Annual Household Expenditure Research Articles

What contributes to out-of-pocket health expenditure in Cambodia's uncovered population? A distributional and decomposition analysis using survey data.

Out-of-pocket health expenditures (OOPE) are an inefficient and inequitable means of health financing. Identifying the factors driving these expenditures is crucial to design effective prepayment schemes. This study uses Cambodia-a country with high OOPE and prevalent informal employment-as a case study to analyse the relative contributions of healthcare, health, and social factors to OOPE and the OOPE budget share (OOPE as a proportion of total annual household expenditure) across different points in their distribution. We used data from a 2023 cross-sectional survey among 3254 households engaged in informal employment with no access to prepayment schemes (uncovered households). We employed unconditional quantile regression to investigate the distributional effects of healthcare, health, and social factors on OOPE and the OOPE budget share. To examine the heterogeneity in the contributions of these factors to the explained variance in OOPE and the OOPE budget share at different quantiles, we combined unconditional quantile regression with Shapley decomposition. Uncovered households incurred high OOPE, leading to elevated incidences of financial hardship. Healthcare factors, including levels of care, private providers, medications, and visits were the largest contributors to the explained variance in OOPE and the OOPE budget share. Health factors, including severity, days lost to illness/injury, noncommunicable diseases, and injuries, also contributed substantially. Social factors contributed less overall, with wealth being the primary driver. Contributions of these factors varied across different points in the outcome distributions. These findings underscore the need to improve financial protection for uncovered households. The Cambodian government should consider expanding prepayment schemes that directly address the main healthcare drivers identified in this study. Schemes should provide effective access to comprehensive outpatient care and essential medications, and necessary services at higher care levels, including in the private sector. Addressing the rising burden of noncommunicable diseases alongside multisectoral efforts to reduce injuries may also be important.

Assessing the determinants of out-of-pocket health expenditures among Cambodian households in informal employment using survey data

BackgroundAs the deadline for the Sustainable Development Goals approaches, financial protection in Cambodia remains inadequate, especially for nonpoor informal workers lacking formal social health protection coverage or access to other prepayment schemes. This exposes them to high out-of-pocket health expenditures (OOPE) and related financial hardship. To better understand the drivers behind these expenditures, our study aims to model their healthcare, health, and social determinants and to assess their relative importance.MethodsIn 2023, we conducted a cross-sectional multistage clustered sampling survey across seven Cambodian provinces, surveying 3,254 households engaged in informal employment and not covered by any formal social health protection scheme. The survey gathered information on households’ use of outpatient and inpatient care and associated OOPE. We employed generalized linear models (GLMs) to analyse the healthcare, health, and social determinants of OOPE and the OOPE budget share (the proportion of total annual household consumption expenditure spent on OOPE) and applied Shapley decomposition analysis to quantify the relative contributions of these determinants to the explained variance in our outcomes.ResultsHealthcare variables were the dominant contributors to the explained variance in all outcomes (41.36–50.73%), followed by health factors. While several social variables were significant, only the wealth quintile made notable contributions to explaining variance in our outcomes. The key healthcare contributors included the sector type and level of care, and the number of outpatient medications. Important health contributors included illness severity and the presence of chronic illnesses or noncommunicable diseases.ConclusionsOur findings emphasize the necessity of integrating nonpoor informal workers and their dependents into formal prepayment schemes to reduce OOPE and enhance financial protection on Cambodia’s path toward universal health coverage. Strategically engaging with private providers and pharmacies to improve access to essential services and medicines, coupled with the implementation of an effective referral system are important policy considerations to this end. Further research is needed on how health determinants are modifiable with policy interventions. Our findings can assist the Cambodian government in advancing its universal health coverage goals and offer insights for other countries aiming to extend coverage to similar population groups.

The Great Indian Budget: Does Migration Influence Household’s Consumption Proportions?

This study employs the two waves (2004–2005 and 2011–2012) of the nationally representative India Human Development Survey (IHDS) to estimate the expenditure gaps (namely, expenditure gaps in food consumption, conspicuous consumption and productive investment) between migrant and non-migrant households. Using propensity score matching and inverse probability weighted regression average, the results indicate that migrant households allocate a lower proportion of their annual household expenditure to food consumption (vis-à-vis the non-migrant households), while allocating higher shares to conspicuous consumption and productive investment. These results vary by whether a loan was sanctioned, the amount sanctioned, the purpose of the loan (productive or otherwise) and the source of the loan (formal or informal channels). The findings propose policy considerations, emphasizing the importance of reassessing loan priorities by extending credit towards productive investment opportunities. This study also explores the consumption spillover effects on non-migrant households, indicating that they emulate the consumption patterns of migrant households by allocating a higher share of expenditure towards conspicuous consumption, with no discernible effect on productive investment.

Household expenditure on control of urban mosquitoes Aedes albopictus and Culex pipiens in Emilia-Romagna, Northern Italy.

In 2007, the first outbreak of Chikungunya in Italy generated great alarm, highlighting the health risks caused by exotic species recently introduced in Europe and the need to strengthen control actions against the vectors. Besides health risks, mosquitoes cause nuisance, and citizens are required to adopt control measures. While the economic aspects of mosquito control by public agencies have been investigated, the scientific literature on the costs of mosquito protection incurred by families is scarce. This study assessed the households' expenditure on protective measures against mosquitoes in Emilia-Romagna, a region in Northern Italy. A phone questionnaire survey was conducted to collect data on the annual expenditure incurred by households for self-protection against mosquitos in relation to the perceived level of nuisance and the household and dwelling characteristics. Univariate and multivariate analyses were conducted to identify the main determinants influencing such expenditure, which resulted affected by dwelling characteristics, presence of children under 6 years of age, and health concerns of family members. The average annual household expenditure was estimated at 84.63 euros, about 30 times higher than the expenditure per household supported by regional and local administrations for interventions against mosquitoes in public areas, as calculated in a previous study. Household expenditure is mainly aimed at providing a direct defense against mosquito bites (mosquito nets, adulticides, skin-on repellents, etc.) while spending for more effective measures addressed to reduce mosquito density results marginal: e.g., only 3.5% of the total expenditure was dedicated to larval control. Control activities that lower the mosquito density in both private and public areas could reduce the use of household insecticides in urban environments and the related costs, and the risk of spread of imported arboviruses as well.

Out-of-pocket and indirect expenditure of spina bifida and hydrocephalus patients admitted for inpatient treatment and follow-up at two university-affiliated hospitals in Ethiopia.

In Ethiopia approximately 3,200,000 babies are born annually and 41.09 per 10,000 live births are affected by spina bifida. Hydrocephalus (HCP) is another common pediatric neurosurgical condition with studies in Ethiopia showing the most common etiology is post spina bifida closure. The out-of-pocket expense (OOPE) and indirect expense of patients treated surgically for spina bifida and hydrocephalus during the first year of life were assessed. A prospective hospital-based study was done on patients treated surgically for spina bifida and HCP in two university-affiliated hospitals, between April 1st, 2022, and April 1st, 2023. Data on direct and indirect expenses were collected during inpatient care and follow-up. Catastrophic health expenditure (CHE) was assessed, defined as total expenditure exceeding 10% of the total annual household expenditure. A total of 245 patients were eligible for analysis. The median annual total expenditure of households for treatment was ETB 11,510.00 with ETB 5700.00 being indirect expenditure. Forty-nine percent of the households suffered CHE. In multivariate analysis, the factors which were found to have a statistically significant association with CHE were the hospital where the patient received the treatment, the household's wealth quintile, the place of residency, and pre-admission duration of stay. Our study revealed a high CHE in households with spina bifida and HCP. We recommend working on primary prevention of spina bifida, expanding surgical services regionally to minimize costs associated with travel for surgical care, and reducing pre-admission duration of stay by improving evaluation and investigations at outpatient clinics.

The impact of financial inclusion on rural–urban households welfare inequality in Ghana: A decomposition analysis

AbstractThis article examined the impact of financial inclusion on rural–urban households' welfare inequality in Ghana using nationally representative survey data sourced from the seventh round of the Ghana Living Standard Survey. The article used a multidimensional financial exclusion index and the real per adult equivalent measures of total annual household consumption expenditure as measures of financial inclusion and welfare, respectively. The article employed the instrumental variable estimation technique to account for the issues of endogeneity and sample selectivity bias associated with measuring financial inclusion. The estimated results from recentered influenced function‐Ordinary Least Squares of the unconditional quantile regression and the Oaxaca‐Blinder techniques show significant rural–urban welfare gaps in favor of urban households at the mean and across the selected quantiles. The study also found that differences in financial inclusion between rural and urban households contribute significantly to the welfare gaps, while the economic returns to financial inclusion reduce the welfare gaps both at the mean and the selected quantiles. The study recommends that policies aimed at improving financial inclusion as well as strengthening financial institutions in rural areas be put in place to help reduce the rural–urban welfare inequality in Ghana.

Impact of Government-Funded Health Insurance on Out-of-Pocket Expenditure and Quality of Hospital-Based Care in Indian States of Madhya Pradesh and Maharashtra.

With its clear focus on financial protection, government-funded health insurance (GFHI) stands out among the strategies for universal health coverage (UHC) implemented by low-to-middle income countries globally. Since 2018, India has implemented a GFHI programme called the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), which covers 500 million individuals. The current study aims to evaluate the performance of GFHI in meeting its key objectives of improving access, quality and financial protection for hospital-based care in two large central Indian states: Madhya Pradesh and Maharashtra. The study measures access in terms of utilisation of inpatient care. Financial protection was measured in terms of catastrophic health expenditure which was defined as the incidence of out-of-pocket expenditure (OOPE) above thresholds of 10% and 25% of annual household expenditure. Patient-satisfaction with care was taken as an indicator of quality. A household survey was conducted in 2023, covering a multi-stage sample of 11,569 and 12,384 individuals in Madhya Pradesh and Maharashtra, respectively. Multi-variate analyses were conducted to find the effect of GFHI-enrolment on the desired outcomes. The instrumental variable method was applied to address potential endogeneity in insurance enrolment. Additionally, propensity score matching was done to ensure robustness. Around 71% and 63% of surveyed individuals were enrolled under GFHI in Madhya Pradesh and Maharashtra, respectively. The hospitalisation rate did not differ much between the GFHI-enrolled and non-enrolled population. The average OOPE on hospitalisation was similar for the GFHI-enrolled and non-enrolled patients. The OOPE and catastrophic health expenditure in private hospitals remained very high, irrespective of GFHI enrolment. The pattern was similar in both states. Multi-variate adjusted models showed that GFHI had no significant effect on utilisation, quality, OOPE and catastrophic health expenditure. The above results were confirmed by propensity score matching. Coverage by GFHI enrolment was ineffective in improving access, quality or financial protection for inpatient hospital care despite 5 years of implementation of the programme. Long-standing supply-side gaps and poor regulation of private providers continue to hamper the effectiveness of GFHI in India.

Catastrophic Health Expenditure among Iranian Households: Evidence from the COVID-19 Era.

Monitoring households' exposure to catastrophic health expenditure (CHE) based on out-of-pocket (OOP) health payments is a critical tool for evaluating the equitable financial protection status within the health system. The COVID-19 pandemic has brought unprecedented global change and potentially affected the mentioned protection indicators. This study aimed to assess the prevalence of CHE among households in Iran during the COVID-19 period. The present study employed a retrospective-descriptive design utilizing data derived from two consecutive cross-sectional Annual Household Income and Expenditure Surveys (HIES) undertaken by the Statistical Centre of Iran (SCI) in 2020 and 2021. The average annual OOP health payments and the prevalence of households facing CHE were estimated separately for rural and urban areas, as well as at the national level. Based on the standard method recommended by the World Health Organization (WHO), CHE was identified as situations in which OOP health payments surpass 40% of a household's capacity to pay (CTP). The intensity of CHE was also calculated using the overshoot measure. All statistical analyses were carried out using Excel-2016 and Stata-14 software. The average OOP health payments increased in 2021, compared to 2020, across rural and urban areas as well as at the national level. Urban residents consistently experienced higher OOP health payments than rural residents and the national level in both years. At the national level, the prevalence of CHE was 2.92% in 2020 and increased to 3.18% in 2021. In addition, rural residents faced a higher prevalence of CHE based on total health services OOP, outpatient services OOP, and inpatient services OOP compared to urban residents and the national level. Regarding the intensity of CHE using overshoot, the results for 2020 and 2021 revealed that the overshoot ranged between 0.60% and 0.65% in rural areas, between 0.30% and 0.33% in urban areas, and between 0.38% and 0.41% at the national level. A considerable percentage of households in Iran still incur CHE. This trend has increased in the second year of COVID-19 compared to the first year, as households received more healthcare services. The situation is even more severe for rural residents. There is an urgent need for targeted interventions in the health system, such as strengthening prepayment mechanisms, to reduce OOP and ensure equitable protection for healthcare recipients.

Association between socioeconomic status and post-stroke depression in middle-aged and older adults: results from the China health and retirement longitudinal study

IntroductionPost-stroke depression (PSD) is a common neuropsychiatric complication that affects approximately one-third of stroke patients. The treatment and prognosis of this disease are poor. Socioeconomic status (SES) is closely related to health outcomes; however, only a few previous studies have focused on the association between SES and PSD. Given the substantial population of stroke patients in China, it is crucial to examine the potential risk factors associated with PSD. Conducting studies on this population and investigating the influence of economic conditions can provide valuable guiding theoretical insights into PSD prevention and management.MethodsWe used data from the 2018 China Health and Retirement Longitudinal Study and selected appropriate samples for analysis. Depression was estimated using the Center of Epidemiologic Studies Depression Scale-10, a validated tool for assessing depression in the general population. Multiple logistic regression analysis was employed to assess the association between SES and PSD and to evaluate any urban–rural differences.ResultsOf the 749 respondents, 370 (49.4%) had depression. Stroke patients with a middle school education demonstrated a greater risk of developing depression than those with a primary school education or below after adjusting for all control variables (odds ratio (OR) = 1.60, 95% confidence interval (CI): 1.03–2.51, P = 0.036). However, stroke patients with a high school education or above had a lower risk of developing depression than those with a primary school education or below (OR = 0.50, 95% CI: 0.28–0.88, P = 0.016). In rural areas, stroke patients with a high school or above education level had lower rates of depression than those with a primary school education or below (OR = 0.44, 95% CI: 0.21–0.91, P = 0.027). This difference was not significant in urban areas.ConclusionsSES significantly influences the occurrence of PSD, which is reflected by education attainment and annual household expenditures. Education attainment was an independent influence on PSD, with a more pronounced effect in rural versus urban areas. We hope to reduce the prevalence of PSD and enhance the comprehensive management of this disease by modifying the influencing factors. Sex, self-reported health status, activities of daily living, night-time sleep duration, and life satisfaction also influenced the occurrence of PSD.

The Impact Logistics Management on Food Security

The assurance that food insecurity is minimized with enabling logistics provisions is evident in the literature, however, the quantified relation between logistics management and food security was limited. This article examines the relationship between logistics management and food security, focusing on the efficacy of the Infrastructure for Poverty Eradication Program (IPEP) warehouses in coordinating Logistics in the agricultural sector. Using a multi-stage sampling technique, 384 smallholder farmers from two regions having access to the IPEP initiative were sampled, in the aftermath, regression analysis was performed. Contrary to the GSS, 2022 Annual Household Income and Expenditure Survey, which claims around 50 percent food insecurity, Ghana's food security has improved, with over 90 percent of foods produced now escaping post-harvest losses. However, Logistics management has a weak relationship with Ghana's food security at p=0.073 and Pearson's R=0.149, indicating that Logistics management has a slight influence (p=0.001) on food security (R2 =1%), and recent improvements in food security cannot be linked to its well-roundedness. Ninety-nine percent of the underlying food security cannot be correlated to effective logistics management; therefore, effective implementation of a national plan is essential to institute the IPEP as the fulcrum in carrying out this administrative responsibility for the optimum gain.

Social protection, community participation and state‐citizen relations: Evidence from a cash transfer program in south‐central Somalia

AbstractWe investigate whether social protection programs can increase participation in community‐driven development programs and examine how this affects state‐citizen relations. Using a randomized controlled trial in south‐central Somalia, we study the impacts of one‐time unconditional cash transfers to vulnerable households that were specifically designed to encourage participation in community development. While the cash transfer is relatively small as a share of annual household expenditure, it is more than sufficient to cover households' anticipated community development contributions. The transfers were funded by an NGO but delivered through state institutions. We collect survey data before and after the intervention with almost 600 individuals eligible to receive cash transfers. We find no substantial differences in participation in community development projects for cash transfer recipient households relative to non‐recipient households. However, we do find positive impacts of the cash transfers on citizen perceptions of clan elders and the local government. Our findings suggest that relatively small social protection interventions may face challenges in increasing vulnerable households' participation in community development and decision‐making, while also highlighting potential positive spillover effects for state‐citizen relations and beliefs about the capacity of local institutions where states institutions are involved in program delivery, even if they do not finance the program.

Catastrophic health expenditure and its association with socioeconomic status in China: evidence from the 2011-2018 China Health and Retirement Longitudinal Study

BackgroundAn increase in healthcare utilization in response to universal health coverage may leave massive economic burden on individuals and households. Identifying catastrophic health expenditure helps us understand such burden. This study aims to examine the incidence of catastrophic health expenditure at various thresholds, explore its trend over years, and investigate whether it varies across socioeconomic status (SES).MethodsData used in this study were from four waves of the China Health and Retirement Longitudinal Study (CHARLS): 2011, 2013, 2015, and 2018. SES was measured by annual per-capita household expenditure, which was then divided into quintiles (Quintile 1 (Q1): the poorest - Quintile 5 (Q5): the wealthiest). Catastrophic health expenditure was measured at both a fixed threshold (40%) and a set of variable thresholds, where the thresholds for other quintiles were estimated by multiplying 40% by the ratio of average food expenditure in certain quintile to that in the index quintile. Multilevel mixed-effects logistic regression models were used to analyze the determinants of catastrophic health expenditure at various thresholds.ResultsA total of 6,953 households were included in our study. The incidence of catastrophic health expenditure varied across the thresholds set. At a fixed threshold, 10.90%, 9.46%, 13.23%, or 24.75% of households incurred catastrophic health expenditure in 2011, 2013, 2015, and 2018, respectively, which were generally lower than those at variable thresholds. Catastrophic health expenditure often decreased from 2011 to 2013, and an increasing trend occurred afterwards. Compared to households in Q5, those in lower quintiles were more likely to suffer catastrophic health expenditure, irrespective of the thresholds set. Similarly, having chronic diseases and healthcare utilization increased the odds of catastrophic health expenditure.ConclusionsThe financial protection against catastrophic health expenditure shocks remains a challenge in China, especially for the low-SES and those with chronic diseases. Concerted efforts are needed to further expand health insurance coverage across breadth, depth, and height, optimize health financing mechanism, redesign cost-sharing arrangements and provider payment methods, and develop more efficient expenditure control strategies.

Out-of-pocket expenditure among patients with diabetes in Bangladesh: A nation-wide population-based study

Background and objectivesDiabetes has become one of the fastest growing public health emergencies worldwide. The objective of this study was to estimate the average annual out-of-pocket cost of diabetes treatment as well as to find out the catastrophic health expenditure (CHE) and their determinants in Bangladeshi context. Data and methodsThe study utilised data from the most recent nationally representative Household Income and Expenditure Survey 2016–2017. The incidence of CHE was estimated by applying 10% and 25% of the annual total household expenditure threshold levels. The factors associated with CHE was presented as adjusted odds ratio with 95% confidence intervals. ResultsThe annual average out-of-pocket cost per diabetes patient was US$ 323 (BDT 25,473). The cost of medication was the main cost driver contributed for 75.43% of the total out-of-pocket cost. The incidence of CHE was 14.34%, and 5.86% of the study households for 10% and 25% of the threshold levels, respectively. The patient aged more than 60 (AOR: 4.89; CI 0.82 to 28.95), uneducated (AOR: 1.83; CI 0.25 to 2.12), comorbid condition (AOR: 1.62; CI 0.94 to 2.79), small household size (AOR: 3.20; CI 0.58 to 17.51), rural resident (AOR: 1.85; CI 0.46 to 1.57), poorest asset quintile (AOR: 4.06; CI 1.43 to 13.87) and private facility type (AOR: 8.16; CI 3.46 to 19.;25) were significantly associated with the incidence of CHE due to diabetes treatment. ConclusionsThere are considerable out-of-pocket costs needed for diabetes care in Bangladesh. The evidence of catastrophic expenditure suggests the urgent need to improve financial risk protection to ensure access to care.

Associations of healthy lifestyle and three latent socioeconomic status patterns with physical multimorbidity among middle-aged and older adults in China

BackgroundMultimorbidity is an emerging global public health concern. However, complex associations of healthy lifestyle and socioeconomic status (SES) with multimorbidity have not been identified. MethodsThis population-based prospective cohort study used data from four waves of the China Health and Retirement Longitudinal Study (CHARLS) to explore these relationships. Physical multimorbidity was measured using 12 non-communicable diseases. Latent class analysis (LCA) was conducted to determine the optimal SES patterns based on annual per-capita household expenditure, occupation, education level, and health insurance. The healthy lifestyle score (0–5) was constructed comprising information on smoking, drinking, physical activity, sleep, and body shape. ResultsOf 17,708 participants in the CHARLS, 7776 were eligible for inclusion in our analysis (13.3% with high SES, 26.1% with medium SES, and 60.6% with low SES). Compared with high SES participants, those with low SES had higher risks of incident physical multimorbidity (OR 1.22, 95% CI 1.05, 1.42), which was competitively mediated by lifestyle (mediation proportion, −10.17%, 95% CI -19.12%, −1.23%). Significant interactions were observed between lifestyle factors and SES in patients with incident diabetes. Participants with low SES and no or one healthy lifestyle factor had a higher risk of incident physical multimorbidity than those with high SES and four to five healthy lifestyle factors (OR 2.19, 95% CI 1.57, 3.04). ConclusionHealthy lifestyles competitively mediate a fractional proportion of socioeconomic inequity in incident physical multimorbidity. Furthermore, healthy lifestyles were associated with lower multimorbidity risk in the SES subgroups, supporting the important role of lifestyle in reducing physical multimorbidity burden.

Impact of the Grain for Green Project on the Well-Being of Farmer Households: A Case Study of the Mountainous Areas of Northern Hebei Province, China

There are close dynamic relationships among the livelihood, well-being, and ecological environment of farmer households. It is of great significance to scientifically clarify the impact of the Grain for Green policy on the livelihoods and well-being of farmer households in mountainous areas. Based on data from a survey of 392 farmer households in Zhangbei County, the system of indicators for livelihood assets and well-being of farmer households were constructed using the sustainable livelihood framework (SLF). The livelihood assets and well-being levels of different types of farmer households were measured, and a multiple linear regression model was used to analyze the impact of the Grain for Green policy implementation on the well-being levels of farmer households. The results showed that (1) the Grain for Green project caused changes in the livelihood of farmer households. The average livelihood diversity of farmer households was 3.008, and the returned farmland households (3.022) were higher than the nonreturned farmland households (2.975) in Zhangbei County. The level of natural assets among the total average livelihood assets of farmer households was the highest at 0.374, while the level of physical assets was the lowest at 0.018. The level of livelihood assets of returned farmland households (0.948) was lower than that of nonreturned farmland households (1.117). (2) The Grain for Green policy had an improving effect on the level of well-being of farmer households, but the effect was not significant. The level of well-being of all farmer households in Zhangbei County was 0.517, with the level of wealth contributing the most to the well-being of farmer households at 40.20% and the quality of the ecological environment contributing the least at 11.99%. The level of well-being of returned farmland households (0.518) was slightly higher than that of nonreturned farmland households (0.514). (3) The influencing degree of each factor on the level of well-being varied significantly. There are three main paths through which the Grain for Green policy affects the well-being of farmer households: by reallocating human assets, optimizing natural assets, and enhancing financial assets. The factor of household size had the highest degree, at 0.366, while educational attainment of household members, household labor capacity, annual household expenditure, livelihood diversity, number of large production tools, and total value of livestock were also important drivers of household well-being, and area of arable land was negatively associated with household well-being. There were also differences in the factors influencing the level of well-being of different types of farmer households.

Prevalence and Determinants Of Intergenerational Métiers Mobility of the Labourers of Assam Tea Gardens

The study aims to explore the intergenerational métiers mobility pattern of Assam tea garden labourers. Simultaneously, the current study unfolds the various factors responsible for this phenomenon. This predominantly empirical study utilises the Transition matrices and Multinomial Logistic Regression on 251 household-level primary data to explore the objectives. The empirical results disclose that horizontal motility is more prominent than vertical motility among the tea garden labourers of Assam. Various social-economic-demographic factors, like years of education, annual household expenditures, sex, and the number of dependents influence the vertical motility among the labourers of Assam tea gardens. The study also offer suitable policy prescriptions.

Small area estimation of average compositions under multivariate nested error regression models

This paper investigates the small area estimation of population averages of unit-level compositional data. The new methodology transforms the compositions into vectors of R^m and assumes that the vectors follow a multivariate nested error regression model. Empirical best predictors of domain indicators are derived from the fitted model, and their mean squared errors are estimated by parametric bootstrap. The empirical analysis of the behavior of the introduced predictors is investigated by means of simulation experiments. An application to real data from the Spanish household budget survey is given. The target is to estimate the average of proportions of annual household expenditures on food, housing and others, by Spanish provinces.

Does professionalizing maintenance unlock demand for more reliable water supply? Experimental evidence from rural Uganda

Professionalization is gaining prominence as a strategy to address the deficiencies in rural water supply reliability and financial sustainability in low- and middle-income countries that have persisted under community management policies. Yet there is little evidence regarding how much water users can and will pay for the higher reliability that professionalized services promise. What evidence exists largely relies on stated preference studies that do not confront water users with paying over time. We conducted a price experiment to measure effective demand (willingness and ability to pay) for a professional handpump maintenance and repair service among 113 water committees and 1,031 households representative of two districts in northern Uganda. We offered a one-year subscription using Becker-DeGroot-Marschak auctions with real money payments. The service largely delivered on its guarantee of fast repairs and satisfied most customers. Nonetheless, we found that just 4% of water committees paid any price for the full service period. None paid for more than one month at prices higher than our estimate of operating cost even though it represented less than 1% of annual household expenditure. Our findings contrast assertions from recent stated preference studies that increasing handpump reliability is a lynchpin to attracting higher payments from rural water users. Misaligned incentives that discourage water users, nonprofits and their donors, local governments, and political candidates from shifting to higher tariffs for maintenance seem to best explain why effective demand was low. Despite the low demand, we estimate that professionally maintaining the existing handpumps in the study districts would cost less in the long run than the de facto practice of letting these assets fail repeatedly and rehabilitating them. As Uganda and other countries embark on maintenance-oriented, post-community management rural water policies, funders, practitioners, and researchers will need to grapple with how to align institutional incentives for sustainable financing.

Financial risk of emergency abdominal surgery: a cross sectional study from Ethiopia

BackgroundThe Lancet Commission on Global Surgery suggested six indicators every country should use to measure their surgical systems. One of these indicators, catastrophic expenditure (CE), is defined as money paid for service which amounts to more than 10% of the patient’s total annual expenditure, or more than 40% of annual non-food household expenditure. Ethiopian Ministry of Health has set a target of 100% protection from CE by 2030. However, so far there is lack of studies that assess financial risk of surgery.MethodsUsing a cross sectional study design, financial risk assessment was carried out on 142 patients from Yekatit 12 and Zewditu Memorial hospitals in Addis Ababa, Ethiopia from May 15 to September 15, 2021.ResultsAppendectomy (69.0%), emergency laparotomy (26.1%) and cholecystectomy (4.9%) resulted in mean direct medical expenditures of 111.7USD, 200.70USD and 224.60USD, respectively. Medications and imaging accounted for 60.8 and 13.9% of total treatment cost. By applying the two definitions of catastrophic expenditure, 67.6 and 62.7% of patients sustained CE, respectively Overall rates of CE across procedures were 67.3 and 59.1% for appendectomy, 70.2 and 70.2% for laparotomy, 57.0 and 71.2% for cholecystectomy. Thirty-five (24.6%) patients had some form of insurance, with Community Based Health Insurance being the most common form (57%). Insured patients were less likely to sustain CE with both definitions (AOR 0.09, p = 0.002 and AOR 0.10, p = 0.006 respectively).Conclusion and recommendationsSubstantial proportion of patients undergoing emergency abdominal surgery sustain CE in Addis Ababa. Medications and imaging take major share of total cost mainly because patients have to acquire them from private set ups. Policy makers should work on availing medications and imaging in public hospitals as well as expand insurance and other forms of surgical care financing to protect patients from CE.

​​Impact of Nagaland State Rural Livelihood Mission (NSRLM) on Livelihood Status of Women in Nagaland

Background: The Nagaland State Rural Livelihood Mission is the implementing agency for the NRLM in the state and embodies the principles and vision of NRLM while keeping in mind the unique features of the state. The Mission aims at bringing about sustained improvement in the household incomes, livelihood, well-being and empowerment status of the rural poor through sustained livelihood enhancements and improved access of financial and non-financial services. The present study was about an impact of NSRLM on socio-economic and livelihood status of rural women in Mon District of Nagaland. Methods: A total of 100 respondents (80 beneficiary and 20 non beneficiary respondents) were surveyed. Ex post facto research design was used for the study. Both primary and secondary data were used. Collected data were scrutinized and statistically analyzed using statistical tools like t-test, Pearson’s correlation analysis and index analysis to draw valid conclusions. To measure the impact, six types of assets viz., human assets, physical assets, natural assets, social assets, financial assets and food security were considered. Result: Annual income earned from different sources, expenditure and saving of NSRLM beneficiary respondents found increase in comparison to non beneficiary respondents. The average assets value, average annual household income and average annual household expenditure per household of the beneficiary respondents were found comparatively greater than that of non-beneficiary respondents. Beneficiary respondents remained significantly better off than that of non-beneficiary respondents in all six types of asset creation. Some of the independent variables viz., age, income and expenditure were found positively and significantly associated with creation of human assets, financial asset and food security among the beneficiary respondents.