparity, intervention is needed to make safe surgery affordable for children worldwide.

Financial risk of road traffic trauma care in public and private hospitals in Addis Ababa, Ethiopia: A cross-sectional observational study

BACKGROUND

Road traffic injuries are among the most important causes of morbidity and mortality and cause substantial economic loss to households in Ethiopia. This study estimates the financial risks of seeking trauma care due to road traffic injuries in Addis Ababa, Ethiopia.

METHODS

This is a cross-sectional survey on out-of-pocket (OOP) expenditures related to trauma care in three public and one private hospital in Addis Ababa from December 2018 to February 2019. Direct medical and non-medical costs (2018 USD) were collected from 452 trauma cases. Catastrophic health expenditures were defined as OOP health expenditures of 10% or more of total household expenditures. Additionally, we investigated the impoverishment effect of OOP expenditures using the international poverty line of $1.90 per day per person (adjusted for purchasing power parity).

RESULTS

Trauma care seeking after road traffic injuries generate catastrophic health expenditures for 67% of households and push 24% of households below the international poverty line. On average, the medical OOP expenditures per patient seeking care were $256 for outpatient visits and $690 for inpatient visits per road traffic injury. Patients paid more for trauma care in private hospitals, and OOP expenditures were six times higher in private than in public hospitals. Transport to facilities and caregiver costs were the two major cost drivers, amounting to $96 and $68 per patient, respectively.

CONCLUSION

Seeking trauma care after a road traffic injury poses a substantial financial threat to Ethiopian households due to lack of strong financial risk protection mechanisms. Ethiopia's government should enact multisectoral interventions for increasing the prevention of road traffic injuries and implement universal public finance of trauma care.

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

OBJECTIVE

To estimate the out-of-pocket expenditures linked to Road Traffic Injuries in Ouagadougou, Burkina Faso, as well as the prevalence of catastrophic expenditures among those out-of-pocket payments, and to identify the socio-economic determinants of catastrophic expenditures due to Road Traffic Injuries.

METHODS

We surveyed every admission at the only trauma unit of Ouagadougou between January and July 2015 at the time of their admission, 7 days and 30 days later. We estimate a total amount of out-of-pocket expenditures paid by each patient. We considered an expense as catastrophic when it represented 10% at least of the annual global consumption of the patient's household. We used linear models to determine if socio-economic characteristics were associated to a greater or smaller ratio between out-of-pocket payment and global annual consumption.

FINDINGS

We surveyed 1323 Road injury victims three times (admission, Days 7 and 30). They paid in average 46,547 FCFA (83.64 US dollars) for their care, which represent a catastrophic expenditure for 19% of them. Less than 5% of the sample was covered by a health insurance scheme. Household economic status is found to be the first determinant of catastrophic health expenditure occurrence, exhibiting a significant and negative on the ratio between road injury expenditures and global consumption.

CONCLUSION

Our findings highlight the importance of developing health insurance schemes to protect poor households from the economic burden of road traffic injuries and improve equity in front of health shocks.

Cost of Illness Due to Severe Enteric Fever in India

Background

Lack of robust data on economic burden due to enteric fever in India has made decision making on typhoid vaccination a challenge. Surveillance for Enteric Fever network was established to address gaps in typhoid disease and economic burden.

Methods

Patients hospitalized with blood culture-confirmed enteric fever and nontraumatic ileal perforation were identified at 14 hospitals. These sites represent urban referral hospitals (tier 3) and smaller hospitals in urban slums, remote rural, and tribal settings (tier 2). Cost of illness and productivity loss data from onset to 28 days after discharge from hospital were collected using a structured questionnaire. The direct and indirect costs of an illness episode were analyzed by type of setting.

Results

In total, 274 patients from tier 2 surveillance, 891 patients from tier 3 surveillance, and 110 ileal perforation patients provided the cost of illness data. The mean direct cost of severe enteric fever was US$119.1 (95% confidence interval [CI], US$85.8–152.4) in tier 2 and US$405.7 (95% CI, 366.9–444.4) in tier 3; 16.9% of patients in tier 3 experienced catastrophic expenditure.

Conclusions

The cost of treating enteric fever is considerable and likely to increase with emerging antimicrobial resistance. Equitable preventive strategies are urgently needed.

Impact of COVID-19 and containment measures on burn care: A qualitative exploratory study

BACKGROUND

Burn care in India is limited by multiple constraints. The COVID-19 pandemic and the containment measures restricted access to non-COVID emergency conditions, including burns. The aim of this study was to explore the impact of the pandemic on burn care in India.

METHODS

Using the qualitative exploratory methods, we conducted in-depth interviews (IDI) with plastic and general surgeons representing burn units from across India. Participants were selected purposively to ensure representation and diversity and the sample size was guided by thematic saturation. Thematic analysis was undertaken adopting an inductive coding using NVivo 12 Pro.

RESULTS

19 participants from diverse geographic locations and provider types were interviewed. Three major emerging themes were, change in patient and burn injury characteristics; health system barriers, adaptation, and challenges; and lessons and emerging recommendations for policy and practice. There was change in patient load, risk factors, and distribution of burns. The emergency services were intermittently disrupted, the routine and surgical services were rationally curtailed, follow-up and rehabilitation services were most affected. Measures like telemedicine and decentralising burn services emerged as the most important lesson.

CONCLUSIONS

The ongoing pandemic has compounded the challenges for burns care in India. Urgent action is required to prioritise targeted prevention, emergency transport, decentralise service delivery, and harnessing technology for ensuring resilience in burns services.

Development of National Cancer Database for Cost and Quality of Life (CaDCQoL) in India: a protocol

INTRODUCTION

The rising economic burden of cancer on healthcare system and patients in India has led to the increased demand for evidence in order to inform policy decisions such as drug price regulation, setting reimbursement package rates under publicly financed health insurance schemes and prioritising available resources to maximise value of investments in health. Economic evaluations are an integral component of this important evidence. Lack of existing evidence on healthcare costs and health-related quality of life (HRQOL) makes conducting economic evaluations a very challenging task. Therefore, it is imperative to develop a national database for health expenditure and HRQOL for cancer.

METHODS AND ANALYSIS

The present study proposes to develop a National Cancer Database for Cost and Quality of Life (CaDCQoL) in India. The healthcare costs will be estimated using a patient perspective. A cross-sectional study will be conducted to assess the direct out-of-pocket expenditure (OOPE), indirect cost and HRQOL among cancer patients who will be recruited at seven leading cancer centres from six states in India. Mean OOPE and HRQOL scores will be estimated by cancer site, stage of disease and type of treatment. Economic impact of cancer care on household financial risk protection will be assessed by estimating prevalence of catastrophic health expenditures and impoverishment. The national database would serve as a unique open access data repository to derive estimates of cancer-related OOPE and HRQOL. These estimates would be useful in conducting future cost-effectiveness analyses of management strategies for value-based cancer care.

ETHICS AND DISSEMINATION

Approval was granted by Institutional Ethics Committee vide letter no. PGI/IEC-03/2020-1565 of Post Graduate Institute of Medical Education and Research, Chandigarh, India. The study results will be published in peer-reviewed journals and presented to the policymakers at national level.

Prevalence, Risk Factors, and Cost Burden of Fall-Related Hospital Admissions in india

OBJECTIVE: To assess prevalence, risk factors, and cost burden of fall-related hospital admissions among older people in India. Previous studies conducted in India have not focused on the number of fall-related hospital admissions.<br/> DESIGN: A prospective observational study was carried out over 12 months. Socio-demographic, medical and medication details were collected from the patients, medical records, and treating physicians.<br/> SETTING: The study was conducted in internal medicine, orthopedics, and emergency departments of a tertiary care teaching hospital in Mysuru, Southern India.<br/> PARTICIPANTS: Patients 60 years of age or older, of any gender, admitted to hospital were included in this study.<br/> MAIN OUTCOME MEASURE: Prevalence of fall-related hospital admission, fall-related hospital admission associated with medication use, and direct cost incurred due to fall-related hospital admission.<br/> RESULTS: A total of 1,036 patients [Males 53.6%] with a mean (SD) age of 69.3 (8.1) years were included in the study. A total of 188 patients were admitted due to falling with the prevalence of 18.1%. The majority of patients fell due to environmental factors [105 (55.8%)]. Among medication-related falls (20), the majority were associated with the use of antihyperglycemics and antihypertensives. Increasing age, female gender, and multiple comorbidities were identified as risk factors for fall-related hospital admissions.<br/> CONCLUSIONS: Falls are a common reason for hospital admission among older populations. Clinicians need to focus on modifiable risk factors to reduce the prevalence of falls and advise patients and their caregivers about appropriate self-care behaviors.

Socioeconomic Impact of Hospitalization Expenditure for Treatment of Noncommunicable Diseases in India: A Repeated Cross-Sectional Analysis of National Sample Survey Data, 2004 to 2018

OBJECTIVES

This article explores the consequences of hospitalization expenditure on noncommunicable diseases (NCD) and its impact on out-of-pocket expenditure (OOPE), catastrophic health expenditure, impoverishment, and hardship financing of households in India.

METHODS

Data on hospitalized cases of NCDs from the 3 rounds of National Sample Surveys (NSS) (2004, 2014, 2018) were used. Bivariate and multivariate analyses were conducted to investigate the socioeconomic differentials of the impact of OOPE on catastrophic health expenditure, impoverishment, and exposure to hardship financing.

RESULTS

Rural households had greater exposure to catastrophic health expenditure but urban households had higher risk of impoverishment due to OOPE. Older patients (aged ≥60 years) had the highest hospitalization rate per 100 000, including increase in average healthcare expenditure from 2004 to 2018. At 10% and 30% thresholds, 50% and 25% of the households, respectively, faced catastrophic health expenditure across all the 3 rounds. Due to OOPE on hospitaliation treatment for NCDs, about 3.8%, 7.4% and 4.8% of households fell below poverty line, and percentage shortfall in income for the population from the poverty line was 3%, 4.9% and 3%, in 2004, 2014 and 2018 respectively. Percentage of households facing hardship financing reduced from 49.2% in 2004 to 24.4% 2014 and 12.7% in 2018.

CONCLUSION

OOPE by households are still very high and hence the higher effects of CHE, impoverishment and exposure to hardship financing due to health expenditure in India. This study proposes that along with increase in budgetary allocations for healthcare, the government should develop suitable policies to expand the effectiveness of government-sponsored health insurance, such as developing a specific NCD service package to be included in the health insurance program.

Medical, transportation and spiritual out-of-pocket health expenditure on outpatient and inpatient visits in Bhutan

Understanding the determinants of out-of-pocket health expenditure (OOP) is important for achieving and sustaining universal health coverage, as well as ensuring that no one is left behind. Focusing on major types of spending, including healthcare-related transportation and spiritual expenses, this study analyses OOP on outpatient and inpatient visits in Bhutan, using a two-part model and data from the nationally representative 2017 Bhutan Living Standards Survey. While OOP based on standard estimates is relatively low in Bhutan, the survey data show that expenses for healthcare-related transportation and spiritual ceremonies are substantive and by far exceed other components of OOP. Demographic, socio-economic, geographic and morbidity-related factors are found to affect the probability of incurring medical, transportation and spiritual OOP, as well as amounts spent. Disaggregating healthcare-related spending into its key components further reveals that living in rural areas increases the probability of incurring expenses for transportation and spiritual ceremonies, but decreases the odds of experiencing positive medical expenditure. Monthly equivalised household expenditure, functional disability, frequency of visits and length of stay are positively associated with total OOP, especially for transportation and spiritual expenses. Going to a public primary healthcare provider for the first outpatient visit, on the other hand, significantly decreases likelihood and amount of medical, transportation and spiritual OOP. These key results highlight the importance of understanding context-specific drivers of healthcare-related spending. In Bhutan, the financial burden particularly impacts respondents in rural areas and those with higher needs for healthcare services. A clear implication of the findings is that primary care and gatekeeping mechanisms need to be strengthened, especially considering that cost pressures have been growing which could lead to higher OOP in the future. Moreover, closer examination of the role of spiritual practices in the provision of health services is needed.

Burden of injuries and its associated hospitalization expenditure in India

Injuries are a major public health concern, affect the most productive age group i.e. (15-60 years) and increases disability adjusted life years (DALYs) and results in a huge financial burden on the household. Disease burden is represented by DALYs and economic burden represents the out of pocket (OOP) and catastrophic health expenditure (CHE). We examined the burden of injury and its impact on household financial burden among the working population (15-60 years) in India. We used data on National and State Level DALYs for Injuries for 2017 from the published National Disease Burden Estimate (NBE, 2019) Study. The cost of treatment was extracted from 75th round of the National Sample Survey Organization (NSSO, 2017-18). DALYs is the sum of YLLs and YLDs. OOPEs were estimated as a per episode of hospitalization expenses after reimbursement and CHE was defined as out of pocket expenditure exceeding 10% of household consumption expenditure. Accidental injuries particularly road traffic injuries have higher DALY rates among 15-60 years in India (1288 DALYs per 100,000). However, the mean OOPE was found to be higher due to intentional self-harm. Persons suffering from injury in states like Punjab, Haryana, UP, Gujarat, Karnataka and Andhra Pradesh approached private facilities more compared to public facilities. Whereas, people from states like Jammu and Kashmir, Orissa, West Bengal, North East availed public facilities more than private. OOPE was found to be five times more in private facilities than in public. The households who sought treatment in private facilities were faced 3 times more to Catastrophic expenditure than those who took the treatment in public hospital of any injury. The present study indicated high DALYs, OOPE and % CHE for injury in India. Higher proportion of households were pushed to catastrophic expenditure due to high OOPE of injury treatment. Disease and economic burden due to road traffic injury and fall was found to be high as compared to other injuries. Our study strengthens the need for executing effective financial protection approach in India like PM-JAY, to minimize the financial burden incurred due to injuries in India.

Burden and cost of communicable, maternal, perinatal and nutrition deficiency diseases in India

BACKGROUND

Globally 36% of deaths and 42% of Disability Adjusted Life Years (DALYs) are due to communicable, maternal, perinatal and nutritional disorders (CMPND). We examined the state-wise disease burden and treatment cost for these diseases in India for 2017.

METHODS

DALYs for CMPND was obtained from National Disease Burden Estimate (NBE) Study and the expenditure was determined from the unit level records of persons who reported hospitalization for one or more CMPND in National Sample Survey (NSS)-75th Round.

RESULTS

The top conditions resulting in high DALYs for India were perinatal conditions and nutritional deficiency disorders. Odisha had the highest DALY rate, while Kerala had the lowest DALY rate for CMPNDs. The out-of-pocket expenditure (OOPE) was highest in Chattisgarh, while percentage of households pushed to CHE was highest in Uttar Pradesh for CMPND.

CONCLUSION

The public healthcare facilities need to be strengthened to facilitate patients with CMPND to undergo treatment that is timely, affordable and cost-effective. Efforts should be made for optimization of strategies aimed at primary and secondary prevention of CMPND and reduce OOPE for treatment of these diseases. In addition, advocacy spreading awareness will reduce the burden and treatment expenditure for CMPNDs in India.

Catastrophic Healthcare Expenditure from Typhoid Perforation in Children in Nigeria

Background: Out-of-pocket payments and catastrophic healthcare expenditures (CHE) are important barriers to achieving equity and access to emergency and essential surgical care in low- and middle-income countries (LMICs), with important implications for universal health coverage (UHC). However, data on CHE for surgical care in these settings are limited, especially with regard to infections. Methods: We performed a retrospective review of 32 children receiving laparotomy for typhoid intestinal perforation in a four-year period. Data on medical costs were reviewed. Because of the lack of reliable data on household incomes and average national incomes for Nigeria, gross domestic product per capita was used to calculate CHE. The GDP per capita for the country during the study period was $2,028.182. Expenditure >10% GDP per capita (or > $202.82) was considered CHE. Results: There were 15 boys and 17 girls aged 2-15 years (mean 7.72 years). Seventeen patients (53%) were referred from district/general hospitals or mission hospitals. After surgical treatment, 16 patients (50%) developed complications (intra-abdominal abscesses and incision complications), and nine (28.1%) required re-operation. Seven patients (21.9%) required intensive care (ICU) treatment and three (9.4%) died from overwhelming infection. The hospital stay was 3-93 days (mean 23 days). The average total medical cost was $452 (range $236-$1,700). The total medical costs exceeded 10% of GDP ($202.82) for all patients. Total expenditure for four patients requiring intensive care exceeded $202.82 for the ICU care alone. Conclusion: Surgical treatment of typhoid intestinal perforation in children is associated with a high rate of CHE if care is provided at tertiary hospitals. Investments in prevention and control of this and other surgical infections as well as scale up of capacity at district hospitals to provide such care are important in preventing CHE.