Average Out Of Pocket Expenditure Research Articles

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.

Out of Pocket Expenditure and Utilization of Government Financial Assistance Among Women Who Had Institutional Delivery in An Urban Slum of Telangana, India

Background: Out of Pocket Expenditure (OOPE) are expenditures directly made by households at the point of receiving health care. In Telangana State the average OOPE per delivery in public health facility is Rs. 3846. The study helps to know the OOPE among mothers undergoing institutional deliveries and emphasise on the expenditure even after utilising the government financial assistance. Objectives: To estimate the OOPE among women undergoing institutional delivery and to find its association with government financial assistance utilization and socio-demographic factors. Methodology: A community based cross sectional study was done among 200 mothers who delivered recently residing in an urban slum under our health and training centre. Ethical clearance was taken before the conduct of study. Results: The median direct out of pocket expenditure among mothers in our study was Rs.500 i.e., 6.6 $ (0 to 1600). OOPE was present among 68.5% of mothers. Availability of government financial assistance, age and occupation of the mother and type of delivery was found to be significantly associated with p value <0.05. Conclusion: The financial assistance definitely reduced the burden of OOPE among the mothers. The implementation of such schemes is important and needs to be evaluated time to time to ensure proper reach of its benefits to the community.

Out-of-pocket expenditure on community healthcare services at end-of-life among decedents from cardiovascular disease in six European countries and Israel

ObjectivesMost people who develop chronic diseases, including cardiovascular disease (CVD), live in their homes in the community in their last year of life. Since cost-sharing is common in most countries, including those with universal health insurance, these people incur out of pocket expenditure (OOPE).The study aims to identify the prevalence and measure the size of OOPE among CVD decedents at end-of-life (EOL) explore differences among countries in OOPE, and examine whether the decedents’ characteristics or their countries’ health policy affects OOPE more.MethodsSHARE data among people aged 50 + from seven European countries (including Israel) who died from CVD are analyzed. Decedents’ family members are interviewed to learn about OOPE on their relatives’ account.ResultsWe identified 1,335 individuals who had died from CVD (average age 80.8 years, 54% men). More than half of CVD-decedent people spend OOPE on community services at EOL and their expenditure varies widely among countries. About one-third of people in France and Spain had OOPE, rising to around two-thirds in Israel and Italy and almost all in Greece. The average OOPE is 391.9 PPT, with wide variance across countries. Significant odds of OOPE exist in the country variable only, and significant differences exist in the amount of OOPE among countries and duration of illness preceding death.ConclusionsSince improving CVD care efficiency and effectiveness are key aims, healthcare policymakers should broaden the investigation into expanding public funding for community services in order to mitigate OOPE, alleviate the economic burden on households, mitigate forgoing of community services due to price, and reduce rehospitalization.

Multimorbidity and out-of-pocket expenditure on medicine in Europe: Longitudinal analysis of 13 European countries between 2013 and 2015.

Many European Health Systems are implementing or increasing levels of cost-sharing for medicine in response to the growing constrains on public spending on health despite their negative impact on population health due to delay in seeking care. This study aims to examine the relationships between multimorbidity (two or more coexisting chronic diseases, CDs), complex multimorbidity (three or more CDs impacting at least three different body systems), and out-of-pocket expenditure (OOPE) for medicine across European nations. This study utilized data on participants aged 50 years and above from two recent waves of the Survey of Health, Aging, and Retirement in Europe conducted in 2013 (n = 55,806) and 2015 (n = 51,237). Pooled cross-sectional and longitudinal study designs were used, as well as a two-part model, to analyse the association between multimorbidity and OOPE for medicine. The prevalence of multimorbidity was 50.4% in 2013 and 48.2% in 2015. Nearly half of those with multimorbidity had complex multimorbidity. Each additional CD was associated with a 34% greater likelihood of incurring any OOPE for medicine (Odds ratio = 1.34, 95% CI = 1.31-1.36). The average incremental OOPE for medicine was 26.4 euros for each additional CD (95% CI = 25.1-27·7), and 32.1 euros for each additional body system affected (95% CI 30.6-33.7). In stratified analyses for country-specific quartiles of household income the average incremental OOPE for medicine was not significantly different across groups. Between 2013 and 2015 in 13 European Health Systems increased prevalence of CDs was associated with greater likelihood of having OOPE on medication and an increase in the average amount spent when one occurred. Monitoring this indicator is important considering the negative association with treatment adherence and subsequent effects on health.

Does community-based health insurance protect women from financial catastrophe after cesarean section? A prospective study from a rural hospital in Rwanda

BackgroundThe implementation of community-based health insurance in (CBHI) in Rwanda has reduced out of pocket (OOP) spending for the > 79% of citizens who enroll in it but the effect for surgical patients is not well described. For all but the poorest citizens who are completely subsidized, the OOP (out of pocket) payment at time of service is 10%. However, 55.5% of the population is below the international poverty line meaning that even this copay can have a significant impact on a family’s financial health. The aim of this study was to estimate the burden of OOP payments for cesarean sections in the context of CBHI and determine if having it reduces catastrophic health expenditure (CHE).MethodsThis study is nested in a larger randomized controlled trial of women undergoing cesarean section at a district hospital in Rwanda. Eligible patients were surveyed at discharge to quantify household income and routine monthly expenditures and direct and indirect spending related to the hospitalization. This was used in conjunction with hospital billing records to calculate the rate of catastrophic expenditure by insurance group.ResultsAbout 94% of the 340 women met the World Bank definition of extreme poverty. Of the 330 (97.1%) with any type of health insurance, the majority (n = 310, 91.2%) have CBHI. The average OOP expenditure for a cesarean section and hospitalization was $9.36. The average cost adding transportation to the hospital was $19.29. 164 (48.2%) had to borrow money and 43 (12.7%) had to sell possessions. The hospital bill alone was a CHE for 5.3% of patients. However, when including transportation costs, 15.4% incurred a CHE and including lost wages, 22.6%.ConclusionTo ensure universal health coverage (UHC), essential surgical care must be affordable. Despite enrollment in universal health insurance, cesarean section still impoverishes households in rural Rwanda, the majority of whom already lie below the poverty line. Although CBHI protects against CHE from the cost of healthcare, when adding in the cost of transportation, lost wages and caregivers, cesarean section is still often a catastrophic financial event. Further innovation in financial risk protection is needed to provide equitable UHC.

Abstract 12031: Out of Pocket Expenditure for In-Patient Care of Cardiovascular Disease in India: A Gender-Based Analysis Using National Sample Survey Data

Introduction: This study aims to examine the out-of-pocket expenditure (OOPE) pattern for hospitalisation in cardiovascular diseases (CVD) from a gender perspective. Methods: This study is based on 75 th round National Sample Survey (NSS) data (2017-2018), conducted by Government of India, covering the sample of 1,13,823 households from all States and Union Territories of India. NSS data considers CVD as Hypertension (HTN) and Heart Disease (HD). The sample size of hospitalisation cases in HTN and HD are 1418 and 4726 respectively based on 365 days recall period from the date of survey. Here, average OOPE per hospitalisation is estimated as μ Medical expenditure includes costs on doctor’s fee, medicine, diagnostic tests, bed charges, and other medical expenses. To analyse the data statistical and econometric tools like, multivariate regression, t test, χ2 test, ANOVA are used. Results: Multivariate analysis confirms that average OOPE per hospitalisation of CVD is significantly lower for female than male (β = -0.233, p = 0.000, CI: -0.348, -0.118) even after controlling socio-economic and demographic factors including place of residence, age, education, income status (Monthly Per capita Consumption Expenditure ,MPCE), social groups, occupation of the household, zones, marital status, household size, and, possession of health insurance. The average OOPE for male is significantly higher than the female, 1.6 and 1.7 times for HD and HTN respectively. For HD, this gap increases with the increase in education level. Across the six zones, average OOPE in both HTN and HD is higher for male than the female except Eastern zone. This gender gap in OOPE is more common among married and widow/divorced as compared to the single. Conclusion: Gender disparity prevails in OOPE for cardiovascular disease, which needs attention at the policy level go achieve the development goals. Fig:Distribution of OOPE per hospitalisation between Male and Female across Socio-economic strata ( in INR '000.)

The unending burden of high out-of-pocket expenditure on institutional deliveries in India

ObjectiveThis study aims to address the question that whether out-of-pocket expenditure (OOPE) on institutional deliveries remained high or reduced over time in India, in particular after the introduction of conditional cash transfer (CCT) incentive programmes such as Janani Suraksha Yojana (JSY) in 2005. Study designThe study presents the trends in average OOPE on institutional deliveries in India, in an effort to evaluate the impact of the JSY programme on it. MethodsFor the purpose, the study used recently released 75th round of National Sample Survey data, 2017/18 about household social consumption (Health) and two of its previous rounds in 2004 and 2014. ResultsThe results suggest that, except at rural public facilities, the average OOPE for institutional delivery has increased significantly in both rural and urban areas from 2004 to 2017/18, even after adjusting to inflation in the prices. In addition, the results have shown that overall 14 of 33 states for rural public facilities, 20 of 25 states in rural private facilities, 21 of 32 states in urban public facilities and 29 of 32 states in urban private facilities have experienced more than 50% raise in OOPE on institutional delivery during 2004–2017/18, despite JSY incentives. ConclusionThe findings suggest that the current level of JSY incentives will not be sufficient to avoid catastrophic spending on institutional deliveries for the households as the incentives in several states are much less than the state average OOPE per delivery. Thus, there is a need to consider a raise in the state or central contribution for CCT under the JSY programme to reduce the burden of OOPE on institutional deliveries through recently launched Pradhan Mantri Matru Vandana Yojana.

Moving to Social Health Insurance Financing and Payment for HIV/AIDS Treatment in Vietnam.

This study estimates the amount antiretroviral therapy (ART) clients paid out of pocket for preventive and treatment services and the percentage of ART clients incurring catastrophic payments during the period when ART services were transitioning from donor funding to domestic social health insurance (SHI) in Vietnam. Using a cross-sectional facility-based survey in 9 provinces, a sample of 582 clients across 18 ART facilities representatives of all facilities where SHI-financed ART was being implemented were interviewed in 2019. Results indicated 13.4% (95% CI: 5.7%, 28.2%) of clients incurred a payment for outpatient ART care. The average out of pocket expenditures for outpatient visits and HIV related outpatient visits was USD $71.2 and $8 per year, respectively. The average out of pocket expenditure for inpatient admission and HIV related inpatient admission was $7.1 and $1.6, respectively. Only 0.1% clients currently experienced HIV-related catastrophic payment at the 25% of total expenditures threshold. The study confirms the transition from donor-financed ART to SHI-financed ART is not causing financial hardship for ART clients. However, more commitment from the Government of Vietnam to strengthen HIV-related services under SHI may be needed in the future, and there is still need to ensure universal SHI coverage among people with HIV/AIDs in Vietnam.

Socioeconomic Burden of Type 2 Diabetes with Complications on Families: A Hospital-Based Study in Puducherry

Abstract Introduction India is on the verge of diabetes mellitus (DM) epidemic. Within the near future, DM will put a big burden on India’s already vulnerable and resourced health care system. The objectives of the study were to (1) estimate DM treatment-related out-of-pocket expenditure (OOPE) among type 2 DM patients with complications from a tertiary care hospital and (2) estimate the economic burden on the household income of these patients due to DM treatment-related OOPE. Methods A hospital-based cross-sectional study was conducted among known type 2 diabetic individuals with complications admitted in a tertiary care hospital. Using a structured pretested questionnaire required data, such as sociodemographic details, direct costs, and indirect costs in health care of DM, which were collected by a personal interview method. Results Males constituted around 57% of the 100 patients who participated in the study. The average age of the population was 56 ± 10.03 years. The mean monthly income of family (in Indian Rupees [INR]) was 10,375.00 ± 9,201.55. Total expenditure includes the cost of medication, investigation, consultation fee, transportation, and miscellaneous expenditure. The average monthly OOPE in the management of DM for government and private facilities was INR 74 and 1,540, respectively. Among the total cost, the highest share was accrued toward medicines followed by diagnostics, miscellaneous, and transportation. There were 22% of families incurring catastrophic expenditure at the highest threshold of 40%. Socioeconomic status, history of at least one hospitalization in the past 6 months, and type of medications were factors found to be associated with costs. Conclusion Heavy economic burden highlights the urgent need for the health care agencies and policy bodies to plan and prioritize local health policies and DM management schemes accordingly.

The socioeconomic cost of chronic rhinosinusitis study.

Chronic rhinosinusitis (CRS) is highly prevalent, affecting 11% of the population. Studies evaluating the socio-economic impact of CRS are mostly limited to the US population. Currently there is no study that has evaluated the socio-economic costs of CRS in the UK. A case-control study of patients with CRS and healthy controls was conducted to investigate the wider socio-economic impact of the disease. Data on demographic and socioeconomic characteristics, out-of-pocket expenditure (OOPE), health resource utilisation, productivity losses and health-related quality of life (HRQoL) via the EQ-5D and SNOT-22 instruments, were collected from questionnaires. A total of 139 CRS participants and 67 control participants completed the questionnaires. The average total OOPE per patient extrapolated to a 12-month period was £304.84. Other important findings include significantly higher reported primary care interactions (4.14 vs. 1.16) as well as secondary care interactions (2.61 vs 0.4) in CRS group as compared to controls over three-months. The average total missed workdays was estimated to be 18.7 per patient per year. The estimated incremental healthcare cost of CRS per year is £16.8 billion or £2.8 billion per million inhabitants. Factors predictive of a higher OOPE include higher household occupancy and income and these accounted for only 9.7% of the total variance in total OOPEs. Other socioeconomic, demographic and HRQoL variables were not found to be predictive factors of OOPE. This study showed that CRS has a significant wider economic burden beyond the immediate direct healthcare costs. CRS participants had a high level of healthcare service use, OOPE and productivity loss. Results from this study will add to the existing limited data both for the UK and abroad and emphasises the need for effective treatments for these patients to reduce the disease impact.

Economic Burden of Head and Neck Cancer Treatment in North India

Background:The rising cost of cancer treatment has imposed a huge financial burden on the affected households, leading to catastrophic outcomes and impoverishment. The present study was designed to estimate the economic burden incurred by households for the treatment of head and neck cancer (HNC) in India. Methods:The present study was undertaken in a large public sector tertiary care hospital of North India. A total of 159 patients were recruited at time of their first registration in the department of Radiation Oncology, and were followed after completion of their treatment. Another 288 were recruited within one month after completion of treatment. Economic burden was assessed in terms of out of pocket (OOP) expenditure incurred, prevalence of catastrophic health expenditure and distress financing (borrowing or selling of assets) related to different modalities of cancer treatment. Results:The average OOP expenditure incurred by a patient of HNC patient was INR 37, 845 (USD 563), which varied from INR 32,379 (USD 482) when a patient undergoes radiotherapy alone to INR 67,480 (USD 1,004) for surgery along with chemo-radiotherapy. Specifically, patients undergoing 2-DRT and IMRT alone had to spend INR 31,487 (USD 469) and INR 42,405 (USD 631) respectively. The prevalence of catastrophic health expenditure (CHE) and distress financing (DF) was 34% and 45% respectively. The odds of incurring both CHE and DF were found to be higher for patients in the lowest income quartile and for those in the younger age groups. Conclusion:Cancer imposes significant economic burden on households. The existing public health system should be strengthened to reduce OOP expenditure incurred by patients. In addition, enhanced coverage of risk pooling mechanisms should be ensured.

Effectiveness of government strategies for financial protection against costs of hospitalization Care in India

BackgroundIn the past decade, India has seen the introduction of many ‘publicly funded health insurance’ schemes (PFHIs) that claim to cover approximately 300 million people and are essentially forms of purchasing care from both public and private providers to reduce out-of-pocket expenditure (OOPE) for hospitalization.MethodsData from a recent government-organized nationwide household survey, The National Sample Survey 71st Round, were used to analyse the effectiveness and equity of tax-funded public health services and PFHIs as distinct but overlapping approaches to financial protection for hospitalization across different socio-economic categories. Cross-tabulation analysis, multivariate logistic regression and propensity score matching were the main analytical methods used.ResultsGovernment hospitals provide access to 45.6% of all hospitalization needs. Although poorer quintiles use public hospitals more often, even in the poorest quintile, as many as 37.2% are utilizing private hospitals. The average OOPE that a household experiences for hospitalization in public hospitals is approximately only one-fifth of the OOPE for hospitalization in the private sector. PFHI schemes cover 12.8% of the population, and coverage is higher in upper quintiles and in urban areas. Hospitalization rates increase with PFHI coverage, and this occurs with both public and private providers. Propensity score matching shows that PFHI contributes to a marginal reduction (1%) in ‘catastrophic health expenditure incidence at the 25% threshold’ (CHE-25) for the bottom three quintiles. The reported coverage of PFHIs was greater in the upper income quintiles. Utilization of public services was greater in the poorer income quintiles and more marginalized social groups.ConclusionsPeriodic surveys are essential to guide policy choices regarding the appropriate mix of strategies for financial protection in pluralistic systems. There is a need for caution regarding any shift in the role of governments from providing services to purchasing care, given the contexts and limitations of currently available PFHIs. Even with tax-funded public services, although the average OOPE is lower than the care purchased through PFHIs, there is still a modest level of CHE and impoverishment due to health care costs that persist. Both strategies need to be synergized for more effective financial protection.

Out of Pocket Expenditures among Hypertensive Patients and their Households who Visit Public Hospitals in Addis Ababa, Ethiopia, 2016

Background: Hypertension like many chronic conditions require long term care, posing financial burden to the patients and their households. Even in countries with universal healthcare coverage, patients including those with chronic conditions can still incur substantial and increasing amounts of out-of-pocket expenditure (OOPE).However, the OOPE burden of hypertension has not been studied in the Ethiopian context. General objective: The objective of the study was to assess out of pocket expenditures among hypertensive patients and their households who visit public hospitals in Addis Ababa, Ethiopia, 2016. Methods: An institution based cross sectional study was conducted on 422 participants in public hospitals that provide care for hypertension in Addis Ababa city from September 01, 2016 to September 20, 2016. Structured questionnaires were used to collect the data. Then the data was entered and analyzed using the statistical package for social scientists version 20 (SPSS-20) and analyses were performed for household out of pocket expenditure that considered estimated direct and indirect out of pocket expenditure and household expenditure by using descriptive statistics. Results: The study covered 422 hypertensive patients and revealed that the total out pocket expenditure was estimated at median 5279.50 (mean 7194.00) birr/month, household expenditure (households food and non-food expenditure) was significant which estimated at median 5148.50 (mean 5003.29) birr/month. The direct cost of hypertensive patient was estimated at median 283 (mean 290.74) birr/month. Conclusion and recommendation: The average OOPE of hypertension to patients and their households were very high when compared with the mean monthly household income. Therefore further research ought to be done including economic consequence, catastrophic Health expenditure, impoverishments, coping mechanism and social resources of hypertension on patients and their households. Health Policymakers and health managers should prioritize the resources need for the hypertension prevention and control activities.

The determinants and costs of bypassing small hospitals in a ‘free’ health system: A cross sectional study in Sri Lanka

Background: Rising out-of-pocket health expenditure due to policy issues is a major factor contributing to deterioration of efficiency and equity of healthcare systems. Objective: The objective of this study was to estimate the determinants of bypassing divisional hospitals in Sri Lanka, and to estimate the effect of bypassing behaviour on the direct out of pocket costs of the patients. Methods: The study employed a hospital based cross sectional analytical design. Out patients department of District General Hospital – Gampaha was selected as the referral facility. Out patients departments of the two selected divisional hospitals were selected as the bypassed facilities. The patients who bypassed the two divisional hospitals and attended the out patients department of the general hospital were identified using a screening tool and a map. The reasons for bypassing were evaluated among those who bypassed. Out of pocket costs of the bypassed were assessed using an interviewer administered questionnaire and compared with the patients who did not bypass the divisional hospitals. Bivariate analysis of the out of pocket expenditure was performed using the Mann-Whitney test, placing the level of significance at 0.05. Results: Patients who bypassed the divisional hospitals were more likely to be married, permanently employed, and have monthly incomes above Rs. 20000. The mean out of pocket expenditure for travelling of bypassed patients and their family members was more than four folds higher than those who did not bypass. The out of pocket expenditure on meals and snacks was also higher among the bypassed. However, more patients among the bypassed group had to spend on outside purchase of medicine and investigations. The average out of pocket expenditure among the bypassed group was about 75% greater than (Rs 63/= more) their counterparts who did not bypass. Conclusions: Bypassing increases the out of pocket expenditure of patients. A primary care based model with designated draining areas and proper referral policies would help to address the issue.

Economic Burden of Hospitalization Due to Injuries in North India: A Cohort Study.

There is little documentation of the potential catastrophic effects of injuries on families due to out of pocket (OOP) expenditure for medical care. Patients who were admitted for at least one night in a tertiary care hospital of Chandigarh city due to injury were recruited and were followed-up at 1, 2 and 12 months after discharge to collect information on OOP expenditure. Out of the total 227 patients, 60% (137/227) had sustained road traffic injuries (RTI). The average OOP expenditure per hospitalisation and up to 12 months post discharge was USD 388 (95% CI: 332–441) and USD 1046 (95% CI: 871–1221) respectively. Mean OOP expenditure for RTI and non-RTI cases during hospitalisation was USD 400 (95% CI: 344–456) and USD 369 (95% CI: 313–425) respectively. The prevalence of catastrophic expenditure was 30%, and was significantly higher among those belonging to the lowest income quartile (OR-26.50, 95% CI: 6.70–105.07, p-value: <0.01) and with an inpatient stay greater than 7 days (OR-10.60, 95% CI: 4.21–26.64, p-value: <0.01). High OOP expenditure for treatment of injury puts a significant economic burden on families. Measures aimed at increasing public health spending for prevention of injury and providing financial risk protection are urgently required in India.

Economic burden of coronary heart disease in North India

Background: The treatment of chronic diseases like coronary heart disease (CHD) is expensive and can consume a significant portion of household's income, leading to catastrophic effects on families, particularly those of low socioeconomic status. Methodology: This was a cross-sectional study carried out in a private super specialty hospital and a government tertiary care hospital. Nonprobability purposive sampling method was used to collect primary data from a sample of 102 households; having a member suffering from CHD. Economic burden was assessed regarding average out of pocket (OOP) expenditure and prevalence of distress financing (DF) (borrowings or selling of assets) among the households. Results: Average OOP expenditure among those having an episode of hospitalization and those who got treated in outpatient department sessions only was INR 243,606 and INR 48,578, respectively. This expenditure was statistically higher (P Conclusion: There is a need to consider the rising OOP expenditure for the treatment of chronic conditions like CHD. There is a need to develop health financing systems that improve the financial risk protection for those requiring treatment.

Estimating the cost of referral and willingness to pay for referral to higher-level health facilities: a case series study from an integrated community case management programme in Uganda.

BackgroundIntegrated community case management (iCCM) relies on community health workers (CHWs) managing children with malaria, pneumonia, diarrhoea, and referring children when management is not possible. This study sought to establish the cost per sick child referred to seek care from a higher-level health facility by a CHW and to estimate caregivers’ willingness to pay (WTP) for referral.MethodsCaregivers of 203 randomly selected children referred to higher-level health facilities by CHWs were interviewed in four Midwestern Uganda districts. Questionnaires and document reviews were used to capture direct, indirect and opportunity costs incurred by caregivers, CHWs and health facilities managing referred children. WTP for referral was assessed through the ‘bidding game’ approach followed by an open-ended question on maximum WTP. Descriptive analysis was conducted for factors associated with referral completion and WTP using logistic and linear regression methods, respectively. The cost per case referred to higher-level health facilities was computed from a societal perspective.ResultsReasons for referral included having fever with a negative malaria test (46.8 %), danger signs (29.6 %) and drug shortage (37.4 %). Among the referred, less than half completed referral (45.8 %). Referral completion was 2.8 times higher among children with danger signs (p = 0.004) relative to those without danger signs, and 0.27 times lower among children who received pre-referral treatment (p < 0.001). The average cost per case referred was US$ 4.89 and US$7.35 per case completing referral. For each unit cost per case referred, caregiver out of pocket expenditure contributed 33.7 %, caregivers’ and CHWs’ opportunity costs contributed 29.2 % and 5.1 % respectively and health facility costs contributed 39.6 %.The mean (SD) out of pocket expenditure was US$1.65 (3.25). The mean WTP for referral was US$8.25 (14.70) and was positively associated with having received pre-referral treatment, completing referral and increasing caregiver education level.ConclusionThe mean WTP for referral was higher than the average out of pocket expenditure. This, along with suboptimal referral completion, points to barriers in access to higher-level facilities as the primary cause of low referral. Community mobilisation for uptake of referral is necessary if the policy of referring children to the nearest health facility is to be effective.