From Procedure to Poverty: Out-of-Pocket and Catastrophic Expenditure for Pediatric Surgery in Uganda

Yap, Ava; Cheung, Maija; Kakembo, Nasser; Kisa, Phyllis; Muzira, Arlene; Sekabira, John; Ozgediz, Doruk

doi:10.1016/j.jss.2018.05.077

Cited by 33 publications

(26 citation statements)

References 17 publications

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“…While the proportion of people who incurred OOPE on medical treatment as well as the absolute value may initially appear low, one needs to appraise both values in relation to the prior evidence on financial protection in the health sector and the overall socio-economic reality of the country. First, one needs to consider that earlier studies have consistently reported the persistence of OOPE in spite of a healthcare system that in principle should afford free healthcare access [48,[66][67][68] and have attributed this persistence to health system failures related to shortages in drugs and lack of staff [66,67]. The fact that our study also identifies OOPE suggests that there has been no progress in increasing financial protection in the health sector.…”

Section: Discussionmentioning

confidence: 77%

“…), and any additional formal or informal fees paid. In spite of being aware that transportation expenses represent an important component of the financial burden imposed on households in rural African settings [46][47][48], we excluded them from the computation of our OOPE variable, since our objective was to estimate the financial protection granted specifically by the Malawian free healthcare policy, and at the time of study (and until today), there is no direct provision to include travel expenses in the EHP. Still, we report transportation expenses separately to provide a comprehensive picture of the financial burden illness episodes impose on Malawian households.…”

Section: Outcome Variablesmentioning

confidence: 99%

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

et al. 2020

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Background: Monitoring financial protection is a key component in achieving Universal Health Coverage, even for health systems that grant their citizens access to care free-of-charge. Our study investigated out-of-pocket expenditure (OOPE) on curative healthcare services and their determinants in rural Malawi, a country that has consistently aimed at providing free healthcare services. Methods: Our study used data from two consecutive rounds of a household survey conducted in 2012 and 2013 among 1639 households in three districts in rural Malawi. Given our explicit focus on OOPE for curative healthcare services, we relied on a Heckman selection model to account for the fact that relevant OOPE could only be observed for those who had sought care in the first place. Results: Our sample included a total of 2740 illness episodes. Among the 1884 (68.75%) that had made use of curative healthcare services, 494 (26.22%) had incurred a positive healthcare expenditure, whose mean amounted to 678.45 MWK (equivalent to 2.72 USD). Our analysis revealed a significant positive association between the magnitude of OOPE and age 15-39 years (p = 0.022), household head (p = 0.037), suffering from a chronic illness (p = 0.019), illness duration (p = 0.014), hospitalization (p = 0.002), number of accompanying persons (p = 0.019), wealth quartiles (p 2 = 0.018; p 3 = 0.001; p 4 = 0.002), and urban residency (p = 0.001). Conclusion: Our findings indicate that a formal policy commitment to providing free healthcare services is not sufficient to guarantee widespread financial protection and that additional measures are needed to protect particularly vulnerable population groups.

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Section: Discussionmentioning

confidence: 77%

Section: Outcome Variablesmentioning

confidence: 99%

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

et al. 2020

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“…It corroborates global estimates as well as estimates for Malawi of the probability of catastrophic expenditure if surgery is required [ 16 ], which were derived from a stochastic model. Empirical studies on household expenditure specifically for surgery were published recently from Bangladesh [ 23 ] and Uganda [ [24] , [25] , [26] ]. National patient-level data for out-of-pocket expenditure for surgery have been collected through patient exit interviews in Ghana, Kenya, Uganda, Zambia and India, by the Access, Bottlenecks, Costs and Equity (ABCE) project of the Institute of Health Metrics and Evaluation [ 27 ].…”

Section: Discussionmentioning

confidence: 99%

Out-of-pocket payments and catastrophic household expenditure to access essential surgery in Malawi - A cross-sectional patient survey

Bijlmakers

Wientjes

Mwapasa

et al. 2019

Annals of Medicine and Surgery

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Background Having to pay out-of-pocket for health care can be prohibitive and even cause financial catastrophe for patients, especially those with low and irregular incomes. Health services at Government-owned hospitals in Malawi are provided free of charge but patients do incur costs when they access facilities and some of them forego income. This research paper presents findings on the direct and indirect expenditure incurred by patients who underwent hernia surgery at district and central hospitals in Malawi. It reports the main cost drivers, how costs relate to patients’ household incomes, the financial burden of undergoing surgery and the extent to which hernia patients had recovered and restored their capacity to work and earn an income. Materials and methods Using a cross-sectional study design, surveys were held with patients who had undergone hernia surgery in four district and two central hospitals in Malawi. Interviews were conducted by surgically trained clinical officers, trained in survey administration, and included, inter alia, questions about patients’ hospital stay, the direct and indirect cost they incurred in accessing surgery, and how they financed the expenditure. Follow-up interviews by telephone were held 8–10 weeks after discharge. Results The sample included 137 patients from district and 86 patients from central hospitals. The main direct cost drivers were transport and food & groceries. More than three quarters of patients who had their surgery at a district hospital incurred indirect costs, because of income lost due to hospital admission, compared with just over a third among central hospital patients. Median reported income losses were US$ 90 and US$ 71, respectively. Catastrophic expenditure for surgery occurred in 94% of district and 87% of central hospital patients. When indirect costs are added to the out-of-pocket expenditure, it constituted more than 10% of the monthly per capita income for 97% and 90% of the district and central hospital patients, respectively. Conclusion Out-of-pocket household expenditure associated with essential surgery in Malawi is high and in many instances catastrophic, putting households, especially those who are already poor, at risk of further impoverishment. The much needed scaling-up of surgical services in rural areas of Malawi needs to be accompanied by financial risk protection measures.

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“…In addition, there is no agreement among health economists on the threshold of household expenditure (9). The basic approach usually uses 10% as the threshold value (10), whereas the ATP approach commonly adopts 40% (11). Some studies also compare a range of thresholds-typically 10-40%-to measure CHE (8).…”

Section: Introductionmentioning

confidence: 99%

The Basic vs. Ability-to-Pay Approach: Evidence From China's Critical Illness Insurance on Whether Different Measurements of Catastrophic Health Expenditure Matter

Zhang

Guan

Ding

et al. 2021

Front. Public Health

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Alleviating catastrophic health expenditure (CHE) is one of the vital objectives of health systems, as defined by the World Health Organization. However, no consensus has yet been reached on the measurement of CHE. With the aim of further relieving the adverse effects of CHE and alleviating the problem of illness-caused poverty, the Critical Illness Insurance (CII) program has been operational in China since 2012. In order to verify whether the different measurements of CHE matter under China's CII program, we compare the two-layer CII models built by using the basic approach and the ability-to-pay (ATP) approach at a range of thresholds. Exploiting the latest China family panel studies dataset, we demonstrate that the basic approach is more effective in relieving CHE for all insured households, while the ATP approach works better in reducing the severity of CHE in households facing it. These findings have meaningful implications for policymaking. The CII program should be promoted widely as a supplement to the current Social Basic Medical Insurance system. To improve the CII program's effectiveness, it should be based on the basic approach, and the threshold used to measure CHE should be determined by the goal pursued by the program.

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From Procedure to Poverty: Out-of-Pocket and Catastrophic Expenditure for Pediatric Surgery in Uganda

Cited by 33 publications

References 17 publications

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

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

Out-of-pocket payments and catastrophic household expenditure to access essential surgery in Malawi - A cross-sectional patient survey

The Basic vs. Ability-to-Pay Approach: Evidence From China's Critical Illness Insurance on Whether Different Measurements of Catastrophic Health Expenditure Matter

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