OOP Expenditure Research Articles

Incidence and determinants of catastrophic health expenditures and impoverishment in Pakistan

ObjectivesOut-of-pocket (OOP) payment is a major health financing mechanisms across developing nations such as Pakistan. Private health expenditures are estimated to be 64.4%, of which 89% are OOP made by the households (National Health Accounts, 2015–16). These high health care expenditures cause households to face financial burden resulting in poverty. This study aims to estimate the incidence and determinants of catastrophic health expenditures and impoverishment for Pakistan. Study designHousehold-based cross-section study. MethodsWe used the data from the Household Integrated Economic Survey (2015–16 and 2018–19), carried out by the Pakistan Bureau of Statistics. The well known methodology developed by Wagstaff and Doorslaer was used in this study for estimating the incidence and impoverishment effect of catastrophic health spending. ResultsIt is found that at 10% threshold (out of total consumption expenditures), catastrophic health payments are incurred by 4.51% and 13.15% of households for 2015–16 and 2018–19, respectively. Moreover, following the 40% threshold (out of non-food expenditures), this incidence is 0.45% and 4.57%. Poverty headcount was 23.28% and 18.43% gross of health payments in both the considered years, respectively, whereas it turns out to be 24.68% and 22.02% net of healthcare payments for the respective years, representing an increase in poverty headcounts of 1.4% and 3.59%. ConclusionOOP health payments exert pressure on household's capacity to pay and push them into poverty. This article recommends that the burden of OOP expenditures borne by households should be reduced to prevent them from falling into poverty by initiating some strategies (health financing policy reforms in terms of financial protection) with political support.

What Went Wrong with Rashtriya Swasthya Bima Yojana

Context: Rashtriya Swasthya Bima Yojana (RSBY) had been implemented in India to improve access to quality health care, reducing out-of-pocket (OOP) and catastrophic health expenditure. Aims: We aimed to evaluate the current status of RSBY in rural areas of a district in West Bengal. Settings and Design: A cross-sectional study was done in erstwhile “Burdwan Health District,” West Bengal. Subjects and Methods: This study was conducted from September 2016 to August 2018. Primary study units were below poverty line (BPL) families; members of selected families comprised the study subjects. The calculated sample size was 350 families, out of which 324 could be studied covering 22 blocks following multistage sampling technique. Data were collected by interviewing head of the family (HOF). Statistical Analysis Used: Descriptive statistics and logistic regression were used for statistical analysis. Results: Awareness on different benefits and features of RSBY varied widely from 6.8% to 97.2%. Overall current enrollment rate was 79.6%, while 20.4% of families remained nonenrolled. On the multivariable logistic regression, type of family, socioeconomic status of the family, and education of HOF were significant variables predicting nonenrollment. Among enrolled BPL families, 24.0% and 8.1% utilized services under RSBY since their enrollment and in the last 1 year, respectively. OOP expenditure, nonprovision of free food, inadequate posthospital treatment, inattentiveness of doctor and hospital staff, etc., were major difficulties faced in utilization of services. Conclusions: Nonenrollment in RSBY was quite high in the area with few predicting variables. Low level of utilization of services was also noted with some obstacles.

Who Experience Out-of-Pocket Expenditures for Modern Contraceptive Use in Indonesian Universal Health Coverage System?

Integration of family planning programs into the universal health coverage system is expected to improveaccess toreproductive health services. All people should have access to sufficient and qualified family planningservices they need without financial hardship. This study aimed to examine out-of-pocket expenditures ofcontraceptive services and the associated factors among fertile age couples that influence their access tomodern contraceptive services.It was quantitative research with a cross-sectional design. Data obtained fromthe Health and Demographic Surveillance System 2016 of Sleman Regency, Indonesia, were analyzed usingmultiple logistic regression to determine factors associated with out-of-pocket expenditures for contraceptiveservices. This study revealed that more than 70% of people should pay for contraceptive services eventhough they had registered as health insurance members. Public non-subsidized and private health insurancemembers were more likely to experience OOP expenditures than public-subsidized participants (AOR=3.12;95%CI=2.25-4.30 and AOR=3.47; 95%CI=1.60-7.52, respectively). Short-term contraception users weremore likely to experience out-of-pocket expenditures thanlong-term users(AOR=6.38; 95%CI=4.79-8.50).Nearly three-quarters of health insurance participants experience out-of-pocket expenditures forcontraceptive services. Out-of-pocket expenditures of contraceptive services significantly associate with thetype of health insurance owned and the types of contraceptive methods used.

PBI9 The TOTAL Medical Expenditure and out-of-Pocket Expenditure of Biologic Disease-Modifying Antirheumatic Drugs in Rheumatoid Arthritis Patients in the United States

Rheumatoid Arthritis (RA) is a chronic disease that leads to significant pain, progressive joint destruction, and functional disability. Given the incurable nature, the condition causes a significant and persistent economic burden in the U.S. and worldwide. The goal is to explore the total medical expenditure, and out-of-pocket (OOP) expenditure among the following RA medication groups: non-Disease-Modifying Antirheumatic Drugs (DMARDs); TNF alpha biologics; conventional DMARDs; combined TNF alpha biologics and conventional DMARDs. This is a retrospective observational study based on the Medical Expenditure Panel Survey Household Component (MEPS-HC) data for a cohort of individuals from 2016 to 2018. A descriptive analysis measured the patient sociodemographic and personal characteristics. Weighted mean and standard deviation (SD) or the weighted median and interquartile range (IQR) were reported for the continuous variables. A chi-square test was performed to evaluate the difference of any OOP expenditure among RA patients in different medication groups. A multivariate regression with logarithmic transformation was used to estimate the relationship between total medical expenditure and RA therapeutic medication class by adjusting the confounding covariates. 1,758 adult RA patients with 10,434 RA-related events with at least one visit to the healthcare provider between 2016 and 2018 were identified. The average total medical expenditure was significantly higher in RA patients with any type of DMARD, residing in the Western U.S., diagnosed with 2 or more comorbidities, and 2 or more health resource visits. The DMARDs groups were more likely to have some positive OOP expenditures, including all patients in the TNF alpha biologics group. RA patients with TNF alpha biologics encounter higher total medical expenditure and OOP expenditures; however, they may experience fewer or no occurrences of high-cost drivers of healthcare utilization. Average OOP expenditures increased from 2016 to 2018 in RA patients with any biologic DMARD.

Burden of out-of-pocket payments among patients with cardiovascular disease in public and private hospitals in Ibadan, South West, Nigeria: a cross-sectional study

ObjectiveGiven that the mechanism for financial protection is underdeveloped in Nigeria, out-of-pocket (OOP) payment for treating cardiovascular disease could impose substantial financial burden on individuals and their families. This study...

Trend in Tyrosine Kinase Inhibitor Utilization, Price, and Out-of-Pocket Costs in Patients With Chronic Myelogenous Leukemia.

Treatment of chronic myelogenous leukemia (CML) with tyrosine kinase inhibitors (TKIs) has improved survival but is associated with significant financial burden. We measured the annual trend in TKI utilization, Medicare gross payment, and patient out-of-pocket (OOP) expenditure from 2007 to 2016. We used SEER linked to Medicare part-D claims data to identify prevalent CML cases from 2007 to 2016. TKI utilization was measured as the proportion of cases with at least one TKI fill in each year. Average TKI gross payment and median per-member per-month OOP expenditure were calculated from claims data and plotted annually from 2007 to 2016. Year-to-year percent change in gross payment and OOP expenditure was compared with inflation indices. The cohort included 3,189 CML cases with at least one TKI claim. The proportion of prevalent patients with a TKI fill in a year increased from 17.9% in 2007 to 52.8% in 2015. The average annual gross payment per 30-day supply of a TKI increased by an average of 12.8% throughout the period from $9,000 to $10,000 US dollars in 2016. There was no increasing trend in median OOP expenditure per 30-day supply, which varied between $450 and $600 US dollars. Rising TKI use and TKI drug prices place considerable financial pressure on Medicare part-D insurers. Although there was no increasing trend in OOP expenditure, it may be burdensome for Medicare patients who are likely retired on a fixed income. Our findings support legislation that mitigates increasing drug prices to protect the Medicare system and its beneficiaries.

The impact of out-of-pocket expenditures on missed appointments at HIV care and treatment centers in Northern Tanzania

BackgroundMissed clinic appointments negatively impact clinic patient flow and health outcomes of people living with HIV (PLHIV). PLHIV likelihood of missing clinic appointments is associated with direct and indirect expenditures made while accessing HIV care. The objective of this study was to examine the relationship between out-of-pocket (OOP) health expenditures and the likelihood of missing appointments. MethodTotally 618 PLHIV older than 18 years attending two HIV care and treatment centres (CTC) in Northern Tanzania were enrolled in the study. Clinic attendance and clinical characteristics were abstracted from medical records. Information on OOP health expenditures, demographics, and socio-economic factors were self-reported by the participants. We used a hurdle model. The first part of the hurdle model assessed the marginal effect of a one Tanzanian Shillings (TZS) increase in OOP health expenditure on the probability of having a missed appointment and the second part assessed the probability of having missed appointments for those who had missed an appointment over the study period. ResultsAmong these 618 participants, 242 (39%) had at least one missed clinic appointment in the past year. OOP expenditure was not significantly associated with the number of missed clinic appointments. The median amount of OOP paid was 5 100 TZS per visit, about 7% of the median monthly income. Participants who were separated from their partners (adjusted odds ratio [AOR] = 1.83, 95% confidence interval [CI]:1.11‒8.03) and those aged above 50 years (AOR = 2.85, 95% CI: 1.01‒8.03) were significantly associated with missing an appointment. For those who had at least one missed appointment over the study period, the probability of missing a clinic appointment was significantly associated with seeking care in a public CTC (P = 0.49, 95% CI: 0.88‒0.09) and aged between > 25‒35 years (P = 0.90, 95% CI: 0.11‒1.69). ConclusionInterventions focused on improving compliance to clinic appointments should target public CTCs, PLHIV aged between > 25‒35 years, above 50 years of age and those who are separated from their partners.

Out-of-Pocket Expenditure of the Hospitalized Patients for Treatment of Liver Cirrhosis in a Tertiary Hopspital

Background: Out-of-pocket expenditure is the major financer for health care expenses in Bangladesh, causing financial burden on affected households. Chronic disease like liver cirrhosis requires long term treatment, exposing households to further economic stress, pushing them into a state where they fail to meet the necessary health expenses from their own household consumption and sacrifices basic necessities of living to pay for healthcare services. This study aims to estimate the OOP expenditure and resulting catastrophic health expenditure among hospitalized patients of liver cirrhosis.
 Methods: This was a cross-sectional study conducted among 42 diagnosed liver cirrhosis patients admitted at Bangabandhu Sheikh Mujib Medical University (BSMMU) under the department of hepatology and department of gastroenterology, aged 18 years and above. Convenient sampling technique was used and data were collected from the respondents using a semi-structured questionnaire through face-to-face interview during discharge from hospital.
 Results: Out of pocket expenditure for liver cirrhosis at BSMMU was BDT 24,898. Direct medical cost was BDT 21,202, direct non-medical cost was BDT 1,895 and indirect cost was BDT 1,801. Among the determinants of OOP healthcare expenditure, medicine and investigation costs were the major cost drivers, 36.91% and 44.13% of the total expenditure, respectively. OOP expenditure was found to be slightly higher among respondents from department of hepatology, than department of gastroenterology, BDT 21,834 and BDT 18,043 respectively, but this difference was not statistically significant. At 10% threshold level, 40.5% of the respondents were affected by Catastrophic Healthcare Expenditure (CHE). Nearly one-third (30.9%) of the respondents were facing distress financing due to OOP Expenditure.
 Conclusions: The high amount of OOP expenditure can be contributed mostly to the high cost of medicine and investigation. Making medicine readily available at an affordable price along with rational use of medication and investigation for diagnostic purpose can help reduce this financial burden on affected households.
 JOPSOM 2020; 39(2): 74-82

Assessing the responsiveness of out-of-pocket healthcare expenditure to macro-fiscal factors and different health financing systems: evidence from the European and OECD area

PurposeIn this paper, the authors assess the responsiveness of OOP healthcare expenditure to macro-fiscal factors, as well as to tax-based, SHI, mixed systems and voluntary PHI financing. Although the relationship between OOP expenditure, macroeconomy, aggregate public and PHI financing is well documented in the existing empirical literature, little is known for the impact of several macro-fiscal drivers and the existing health financing arrangements associated with voluntary PHI on OOP expenditure.Design/methodology/approachThe authors gather panel data by applying three official organizations’ databases. They elaborate static and dynamic panel data methodology to a dataset of 49 European and OECD countries from 2000 to 2015.FindingsThe authors’ findings do not indicate a considerable impact of GDP growth and general government debt as a share of GDP on OOP payments. Unemployment rate presents as a positive driver of OOP payments in all three compulsory national health systems post to the 2008 economic crisis. OOP payments are significantly influenced by countries’ fiscal capacity to increase general government expenditure to GDP in SHI and mixed health systems. Additionally, study findings present that government health financing, irrespective of the different health systems structure characteristics, and OOP healthcare payments follow different directions. Voluntary PHI financing considerably counteracts OOP payments only in tax-based health systems.Practical implicationsIn the backdrop of a new economic crisis associated to the COVID-19 epidemic, health policy planners have to deal with the emerging unprecedented challenges in financing of health systems, especially for these economies that have to face the fiscal capacity constraints owing to the 2008 financial crisis and its severe recession.Originality/valueTo the best of authors’ knowledge, there is no empirical consensus on the effects of macro-fiscal parameters, different compulsory health systems financing associated with the parallel voluntary PHI institution funding on OOP expenditure, for the majority of European and OECD settings.

Out-of-Pocket Costs and Importance of Nonmedical and Indirect Costs of Inpatients

ObjectivesOut-of-pocket (OOP) costs are a major part of the expenditures for healthcare services. In most cases, patient financial protection plans cover only direct medical costs and not other expenses by patients. MethodsThis cross-sectional study was conducted on 800 patients referring medical centers of Kerman to analyse all aspects of OOP, especially after the Health Transformation Plan in Iran. Using the probability proportional to the size of the medical center, samples from each ward in each medical center were determined in accordance with the previous year’s patient number. Randomly selected medical records of the last 2 weeks of patients discharged were collected, information was extracted, and telephone interviews were conducted. ResultsThe mean total OOP costs of a one-time hospitalization in all medical centers in Kerman was equal to 7 561 977 Iranian rials. Assuming a 5% threshold, 37% of patients in public centers were faced with catastrophic health expenditures for a one-time hospitalization. Based on the results of the regression model, reduction of length of stay, elimination of the need for the presence of next of kin, and provision of healthcare services out of hospitals can greatly reduce OOP expenditures. ConclusionAlthough direct medical costs are of special importance, and it is very necessary to protect patients against such costs, patients usually incur a variety of costs when receiving inpatient services. Inattention to direct nonmedical costs and indirect costs due to patients’ and their next of kin’s absenteeism may cause households to face catastrophic expenditures.

Expenditures among young adults with acute lymphoblastic leukemia by site of care.

Individuals diagnosed with acute lymphoblastic leukemia (ALL) between the ages of 22 and 39 years experience worse outcomes than those diagnosed when they are 21 years old or younger. Treatment at National Cancer Institute-designated Comprehensive Cancer Centers (CCC) mitigates these disparities but may be associated with higher expenditures. Using deidentified administrative claims data (OptumLabs Data Warehouse), the cancer-related expenditures were examined among patients with ALL diagnosed between 2001 and 2014. Multivariable generalized linear model with log-link modeled average monthly health-plan-paid (HPP) expenditures and amount owed by the patient (out-of-pocket [OOP]). Cost ratios were used to calculate excess expenditures (CCC vs non-CCC). Incidence rate ratios (IRRs) compared CCC and non-CCC monthly visit rates. Models adjusted for sociodemographics, comorbidities, adverse events, and months enrolled. Clinical and sociodemographic characteristics were comparable between CCC (n = 160) and non-CCC (n = 139) patients. Higher monthly outpatient expenditures in CCC patients ($15,792 vs $6404; P < .001) were driven by outpatient hospital HPP expenditures. Monthly visit rates and per visit expenditures for nonchemotherapy visits (IRR = 1.6; P = .001; CCC = $8247, non-CCC = $1191) drove higher outpatient hospital expenditures among CCCs. Monthly OOP expenditures were higher at CCCs for outpatient care (P = .02). Inpatient HPP expenditures were significantly higher at CCCs ($25,918 vs $13,881; ꞵ = 0.9; P < .001) before accounting for adverse events but were no longer significant after adjusting for adverse events (ꞵ = 0.4; P = .1). Hospitalizations and length of stay were comparable. Young adults with ALL at CCCs have higher expenditures, likely reflecting differences in facility structure, billing practices, and comprehensive patient care. It would be reasonable to consider CCCs comparable to the oncology care model and incentivize the framework to achieve superior outcomes and long-term cost savings. Health care expenditures in young adults (aged 22-39 years) with acute lymphoblastic leukemia (ALL) are higher among patients at National Cancer Institute-designated Comprehensive Cancer Centers (CCC) than those at non-CCCs. The CCC/non-CCC differences are significant among outpatient expenditures, which are driven by higher rates of outpatient hospital visits and outpatient hospital expenditures per visit at CCCs. Higher expenditures and visit rates of outpatient hospital visits among CCCs may also reflect how facility structure and billing patterns influence spending or comprehensive care. Young adults at CCCs face higher inpatient HPP expenditures; these are driven by serious adverse events.

Importance of Evidence-Based Health Insurance Reimbursement and Health Technology Assessment for Achieving Universal Health Coverage and Improved Access to Health in India

ObjectiveTo review the importance of evidence-based methods in health insurance reimbursement for achieving universal health coverage in India. MethodsA narrative literature review was performed. ResultsThe out-of-pocket (OOP) healthcare expenditure in India is among the highest in the world. This situation is despite the implementation of numerous government health schemes and the availability of a large number of health insurance programs, both public and private. Compromised quality of care in many public healthcare facilities is a major factor driving the average Indian citizen to increasingly depend upon private healthcare facilities, further escalating OOP spending. The low awareness and poor uptake of insurance policies among Indians is one of the biggest challenges in the implementation of universal health coverage (UHC) in India. The catastrophic burden of high OOP expenses on individual households could be reduced by taking steps to enhance health insurance uptake, which can be in turn achieved by strengthening the healthcare reimbursement system in India. ConclusionsThe application of the principles of evidence-based healthcare for reimbursement requires the systematic assessment of all health technologies, which is already being done in developed countries. The enactment of health schemes such as Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana and setting up of Health Technology Assessment in India are steps toward reducing OOP expenditure and achieving UHC in India. We review the importance and challenges of evidence-based reimbursement and health technology assessment toward achieving UHC in India.

Economic burden of cardiovascular diseases before and after Iran\u2019s health transformation plan: evidence from a referral hospital of Iran

BackgroundDifferent countries have set different policies to control and decrease the costs of cardiovascular diseases (CVDs). Iran was aiming to reduce the economic burden of different disease by a recent reform from named as health transformation plan (HTP). This study aimed to examine the economic burden of CVDs before and after of HTP.MethodsThis cross-sectional study was conducted on 600 patients with CVDs, who were randomly selected from a specialized cardiovascular hospital in the north-west of Iran. Direct and indirect costs of CVDs were calculated using the cost of illness and human capital approaches. Data were collected using a researcher-made checklist obtained from several sources including structured interviews, the Statistical Center of Iran, Iran’s Ministry of Cooperatives, Labor, and Social Welfare, the central bank of Iran, and the data of global burden of disease obtained from the Institute for Health Metrics and Evaluation to estimate direct and mortality costs. All costs were calculated in Iranian Rials (IRR).ResultsTotal costs of CVDs were about 5571 and 6700 billion IRR before and after the HTP, respectively. More than 62% of the total costs of CVDs accounted for premature death before (64.89%) and after (62.01%) the HTP. The total hospitalization costs of CVDs was significantly increased after the HTP (p = 0.038). In both times, surgical services and visiting had the highest and lowest share of hospitalization costs, respectively. The OOP expenditure decreased significantly and reached from 54.2 to 36.7%. All hospitalization costs, except patients’ OOP expenditure, were significantly increased after the HTP about 1.3 times. Direct non-medical costs reached from 2.4 to 3.3 billion before and after the HTP, respectively.ConclusionEconomic burden of CVDs increased in the north-west of Iran after the HTP due to the increase of all direct and indirect costs, except the OOP expenditure. Non-allocation of defined resources, which coincided with the international and national political and economic challenges in Iran, led to unsustainable resources of the HTP. So, no results of this study can be attributed solely to the HTP. Therefore, more detailed studies should be carried out on the reasons for the significant increase in CVDs costs in the region.

National sample surveys show poor households face catastrophic expenditure for oral healthcare services in India.

Introduction:Globally people pay out-of-pocket (OOP) to access Oral healthcare services. In India, there is limited evidence on estimates of OOP expenditure. We undertook an analysis of national sample survey data on household health care expenditure to understand the expenditure pattern for Oral healthcare services and the catastrophic burden.Method:The expenditure reported for Oral healthcare services from two surveys: 71st round and 75th round, published by National Sample Survey Office (NSSO) was extracted. Based on monthly household consumption expenditure three economic groups were made: poor, middle- and rich-income groups. The OOP expenditure pattern while accessing day-care services and hospitalization and in public and private sector and the catastrophic expenditure were analysed.Results:A total of 204 and 155 households from two national surveys reported to have accessed day-care Oral services respectively. The median OOP expenditure in public sector remained same at US $ 4 in both surveys. Over 35% of 78 households in 71st round and 42% of 167 in 75th round used public sector hospitalization services. The median expenditure of hospitalization doubled from US$ 58 (IQR 21–263) in 71st round to US $ 125 (IQR 45-363) in 75th round. Households from poor income groups spent seven times more for Oral healthcare services during the recent survey and faced catastrophic expenditure.Conclusion:The OOP expenditure for Oral healthcare has significant catastrophic household expenditure among the poor. There is a need to increase investment in public sector and insurance to protect poor against hospitalization expenditure in private sector.

Out-of-pocket expenditure and its predictors for illness of under-five children: A cross-sectional study in urban slums of Eastern India

Introduction:Out-of-pocket (OOP) expenditure influences the access to the healthcare of the marginalized and vulnerable population including under-five children (U5C). The aim of the study is to estimate the OOP expenditure and its predictors in Bhubaneswar, a region of eastern India.Methods:A cross-sectional study was conducted using a semi-structured interview schedule in 20 urban slums of Bhubaneswar. The survey was carried out by using the National Sample Survey Office (NSSO) health consumption schedule 25.0 in which mothers of U5C with illness (n = 530) were interviewed. For data analysis, the nonparametric Wilcoxon rank-sum test and Kruskal–Wallis test were used as tests of significance.Results:The study revealed that the mean OOP expenditure for outpatient department (OPD) care was ₹375.9 (₹219.48). The mean approximated expenditure was ₹1669.8 (₹1131.9) for inpatient department (IPD) care. In OPD care, doctors' fee and medicine cost constituted 65.01% and 50.46% of OOP expenditure, respectively. In IPD care, medicine cost and doctors' fee contributed to 36.62% and 30.54% of OOP expenditure, respectively. The major significant predictors that contributed to increased OOP were gender and delay in approaching the source of treatment in OPD, whereas in IPD no such predictors were observed.Conclusions:This study prominently sheds light on the issue of accessibility and affordability of health services without a comprehensive health insurance scheme for U5C illness among the vulnerable urban slum dwellers to achieve universal health coverage.

Insights from national survey on household expenditure for primary healthcare services availed through informal healthcare providers.

Introduction:Ensuring accessible and affordable primary healthcare services of optimal quality is a core component of universal health coverage (UHC). Though a substantial percentage of population avail healthcare services from informal healthcare providers (IHPs) in rural India, the information regarding the extent of out-of-pocket (OOP) expenditure during such encounters is limited.Method:The study analyzed publicly available data of 75th National Sample Survey (NSS) to understand the household expenditure pattern on availing service from IHPs. OOP expenditure for services availed from IHPs were extracted from main data sets and analyzed for both out-patient care and hospitalization. The OOP was summarized across the five wealth quintiles based on monthly per capita expenditure (MPCE) and disease groupings derived from the ailments recorded during the survey.Results:In total, 721 households accessed IHPs as part of out-patient consultation for infectious disease (67%). Households from rural areas (78%), households belonging to backward groups (75%), households from the poorest quintile and women (52%) access the services of IHPs. The median OOP for all services was INR 240 (IQR 120–600) and more than 90% of total OOP is accounted for medical expenditure.Conclusion:The programs need to define healthcare packages to engage IHPs to increase the reach and reduce OOP expenditure on households.

Out-of-pocket payments by end-stage kidney disease patients on regular hemodialysis: Cost of illness analysis, experience from Sudan.

In Sudan, the number of end-stage kidney disease (ESKD) patients receiving hemodialysis (HD) is growing. Patients and their families incur a high out-of-pocket expenditure (OOPE), given that HD treatment is expensive. There are limited data about OOP spending on HD in the country. This study aims to explore patients' OOP expense on direct medical and nonmedical goods and services and to which extent they can be predicted from sociodemographic characteristics, health insurance status, comorbidity, and accommodation change. This is descriptive a cross-sectional study conducted in Ibn Sina Hospital. One hundred and thirty patients undergo regular HD were randomly selected. Among the study participants (130), the median of the overall total OOP (direct medical and direct nonmedical) spending per patients per year was found to be US$ 3859.1 (interquartile range [IQR]: 2298.1-6261.1). As for the medians OOP expenditure on direct medical and nonmedical costs, they were found to be US$ 2327.6 (IQR: 1421.5-3804.8) and US$ 1096 (IQR: 715.2-2345.2), respectively. The direct medical expenditure (355,586 US$) accounted for 60% of the overall total expenses. Medications and investigations were the primary drivers of direct medical spending. Higher OOPE rates were found among those with one or more of these factors; uninsured patients, patient with comorbidity, female gender, and over 40 years aged. The multivariate analysis showed that the significant predictors of direct medical expenditure were health insurance and comorbid conditions, where as the predictors for direct nonmedical expenditure were accommodation change and gender. This study results in a better understanding of OOP spending on direct medical and nonmedical services and its associated predictors among HD patients within the context of Sudan. Further research is needed in this area.

Examining the distribution of benefits of a free Maternal and Child Health programme in Enugu State, Nigeria: a benefit incidence analysis.

To determine the population groups that benefit from a Free Maternal and Child Health (FMCH) programme in Enugu State, South-east Nigeria, so as to understand the equity effects of the programme. A community-based survey was conducted in rural and urban local government areas (LGAs) to aid the benefit incidence analysis (BIA) of the FMCH. Data were elicited from 584 randomly selected women of childbearing age. Data on their level of utilisation of FMCH services and their out-of-pocket expenditures on various FMCH services that they utilised were elicited. Benefits of the FMCH were valued using the unit cost of providing services while the net benefit was calculated by subtracting OOP expenditures made for services from the value of benefits. Costs were calculated in local currency (Naira (₦)) and converted to US Dollars. The net benefits were disaggregated by urban-rural locations and socio-economic status (SES). Concentration indices were computed to provide the level of SES inequity in BIA of FMCH. The total gross benefit incidence was ₦2.681million ($7660). The gross benefit that was consumed by the urban dwellers was ₦1.581million ($4517.1), while the rural dwellers consumed gross benefits worth ₦1.1 million ($3608.20). However, OOP expenditure for the supposedly FMCH was ₦6527580 (US$18650.2) in the urban area, while it was ₦3, 194, 706 (US$ 9127.7) among rural dwellers. There was negative benefit incidence for the FMCH because the OOP exceeded the gross benefits at the point of use of services. There was no statistically significant difference in the benefit incidence and OOP expenditure between the urban and rural dwellers and across socio-economic groups. The distribution of the gross benefits of the FMCH programme indicates that it may not have achieved the desired aim of enhanced access particularly to the low-income population. Crucially, the high level of OOP erased whatever societal gain the FMCH was developed to provide. Hence, there is a need to review its implementation and re-strategise to reduce OOP and achieve greater access for improved effectiveness of the programme.

Contemporary relationship between medical expenditures and quality of life among adults with epilepsy in the United States

AimsEpilepsy exacts substantial adverse economic and quality of life (QoL) costs. Clarifying the quantitative and qualitative relationships between total and out-of-pocket (OOP) healthcare expenditures and QoL could shed insights into how they influence each other, and have done so over recent times. MethodsWe used the Medical Expenditure Household Components 2003–2014 to identify a total of 2450 adults with epilepsy, representing a weighted population of 1,942,413. Quality of life was assessed using the Physical Component Summary (PCS) and the Mental Component Summary (MCS) derived from the Short-form 12 Version 2 (SF-12 V2), converted into quartiles of equal distribution, with higher quartiles indicating a better QoL. We computed unadjusted mean and adjusted (through a generalized linear model (GLM)) total and OOP healthcare expenditures by QoL categories among adults with epilepsy (reported as dollars in 2016). ResultsThe pooled estimates of total healthcare expenditures decreased as PCS and MCS quartiles of QoL increased [PCS: costs for quartile 1 = $21,792 (95% confidence interval (CI): $18,416–$25,168 vs. costs for quartile 4 = $6057 (95% CI: $4648–$7466) and MCS: costs for quartile 1 = $19,040 (95% CI: $15,544–$22,535) vs. quartile 4 = $12,939 (95% CI: $8450–$17,429)]. Similarly, the pooled estimates of OOP healthcare expenditures and QoL were inversely related [PCS: costs for quartile 1 = $1849 (95% CI: $1583–$2114) vs. costs for quartile 4 = $948 ($709–$1187) and MCS: costs for quartile 1 = 1812 (95% CI: $1483–2141) vs. quartile 4 = $1317 (95% CI: $982–$1652)]. The association between QoL and total and OOP healthcare expenditures was unchanged after adjusting for socioeconomic and healthcare system related confounders in the GLM. Overall, healthcare expenditures were stable across years independently of the QoL; only OOP expenditures decreased between 2003–2006 and 2011–2014 for quartile 1 of PCS and MCS. ConclusionQuality of life and OOP health expenditures are independently and inversely related to each other among adults with epilepsy. Over the decade studied in the United States, there was a decrease in OOP health expenditures among those patients with epilepsy with the lowest QoL, possibly reflecting a rise in insurance coverage after the Affordable Care Act.

Healthcare utilisation and expenditure patterns for cardio-metabolic diseases in South Asian cities: the CARRS Study.

ObjectiveTo estimate average annual expenditures per person, total economic burden and distress health financing associated with the treatment of five cardio-metabolic diseases (CMDs—hypertension, diabetes, heart disease (angina, myocardial infarction and heart failure), stroke and chronic kidney disease) in three metropolitan cities in South Asia.DesignCross-sectional surveys.SettingWe analysed community-based baseline data from the Centre for cArdio-metabolic Risk Reduction in South Asia (CARRS) Study collected in 2010–2011 representing Chennai and New Delhi (India), and Karachi (Pakistan).ParticipantsWe used data from non-pregnant adults (≥20 years) from the aforementioned cities that responded to a cost-of-illness questionnaire. We estimated health utilisation and expenditures among those reporting taking treatment(s) for the aforementioned CMDs in the last 1 year. We converted all costs to International Dollars (Int$ 2011) and inflated to 2018 values. The annual costs per person were stratified by city, sociodemographic characteristics, contributor of costs and financing methods. The total economic burden of CMDs for each city was projected using age-standardised prevalence and per-person costs of diseases reported in CARRS, applying these to population data from the most recent census. We also calculated distress financing (DF) as having to borrow or sell assets to pay for CMD treatment and identified sociodemographic groups at most risk of DF using multiple regression.ResultsOf 16 287 CARRS participants, 2883 (17.7%) reported receiving treatment for CMDs. The total annual expenditures reported per patient for CMDs ranged from Int$358 to Int$2425. Medications constituted 46% of total direct expenditures and out-of-pocket (OOP) expenditures accounted for nearly 80% of financing these health expenditures. Total economic burdens of CMDs were Int$0.42 billion, Int$3.4 billion and Int$1.4 billion in Chennai, New Delhi and Karachi, respectively. Overall, 36.1% experienced DF, and women (OR=4.4), unemployed (OR=10.7) and uninsured (OR=8.1) adults experienced higher odds of DF.ConclusionCMDs are associated with large economic burdens in South Asia. Due to most payments coming from OOP expenditures and limited insurance, the odds of DF are high.