Does HIV services decentralization protect against the risk of catastrophic health expenditures?: some lessons from Cameroon.
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ABSTRACT: Objective
Scaling up antiretroviral treatment (ART) through decentralization of HIV care is increasingly recommended as a strategy toward ensuring equitable access to treatment. However, there have been hitherto few attempts to empirically examine the performance of this policy, and particularly its role in protecting against the risk of catastrophic health expenditures (CHE). This article therefore seeks to assess whether HIV care decentralization has a protective effect against the risk of CHE associated with HIV infection. DATA SOURCE AND STUDY DESIGN: We use primary data from the cross-sectional EVAL-ANRS 12-116 survey, conducted in 2006-2007 among a random sample of 3,151 HIV-infected outpatients followed up in 27 hospitals in Cameroon. DATA COLLECTION AND METHODS: Data collected contain sociodemographic, economic, and clinical information on patients as well as health care supply-related characteristics. We assess the determinants of CHE among the ART-treated patients using a hierarchical logistic model (n = 2,412), designed to adequately investigate the separate effects of patients and supply-related characteristics.Principal findings
Expenditures for HIV care exceed 17 percent of household income for 50 percent of the study population. After adjusting for individual characteristics and technological level, decentralization of HIV services emerges as the main health system factor explaining interclass variance, with a protective effect on the risk of CHE.Conclusion
The findings suggest that HIV care decentralization is likely to enhance equity in access to ART. Decentralization appears, however, to be a necessary but insufficient condition to fully remove the risk of CHE, unless other innovative reforms in health financing are introduced.
SUBMITTER: Boyer S
PROVIDER: S-EPMC3392995 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:OBJECTIVE: There is limited evidence about levels of socio-economic and other differences in catastrophic health spending in Nigeria and in many sub-Saharan African countries. The study estimated the level of catastrophic healthcare expenditures for different healthcare services and facilities and their distribution across socioeconomic status (SES) groups. METHODS: The study took place in four Local Government Areas in southeast Nigeria. Data were collected using interviewer-administered questionnaires administered to 4873 households. Catastrophic health expenditures (CHE) were measured using a threshold of 40% of monthly non-food expenditure. We examined both total monthly health expenditure and disaggregated expenditure by source and type of care. RESULTS: The average total household health expenditure per month was 2354 Naira ($19.6). For outpatient services, average monthly expenditure was 1809 Naira ($15.1), whilst for inpatient services it was 610 Naira ($5.1). Higher health expenditures were incurred by urban residents and the better-off SES groups. Overall, 27% of households incurred CHE, higher for poorer socioeconomic groups and for rural residents. Only 1.0% of households had a member that was enrolled in a health insurance scheme. CONCLUSION: The worse-off households (the poorest SES and rural dwellers) experienced the highest burden of health expenditure. There was almost a complete lack of financial risk protection. Health reform mechanisms are needed to ensure universal coverage with financial risk protection mechanisms.
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Project description:BACKGROUND:Monitoring financial protection against catastrophic health expenditures is important to understand how health financing arrangements in a country protect its population against high costs associated with accessing health services. While catastrophic health expenditures are generally defined to be when household expenditures for health exceed a given threshold of household resources, there is no gold standard with several methods applied to define the threshold and household resources. These different approaches to constructing the indicator might give different pictures of a country's progress towards financial protection. In order for monitoring to effectively provide policy insight, it is critical to understand the sensitivity of measurement to these choices. METHODS:This paper examines the impact of varying two methodological choices by analysing household expenditure data from a sample of 47 countries. We assess sensitivity of cross-country comparisons to a range of thresholds by testing for restricted dominance. We further assess sensitivity of comparisons to different methods for defining household resources (i.e. total expenditure, non-food expenditure and non-subsistence expenditure) by conducting correlation tests of country rankings. RESULTS:We found country rankings are robust to the choice of threshold in a tenth to a quarter of comparisons within the 5-85% threshold range and this increases to half of comparisons if the threshold is restricted to 5-40%, following those commonly used in the literature. Furthermore, correlations of country rankings using different methods to define household resources were moderate to high; thus, this choice makes less difference from a measurement perspective than from an ethical perspective as different definitions of available household resources reflect varying concerns for equity. CONCLUSIONS:Interpreting comparisons from global monitoring based on a single threshold should be done with caution as these may not provide reliable insight into relative country progress. We therefore recommend financial protection against catastrophic health expenditures be measured across a range of thresholds using a catastrophic incidence curve as shown in this paper. We further recommend evaluating financial protection in relation to a country's health financing system arrangements in order to better understand the extent of protection and better inform future policy changes.
| S-EPMC5984475 | biostudies-literature
Project description:BackgroundTo foster access to care and reduce the burden of health expenditures on people living with HIV (PLHIV), several sub-Saharan African countries, including Cameroon, have adopted a policy of removing HIV-related fees, especially for antiretroviral treatment (ART). We investigate the impact of Cameroon's free antiretroviral treatment (ART) policy, enacted in May 2007, on catastrophic health expenditure (CHE) risk according to socioeconomic status, in PLHIV enrolled in the country's treatment access program.MethodsBased on primary data from two cross-sectional surveys of PLHIV outpatients in 2006-2007 and 2014 (i.e., before and after the policy's implementation, respectively), we used inverse propensity score weighting to reduce covariate imbalances between participants in both surveys, combined with probit regressions of CHE incidence. The analysis included participants treated with ART in one of the 11 HIV services common to both surveys (n = 1275).ResultsThe free ART policy was associated with a significantly lower risk of CHE only in the poorest PLHIV while no significant effect was found in lower-middle or upper socioeconomic status PLHIV. Unexpectedly, the risk of CHE was higher in those with middle socioeconomic status after the policy's implementation.ConclusionsOur findings suggest that Cameroon's free ART policy is pro-poor. As it only benefitted PLHIV with the lowest socioeconomic status, increased comprehensive HIV care coverage is needed to substantially reduce the risk of CHE and the associated risk of impoverishment for all PLHIV.
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Project description:BackgroundLeukemia can create a significant economic burden on the patients and their families. The objective of this study is to assess the medical expenditure and compensation of pediatric leukemia, and to explore the incidence and determinants of catastrophic health expenditure (CHE) among households with pediatric leukemia patients in China.MethodsA cross-sectional interview was conducted among households living with pediatric leukemia using a questionnaire in two tertiary hospitals. CHE was defined as out-of-pocket (OOP) payments that were greater than or equal to 40% of a household's capacity to pay (CTP). Chi-square tests and logistic regression analysis were performed to identify the determinants of CHE.ResultsAmong 242 households living with pediatric leukemia, the mean OOP payment for pediatric leukemia healthcare was $9860, which accounted for approximately 35.7% of the mean household's CTP. The overall incidence of CHE was 43.4% and showed a downward trend with the lowest income group at 69.0% to the highest income group at 16.1%. The logistic regression model found that medical insurance, frequency of hospital admissions, charity assistance, and income level were significant predictors of CHE.ConclusionThe results revealed that pediatric leukemia had a significant catastrophic effect on families, especially those with lower economic status. The occurrence of CHE in households living with pediatric leukemia could be reduced by addressing income disparity. In addition, extending coverage and improving compensation from medical insurance could also alleviate CHE. Some other measures that can be implemented are to address the barriers of charity assistance for vulnerable groups.
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Project description:ObjectiveTo describe prevalence, trends, and risk factors for catastrophic health expenditures in the year of delivery among birth parents (delivering people).MethodsWe conducted a retrospective, cross-sectional study of the Medical Expenditure Panel Survey from 2008-2016. We identified newborn birth parents and a 2:1 nearest-neighbor propensity-matched control cohort of nonpregnant reproductive-aged individuals, then assessed for catastrophic health expenditures (spending greater than 10% of family income) in the delivery year. We applied survey weights to extrapolate to the noninstitutionalized U.S. population and used the adjusted Wald test for significance testing. We compared risk of catastrophic health expenditures between birth parents and the control cohort and described time trends and risk factors for catastrophic spending with subgroup comparisons.ResultsWe analyzed 4,056 birth parents and 7,996 reproductive-aged females without pregnancy in a given year. Birth parents reported higher rates of unemployment (52.6% vs 46.6%, P<.001), and high rates of gaining (22.4%) and losing (25.6%) Medicaid in the delivery year. Birth parents were at higher risk of catastrophic health expenditures (excluding premiums: 9.2% vs 6.8%, odds ratio [OR] 1.95, 95% CI 1.61-2.34; including premiums: 21.3% vs 18.4%, OR 1.53, 95% CI 1.32-1.82). Birth parents living on low incomes had the highest risk of catastrophic health expenditures (18.8% vs 0.7% excluding premiums for 138% or less vs greater than 400% of the federal poverty level, relative risk [RR] 26.9; 29.8% vs 5.9% including premiums, RR 5.1). For birth parents living at low incomes, public insurance was associated with lower risks of catastrophic health expenditures than private insurance, particularly when including premium spending (incomes 138% of the federal poverty level or lower: 18.8% public vs 67.9% private, RR 0.28; incomes 139-250% of the federal poverty level: 6.5% public vs 41.1% private, RR 0.16). The risk of catastrophic spending for birth parents did not change significantly over time from before to after Affordable Care Act implementation.ConclusionPregnancy and delivery are associated with increased risk of catastrophic health expenditures in the delivery year. Medicaid and public coverage were more protective from high out-of-pocket costs than private insurance, particularly among low-income families.
| S-EPMC9124691 | biostudies-literature
Project description:Background:Catastrophic health expenditures (CHE) are of concern to policy makers and can prevent individuals accessing effective health care services. The exposure of households to CHE is one of the indices used to evaluate and address the level of financial risk protection in health systems, which is a key priority in the global health policy agenda and an indicator of progress toward the UN Sustainable Development Goal for Universal Health Coverage. This study aims to assess the CHE at population and disease levels and its influencing factors in Iran. Methods:This study is a systematic review and meta-analysis. The following keywords and their Persian equivalents were used for the review: Catastrophic Health Expenditures; Health Equity; Health System Equity; Financial Contribution; Health Expenditures; Financial Protection; Financial Catastrophe; and Health Financing Equity. These keywords were searched with no time limit until October 2019 in PubMed, Web of Science, Scopus, ProQuest, ScienceDirect, Embase, and the national databases of Iran. Studies that met a set of inclusion criteria formed part of the meta-analysis and results were analyzed using a random-effects model. Results:The review identified 53 relevant studies, of which 40 are conducted at the population level and 13 are disease specific. At the population level, the rate of CHE is 4.7% (95% CI 4.1% to 5.3%, n?=?52). Across diseases, the percentage of CHE is 25.3% (95% CI 11.7% to 46.5%, n?=?13), among cancer patients, while people undergoing dialysis face the highest percentage of CHE (54.5%). The most important factors influencing the rate of CHE in these studies are health insurance status, having a household member aged 60-65 years or older, gender of the head of household, and the use of inpatient and outpatient services. Conclusion:The results suggest that catastrophic health spending in Iran has increased from 2001 to 2015 and has reached its highest levels in the last 5 years. It is therefore imperative to review and develop fair health financing policies to protect people against financial hardship. This review and meta-analysis provides evidence to help inform effective health financing strategies and policies to prioritise high-burden disease groups and address the determinants of CHE.
| S-EPMC7229629 | biostudies-literature
Project description:BackgroundOut- of-pocket health expenditures (OOPs) constitute a significant proportion of total health expenditures in many low- and middle-income countries (LMICs), leading to an increased likelihood of exposure to financial catastrophe in the event of illness. Health insurance has the potential to reduce catastrophic health expenditures (CHE), but rigorous evidence of its sustained impact is limited, especially in LMICs. This study examined the short- and longer-term effects of a health insurance program in Kwara State, Nigeria on CHE.MethodsThe analysis is based on a panel dataset consisting of 3 waves of household surveys in program and comparison areas. The balanced data consists of 1,039 households and 3,450 individuals. We employed a difference-in-differences (DiD) regression approach to estimate intention-to-treat effects, and then computed average treatment effects on the treated by combining DiD with propensity score weighting and an instrumental variables analysis. CHE was measured as OOPs exceeding 10% of household consumption and 40% of capacity-to-pay (CTP).ResultsUsing 10% of consumption as a CHE measure, we found that living in the program area was associated with a 4.3 percentage point (pp) decrease in CHE occurrence (p < 0.05), while the effect on insured households was 5.7 pp (p < 0.05). The longer-term impact four years after program introduction was not significant. Heterogeneity analyses show a reduction in CHE of 7.2 pp (p < 0.01) in the short-term for the poorest tercile. No significant effects were found for the middle and richest terciles, nor in the longer-term. Households with a chronically ill member experienced a reduction in CHE of 9.4 pp (p < 0.01) in the short-term, but not in the longer-term. Most estimates based on the 40% of CTP measure were not statistically significant.ConclusionThese findings highlight the critical role of health insurance in reducing the likelihood of catastrophic health expenditures, especially for vulnerable populations such as the poor and the chronically ill, and by extension in achieving universal health coverage. They also show that the beneficial impacts of health insurance may attenuate over time, as households potentially adjust their health-seeking behavior to the new scheme.
| S-EPMC9764477 | biostudies-literature
Project description:The Sustainable Development Goal 3.8.2 is an indicator to track a country's progress toward universal health coverage on the financial protection against catastrophic health expenditure (CHE). The purpose of this study is to determine the proportion of households with catastrophic health expenditure, and its associated factors among Malaysian households. A secondary data analysis was performed using the Household Expenditure Survey 2015/2016. The inclusion criterion was Malaysian households with some health spending in the past 12 months before the date of the survey. Catastrophic health expenditure was defined as out-of-pocket health expenditures exceeding 10% of the total household consumption. The study included a total of 13015 households. The proportion of households with CHE in the sample was 2.8%. Female-led households (AdjOR 1.6; CI 1.25, 2.03; p-value <0.001), households in rural areas (AdjOR 1.29; 95% CI 1.04, 1.61; p-value = 0.022), small household size (AdjOR 2.4; 95% CI 1.81, 3.18; p-value <0.001) and heads of household under 60 years old (AdjOR2.34; 95% CI 1.81, 3.18; p-value <0.001) were significantly associated with CHE. Although the proportion of Malaysian households affected by CHE is small, it is increasing in comparison to previous findings. This is concerning because it may jeopardise efforts to achieve universal health coverage by 2030. To ensure financial protection and access to care, a health financing policy that includes safety net measures for households at risk of CHE is required.
| S-EPMC8880746 | biostudies-literature
Project description:BackgroundThe extent of healthcare expenditure within households stands as a crucial indicator in low and middle-income countries (LMICs). When out-of-pocket healthcare expenses surpass household income or become unduly burdensome, it serves as a significant socio-economic alarm, resulting in a reduced quality of life, a phenomenon referred to as 'catastrophic health expenditure (CHE).' Multiple factors can contribute to the occurrence of CHE. The study's objective was to identify the key uncertainties and driving forces influencing CHE to develop scenarios in Iran on the horizon of 2030.MethodsThis study was conducted between December 2021 and January 2023, data were collected through a literature review, and experts' opinions were gathered via questionnaires, interviews, and expert panels. The statistical population included experts in the fields of health policy, health economics, and futures studies. Scenario Wizard software and MICMAC analysis were employed for data analysis, providing valuable insights into potential future scenarios of health expenditures in Iran.ResultsBased on the results of the scoping review and semi-structured interview, 65 key factors in the fields of economics, politics, technology, social, and environmental were identified. The findings of the MICMAC analysis presented 10 key variables. Finally, six main scenario spaces are depicted using Scenario Wizard. These scenarios included catastrophic cost crises, sanction relief, selective information access, technological ambiguity, induced demand management, and incremental reforms.ConclusionsEach of the six drawn scenarios provides images of the future of health expenditure in Iranian households on the horizon of 2030. The worst-case scenario from all scenarios was scenario one, with the most probable and critical features to derive Iran's health expenditures. The current study is a valuable addition to the literature depicting the key drivers that all developing nations can consider to decrease exposing households to catastrophic and impoverishing health expenditures.
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Project description:ObjectiveWe evaluated the patient satisfaction with HIV/AIDS care and treatment and its determinants across levels of health service administration in Vietnam.MethodsWe interviewed 1016 patients at 7 hospitals and health centers in three epicenters, including Hanoi, Hai Phong, and Ho Chi Minh City. The Satisfaction with HIV/AIDS Treatment Interview Scale (SATIS) was developed, and 3 dimensions were constructed using factor analysis, namely "Quality and Convenience"; "Availability and Responsiveness"; and "Competence of health care workers".ResultsIn a band score of (0; 10), the mean scores of all domains were large; it was the highest in "Competence of health workers" (9.34±0.84), and the lowest in "Quality and Convenience" (9.03±1.04). The percentages of respondents completely satisfied with overall service quality and treatment outcomes were 42.4% and 18.8%, respectively. In multivariate analysis, factors related to higher satisfaction included female sex, older age, and living with spouses or partners. Meanwhile, lower satisfaction was found among patients who were attending provincial and district clinics; in the richest group; had higher CD4 count; and drug users.ConclusionThis study highlights the importance of improving the quality of HIV/AIDS services at the provincial and district clinics. Potential strategies include capacity building for health workers, integrative service delivery, engagements of family members in treatment supports, and additional attention and comprehensive care for drug users with HIV/AIDS.
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