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Challenges and experiences in linking community level reported out-of-pocket health expenditures to health provider recorded health expenditures: Experience from the iHOPE project in Northern Ghana.

ABSTRACT: Out of pocket health payment (OOPs) has been identified by the System of Health Accounts (SHA) as the largest source of health care financing in most low and middle-income countries. This means that most low and middle-income countries will rely on user fees and co-payments to generate revenue, rationalize the use of services, contain health systems costs or improve health system efficiency and service quality. However, the accurate measurement of OOPs has been challenged by several limitations which are attributed to both sampling and non-sampling errors when OOPs are estimated from household surveys, the primary source of information in LICs and LMICs. The incorrect measurement of OOP health payments can undermine the credibility of current health spending estimates, an otherwise important indicator for tracking UHC, hence there is the need to address these limitations and improve the measurement of OOPs. In an attempt to improve the measurement of OOPs in surveys, the INDEPTH-Network Household out-of-pocket expenditure project (iHOPE) developed new modules on household health utilization and expenditure by repurposing the existing Ghana Living Standards Survey instrument and validating these new tools with a 'gold standard' (provider data) with the aim of proposing alternative approaches capable of producing reliable data for estimating OOPs in the context of National Health Accounts and for the purpose of monitoring financial protection in health. This paper reports on the challenges and opportunities in using and linking household reported out-of-pocket health expenditures to their corresponding provider records for the purpose of validating household reported out-of-pocket health expenditure in the iHOPE project.

SUBMITTER: Agorinya IA

PROVIDER: S-EPMC8423291 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundApproximately 150 million people suffer from financial catastrophe annually because of out-of-pocket expenditures (OOPEs) on health. Although the National Health Insurance Scheme (NHIS) of Ghana was designed to promote universal health coverage, OOPEs as a proportion of total health expenditures remains elevated at 26%, exceeding the WHO's recommendations of less than 15-20%. To determine whether enrollment in the NHIS reduces the likelihood of OOPEs and catastrophic health expenditures (CHEs) in Ghana, we undertook a systematic review of the published literature.MethodsWe searched for quantitative articles published in English between January 1, 2003 and August 22, 2017 in PubMed, Google Scholar, Economic Literature, Global Health, PAIS International, and African Index Medicus. Two independent authors (J.S.O. & S.E.) reviewed the articles for inclusion, extracted the data, and conducted a quality assessment of the studies. We accepted the World Health Organization definition of catastrophic health expenditures which is out of pocket payments for health care which exceeds 20% of annual house hold income, 10% of household expenditures, or 40% of subsistence expenditures (total household expenditures net food expenditures).ResultsOf the 1094 articles initially identified, 7 were eligible for inclusion. These were cross-sectional household studies published between 2008 and 2016 in Ghana. They demonstrated that the uninsured paid 1.4 to 10 times more in out-of-pocket payments (OOPs) and were more likely to incur CHEs than the insured. Yet, 6 to 18% of insured households made catastrophic payments for healthcare and all studies reported insured members making OOPs for medicines.ConclusionEvidence suggests that the national health insurance scheme of Ghana over the last 14 years has made some impact on reducing OOPEs, and yet healthcare costs remain catastrophic for a large proportion of insured households in Ghana. Future studies need to explore reasons for the persistence of OOPs for medicines and services that are covered under the scheme.

Project description:BackgroundGhana introduced a national health insurance program in 2005 with the goal of removing user fees, popularly called "cash and carry", along with their associated catastrophic and impoverishment effects on the population and ensuring access to equitable health care. However, after a decade of implementation, the impact of this program on user fees and out-of-pocket payment (OOP) is not properly documented. This paper contributes to understanding the impact of Ghana's health insurance program on out-of-pocket healthcare payments and the factors associated with the level of out-of-pocket payments for primary healthcare in a predominantly rural region of Ghana.MethodsUsing a five-year panel data of revenues accruing to public primary health facilities in seven districts, We employed mean comparison tests (t-test) to examine the trend in revenues accruing from out-of-pocket payments vis-à-vis health insurance claims for health services, medication, and obstetric care. Furthermore, generalized estimation equation regression models were used to assess the relationship between explanatory variables and the level of out-of-pocket payments and health insurance claims.ResultsOut-of-pocket payment for health services and medications declined by 63% and 62% respectively between 2010 and 2014. Insurance claims however increased by 16% within the same period. There was statistically a significant mean reduction in out-of-pocket payment over the period. Factors significantly associated with out-of-pocket payments in a given district are the number of community health facilities, availability of a district hospital and the year of observation.ConclusionThe study provides evidence that Ghana's national health insurance program is significantly contributing to a reduction in out-of-pocket payment for primary healthcare in public health facilities. Efforts should therefore be put in place to ensure the sustainability of this policy as a major pathway for achieving universal health coverage in Ghana.

Project description:BACKGROUND: Aligned with the international call for universal coverage of affordable and quality health care, the government of Tajikistan is undertaking reforms of its health system aiming amongst others at reducing the out-of-pocket expenditures (OPE) of patients seeking care. Household surveys were conducted in 2005, 2007, 2008 and 2011 to explore the scale and determinants of OPE of users in four district of Tajikistan, where health care is legally free of charge at the primary level. METHODS: Using the data from four cross-sectional household surveys conducted between 2005 and 2011, time trends in OPE for consultation fees, drugs and transport costs of adult users of family medicine services were analysed. To investigate differences along the economic status, an asset index was constructed using principal component analysis. RESULTS: Adjusted for inflation, OPE for primary care have substantially increased in the period 2005 to 2011. While the proportion of patients reporting the payment of informal consultation fees to providers and their amount were constant over time, the proportion of patients reporting expenditures for drugs has increased, and the median amounts have doubled from 5.3 US$ to 10.7 US$. Thus, the expenditures on medicine represent the biggest financial burden for patients accessing a primary care facility. Regression models showed that in 2011 patients from the most remote district with spread-out villages reported significant higher expenditures on medicine. Besides the steady increase in the median amount for OPE, the proportion of patients reporting making an informal payment to their care provider showed great variations across district of residence (between 20% and 73%) and economic status (between 33% among the 'worst-off' group and 68% among the 'better-off' group). CONCLUSIONS: In a context of limited governmental funds allocated to health and financing reforms aiming to improve financial access to primary care, the present paper indicates that in Tajikistan OPE - especially in relation to expenditures for drugs - have increased over time, and vary substantially across geographical areas and economic status. The fact that better-off households report disbursing more and in higher proportions hints towards a discrimination along the capacity to pay from providers. Increased public investments in the health sector, incentives for family doctors to provide PHC services free of charge and a strengthened drug control and supply system are necessary strategies to improve access of patients to services.

Project description:IntroductionThe free maternal health policy was implemented in Ghana in 2008 under the National Health Insurance Scheme (NHIS). The policy sought to eliminate out of pocket (OOP) payments and enhance the utilisation of maternal health services. It is unclear whether the policy had altered OOP payments for services. The study explored views on costs and actual OOP payments during pregnancy. The source of funding for payments was also explored.MethodsA convergent parallel mixed methods design, involving quantitative and qualitative data collection approaches. The study was set in the Kassena-Nankana municipality, a rural area in Ghana. Women (n = 406) who utilised services during pregnancy were surveyed. Also, 10 focus groups discussions (FGDs) were held with women who used services during pregnancy as well as 28 in-depth interviews (IDIs) with midwives/nurses (n = 25) and insurance managers/directors (n = 3). The survey was analysed using descriptive statistics, focussing on costs from the women's perspective. Qualitative data were audio recorded, transcribed and translated verbatim into English where necessary. The transcripts were read and coded into themes and sub-themes.ResultsThe NHIS did not cover all expenses in relation to maternal health services. The overall mean for OOP cost during pregnancy was GH¢17.50 (US$8.60). Both FGDs and IDIs showed that women especially paid for drugs and ultrasound scan services. Sixty-five percent of the women used savings, whilst twenty-two percent sold assets to meet the OOP cost. Some women were unable to afford payments due to poverty and had to forgo treatment. Participants called for payments to be eliminated and for the NHIS to absorb the cost of emergency referrals. All participants admitted the benefits of the policy.ConclusionWomen needed to make payments despite the policy. Measures should be put in place to eliminate payments to enable all women to receive services and promote universal health coverage.

Project description:BACKGROUND:Within its reform efforts, the Government of Tajikistan is embracing the essential role of primary health care (PHC) in decreasing out of pocket (OOP) expenditures and increasing equity in access to health services. In the light of the increasing burden of disease relating to chronic conditions, we investigated OOP expenditures of patients with chronic conditions within a PHC setting; and if and how those expenditures are impacted by several interventions currently being implemented within Tajikistan. METHODS:A cross-sectional survey among 1600 adult patients who had visited a PHC facility was conducted. The data obtained through interviews were descriptively analysed, and logistic regressions and gamma generalized linear models were performed. RESULTS:The total OOP expenditures related to a patient's last visit to the PHC facility were 17.2 USD for those with chronic conditions and 13.9 USD for those visiting due to an acute condition. Adjustment for potential confounders reduced the discrepancy from 3.3 USD to 0.5 USD. This convergence of costs was only observed in districts covered by the Basic Benefit Package (BBP), a governmental pilot project, aiming to standardise exemptions for payment and formal co-payments for health care services. Hence, we found the BBP to have a protective impact for patients with chronic conditions. However, considering the demographics of these patients (older in age, with greater dependency on pensions and social aid, and lower socio-economic status) in combination with the 40% higher utilisation rate of PHC and the high rate of onward referrals to specialists; it is clear that patients with chronic conditions continue to face substantial long-term costs and disadvantages. CONCLUSIONS:After accounting for confounders, patients with chronic and acute conditions faced similar costs related to a single visit to a PHC facility in districts covered by the BBP. However, greater efforts are required to ensure that citizens are well informed about their rights to health care, the BBP and the services that should be provided at no cost at the point of delivery. Moreover, the needs of patients with chronic conditions warrant a more integrative approach that takes long-term expenditures and services beyond the level of PHC into account.

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Challenges and experiences in linking community level reported out-of-pocket health expenditures to health provider recorded health expenditures: Experience from the iHOPE project in Northern Ghana.

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