Selling my sheep to pay for medicines – household priorities and coping strategies in a setting without universal health coverage

Abstract

BackgroundThe first month of life is the period with the highest risk of dying. Despite knowledge of effective interventions, newborn mortality is high and utilization of health care services remains low in Ethiopia. In settings without universal health coverage, the economy of a household is vulnerable to illness, and out-of-pocket payments may limit families’ opportunities to seek health care for newborns. In this paper we explore intra-household resource allocation, focusing on how families prioritize newborn health versus other household needs and their coping strategies for managing these priorities.MethodsA qualitative study was conducted in 2015 in Butajira, Ethiopia, comprising observation, semi-structured interviews, and focus group discussions with household members, health workers, and community members. Household members with hospitalized newborns or who had experienced neonatal death were primary informants.ResultsIn this predominantly rural and poor district, households struggled to pay out-of-pocket for services such as admission, diagnostics, drugs, and transportation. When newborns fell ill, families made hard choices balancing concerns for newborn health and other household needs. The ability to seek care, obtain services, and follow medical advice depended on the social and economic assets of the household. It was common to borrow money from friends and family, or even to sell a sheep or the harvest, if necessary. In managing household priorities and high costs, families waited before seeking health care, or used cheaper traditional medicines. For poor families with no money or opportunity to borrow, it became impossible to follow medical advice or even seek care in the first place. This had fatal health consequences for the sick newborns.ConclusionsWhile improving neonatal health is prioritized at policy level in Ethiopia, poor households with sick neonates may prioritize differently. With limited money at hand and high direct health care costs, families balanced conflicting concerns to newborn health and family welfare. We argue that families should not be left in situations where they have to choose between survival of the newborn and economic ruin. Protection against out-of-pocket spending is key as Ethiopia moves towards universal health coverage. A necessary step is to provide prioritized newborn health care services free of charge.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-2943-y) contains supplementary material, which is available to authorized users.

Factors affecting community based health insurance utilization in Ethiopia: A systematic review

“…The health care effectiveness largely depends on the socio-economic aspects of the family/household [25]. Six and four studies reported that there was a positive relationship between CBHI, and being male [20,38,42,43,46,47] and female [15,21,37,40] headed of the households respectively.…”

“…If CBHI is not in place, households face catastrophic OOP expense through borrowing to cover direct and indirect health care costs. For those who are unable to get money, it is unthinkable to take health care [25]. Hence, with no any risk pooling mechanism, households face impoverishment from OOP expense [26].…”

Coping strategies of cancer patients in Ukraine

“…24 There is a lack of knowledge of how patients obtain cancer diagnosis and treatment in a system where the financial burden for patients is enormously tangible and where self-help strategies and informal practices are widespread. [25][26][27][28] To fill this gap in our knowledge, our study explores how patients cope with the failures in the system of oncology treatment in Ukraine. We thus illustrate oncopatient's experiences and the strategies that are used by the patients themselves, and their family members-carers, as a response to the financial and organizational barriers to cancer treatment, so-called coping strategies.…”

“…This study uses data from key stakeholder groups: physicians, patients, representatives of pharmaceutical companies, and charitable foundations. It builds on and expands the existing literature on coping strategies and informal practices 27,28,30 as well as on out-of-pocket payments for cancer treatment using qualitative methodologies, 8 and it is organized as follows. The next section provides information on the organization and financing of health care services in Ukraine with a focus on cancer diagnostics and treatment.…”

“…Lack of a clear structure of the patient's pathway creates ample possibilities to navigate within the system according to (a) personal preferences (of users, their carers, and providers), (b) negotiation skills, (c) social network, and (d) financial abilities. It is relevant for "active users," 28,29 while "passive patients" most probably remain overboard of a service provision system. By and large, patients with cancer diagnosis cope with various financial costs (expenditures on surgery, medication, work absence, disability, transportation, and food), spend time on overcoming organizational barriers (lack of information and chaotic treatment pathways), and struggle with disease and treatment symptoms at the same time.…”