What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts?

This paper presents the findings of a critical review of studies carried out in low- and middle-income countries (LMICs) focusing on the economic consequences for households of illness and health care use. These include household level impacts of direct costs (medical treatment and related financial costs), indirect costs (productive time losses resulting from illness) and subsequent household responses. It highlights that health care financing strategies that place considerable emphasis on out-of-pocket payments can impoverish households. There is growing evidence of households being pushed into poverty or forced into deeper poverty when faced with substantial medical expenses, particularly when combined with a loss of household income due to ill-health. Health sector reforms in LMICs since the late 1980s have particularly focused on promoting user fees for public sector health services and increasing the role of the private for-profit sector in health care provision. This has increasingly placed the burden of paying for health care on individuals experiencing poor health. This trend seems to continue even though some countries and international organisations are considering a shift away from their previous pro-user fee agenda. Research into alternative health care financing strategies and related mechanisms for coping with the direct and indirect costs of illness is urgently required to inform the development of appropriate social policies to improve access to essential health services and break the vicious cycle between illness and poverty.     

Housing conditions and mental health in a disadvantaged area in Scotland.

OBJECTIVE: To examine the mental health impact of different aspects of poor housing. DESIGN: This was a post hoc analysis of data from a household interview survey. SETTING: A public sector housing estate on the outskirts of Glasgow. SUBJECTS: These comprised 114 men and 333 women aged between 17 and 65 from 451 households. MEASURES: Dependent variable: scoring > or = 5 on the 30 item general health questionnaire (GHQ30). Independent variables: self reported data on household composition, whether ill health was a factor in the move to the current dwelling, length of time at address, household income, whether the respondent was employed, chronic illness, and 6 problems with the dwelling. RESULTS: Reporting a problem with dampness was significantly and independently associated with scores of > or = 5 on the GHQ30 after controlling for possible confounding variables. CONCLUSION: Initiatives to tackle housing dampness may be important in developing a strategy to improve mental health for the study area. More research on the mental health impact of different aspects of poor housing is required.     

Costs of illness and coping strategies in a coffee-growing rural district of Ethiopia

The paper describes a cross-sectional household survey conducted in randomly-selected villages in rural Ethiopia to assess strategies of households for coping with financial and time costs of illness. Results of the survey showed that the average monthly household health expenditure was 32.87 Birr (about 4.1 US dollars [1 US dollar = 8 Birr at the time of study]). In addition, the average time lost due to illness was 9.23 days for the sick and 7.38 days for their caretakers. Monetary price was a significant (p<0.05) deterrent from visiting health facilities among households with no land or house, the divorced or widowed, and those with annual income less than 500 Birr (62.5 US dollars). The main strategies to cope with the financial costs of illness were waiver privileges, selling household assets, and using savings. Division of labour among household members was used for compensating for the loss of working time due to sickness. The findings of the study indicate that financial and time costs of illness seem to significantly contribute to the impoverishment of rural households.     

农村贫困家庭健康风险及其干预策略

贫困与健康的关系已经被很多文献很好地论述了。健康贫困实则为贫困的一个重要部分．农村贫困家庭应对健康风险时具有很强的脆弱性，如果缺乏有效的健康风险处理机制，则很容易进入健康贫困状态。而传统健康保障模式在解决贫困家庭健康风险问题上可能产生以下方面的问题：过分强调公共部门的作用和政府目标：过分强调疾病成本和支出从而忽略可持续发展的健康促进；容易混淆不同部门问的职责，降低相互支持度。基于社会风险管理的理论框架描述了农村贫困家庭健康风险管理预防、缓和及应对策略。     

Risk,trust and patients’ strategic choices of healthcare practitioners

Research on patients’ choice of healthcare practitioners has focussed on countries with regulated and controlled healthcare markets. In contrast, low‐ and middle‐income countries have a pluralistic landscape where untrained, unqualified and unlicensed informal healthcare providers (IHPs) provide significant share of services. Using qualitative data from 58 interviews in an Indian village, this paper explores how patients choose between IHPs and qualified practitioners in the public and formal private sectors. The study found that patients’ choices were structurally constrained by accessibility and affordability of care and choosing a practitioner from any sector presented some risk. Negotiation and engagement with risks depended on perceived severity of the health condition and trust in practitioners. Patients had low institutional trust in public and formal private sectors, whereas IHPs operated outside any institutional framework. Consequently, people relied on relational or competence‐derived interpersonal trust. Care was sought from formal private practitioners for severe issues due to high‐competence‐based interpersonal trust in them, whereas for other issues IHPs were preferred due to high relationship‐based interpersonal trust. The research shows that patients develop a strategic approach to practitioner choice by using trust to negotiate risks, and crucially, in low‐ and middle‐income countries IHPs bridge a gap by providing accessible and affordable care imbued with relational–interpersonal trust.     

Effectiveness of community health financing in meeting the cost of illness

How to finance and provide health care for the more than 1.3 billion rural poor and informal sector workers in low- and middle-income countries is one of the greatest challenges facing the international development community. This article presents the main findings from an extensive survey of the literature of community financing arrangements, and selected experiences from the Asia and Africa regions. Most community financing schemes have evolved in the context of severe economic constraints, political instability, and lack of good governance. Micro-level household data analysis indicates that community financing improves access by rural and informal sector workers to needed heath care and provides them with some financial protection against the cost of illness. Macro-level cross-country analysis gives empirical support to the hypothesis that risk-sharing in health financing matters in terms of its impact on both the level and distribution of health, financial fairness and responsiveness indicators. The background research done for this article points to five key policies available to governments to improve the effectiveness and sustainability of existing community financing schemes. This includes: (a) increased and well-targeted subsidies to pay for the premiums of low-income populations; (b) insurance to protect against expenditure fluctuations and re-insurance to enlarge the effective size of small risk pools; (c) effective prevention and case management techniques to limit expenditure fluctuations; (d) technical support to strengthen the management capacity of local schemes; and (e) establishment and strengthening of links with the formal financing and provider networks.     

Access to medicines for acute illness in middle income countries in Central America

OBJECTIVE

To analyze the main predictors of access to medicines for persons who experienced acute health conditions.

METHODS

This was a cross-sectional analytic study, based on data from household surveys. We examined the predictors of: (1) seeking care for acute illness in the formal health care system and (2) obtaining all medicines sought for the acute condition.

RESULTS

The significant predictors of seeking health care for acute illnesses were urban geographic location, head of household with secondary school education or above, age under 15, severity of illness perceived by the respondent, and having health insurance. The most important predictor of obtaining full access to medicines was seeking care in the formal health care system. People who sought care in the formal system were three times more likely to receive all the medicines sought (OR 3.0, 95%CI 2.3;4.0). For those who sought care in the formal health system, the strongest predictors of full access to medicines were seeking care in the private sector, having secondary school education or above, and positive perceptions of quality of health care and medicines in public sector health facilities. For patients who did not seek care in the formal health system, full access to medicines was more likely in Honduras or Nicaragua than in Guatemala. Urban geographic location, higher economic status, and male gender were also significant predictors.

CONCLUSIONS

A substantial part of the population in these three countries sought and obtained medicines outside of the formal health care system, which may compromise quality of care and pose a risk to patients. Determinants of full access to medicines inside and outside the formal health care system differ, and thus may require different strategies to improve access to medicines.      

Coping with health care expenses among poor households: evidence from a rural commune in Vietnam

With the 1980s "Doi Moi" economic reforms, Vietnam transitioned from state-funded health care to a privatized user fee system. Out-of-pocket payments became a major source of funding for treatments received at both public and private health facilities. We studied coping strategies used by residents of Dai Dong, a rural commune of Hanoi, for paying health care costs, assessing the effects of such costs on economic and health stability. We developed a 2008 survey of 706 households (166 poor, 184 near-poor, 356 non-poor; 100% response rate). Outcome measures were reported episodes of illness; inpatient, outpatient, and self-treatments; out-of-pocket expenditures; and funding sources for health care costs. Households of all income levels borrowed to pay for inpatient treatments; loans are also more heavily used by the poor and near-poor than the non-poor for outpatient treatments. Compared to low cost treatments, the use of loans is intensified for extremely high cost health treatments for all poverty levels, but especially for the poor and near-poor. The likelihood of reducing food consumption to pay for extremely high cost treatment versus low cost treatments increased most for the poor in both inpatient and outpatient contexts. Decreased funding and increased costs in health care rendered Dai Dong's population vulnerable to the consequences of detrimental coping strategies such as debt and food reduction. Future reforms should focus on obviating these funding measures among at-risk populations.     

农户疾病风险处理策略研究述评

疾病影响农户生计。本文从疾病风险测度、疾病对农户生计影响、农户疾病风险处理策略等方面对现有研究进行述评。疾病对农户生计短期影响表现为减少劳动时间和降低正常消费水平等;大病可能导致10年或更长的严重负面影响,特别是影响农户人力资本发展。面对疾病风险,农户采取诸如计划免疫、安全饮水及参加医保项目等"事前"预防措施;他们还积极采取收入和消费平滑的"事后"风险处理策略来度过难关,例如减少家庭消费、借贷、变卖消费性和生产性资产、向外地移居等策略。不同经济状况的农户会采取适合于自身经济能力的疾病风险处理策略。未来的研究需要在疾病对农户收入的持续影响以及对贫困农户生计的影响,不同特征农户疾病风险处理策略比较等方面进行深入分析。     

Drought Adaptation and Coping Strategies Among the Turkana Pastoralists of Northern Kenya

This study highlights drought characteristics and the many responses to drought stresses employed by Turkana pastoralists of northwestern Kenya. Multiple data sources, including socioeconomic interviews with 302 households, focus group discussions, and informal interviews with pastoralists were used to capture various aspects of drought and drought adaptation and coping practices.Standardized precipitation index derived from long-term rainfall data obtained from the Kenya Meteorological Service was used to quantify different degrees of drought intensity between 1950 and 2012. Results revealed that extreme drought events were increasingly frequent, and have impacted negatively on pastoral livelihoods. In order to adapt to or cope with climatic anomalies, households are using a variety of strategies. In addition to the traditional short-term coping mechanisms, the long-term adaptation strategies used include diversification of livelihood sources; livestock mobility to track forage and water resources;diversification of herd composition to benefit from the varied drought and disease tolerance, as well as fecundity of diverse livestock species; and sending children to school for formal education as a long term investment expected to pay back through income from employment. Policies anddevelopment interventions that reduce risks, diminish livelihood constraints, and expand opportunities for increased household resilience to drought are critical complements to the existing pastoral strategies.     

Strategies and outcomes of introducing a mental health plan in Brazil

Prior to 1978, the majority of Brazilians suffering from mental illness had no recourse other than hospitalization in inadequate institutions. The government introduced an official plan which stressed primary health care delivery of mental health services. This paper describes the role of the anthropologist in different stages of the implementation of this plan and the research conducted in informal and formal health systems, utilization patterns, public health conditions in a Northeastern Brazilian favela and strategies for integrating formal and informal mental health resources in this favela. The problems involved in carrying out primary prevention in mental health and strategies for articulating medical and non-medical healing systems are analyzed.     

Mental health and social capital in Cali, Colombia

Mental ill health forms an increasingly significant part of the burden of disease in developing countries. The growing interest in social risk factors for mental health coincides with the development of social capital research which may further inform the social model of mental health. The objective of the study reported here was to discover if there is an independent association between social capital and mental health when taking into account an array of demographic and violence variables. A total of 1168 youth (15-25 years) in a low income community in Cali, Colombia were surveyed. Mental health was measured by a 20 item self-report questionnaire. The instrument used to measure social capital covered structural and cognitive social capital. Twenty-four per cent of the sample were probable cases of mental ill health. Females had a prevalence rate three times higher than males. Using a model which considered demographic and social capital measures as potential risk factors for mental ill health, the significant risk factors emerged as being female, having limited schooling, working in the informal sector, being a migrant, and having low trust in people. The 'classic' poverty type variables (poor education and employment) were more important than social capital, as was the commonly dominant risk factor for mental ill health-being a woman. When violence factors were added to the model, the 'trust' factor fell out and the most important risk factors became (in descending order of importance): being female; no schooling/incomplete primary; and being a victim of violence. The dominance of poverty related factors, as opposed to social capital, prompts renewed attention to the explanatory mechanisms that link income inequality and poor mental health.     

Informal care for illness in rural southwest Uganda: the central role that women play

In rural Uganda care for those who are ill tends to be home based because of inadequate and expensive health care facilities, lack of medication and poor staffing levels in health units. Research findings suggest that women are responsible for the bulk of caring activities. This paper questions the assumption that female informal carers are in a position to cope with illness episodes in the home. Data were collected from 54 female informants in a rural population in southwest Uganda. Supplementary data from in-depth interviews with survey participants and counsellors were also collected. Findings suggest that women are the main providers of informal care within the home. Many women, particularly in female-headed households, did not own or have direct access to the necessary finances to meet the family's health care needs as expected of them. Although relatives and friends were seen as a valuable resource, because of poor household proximity and financial constraints they were not always in a position to offer or provide assistance. The women also identified themselves as responsible for a variety of home and agricultural tasks; such activities were frequently disrupted by illness episodes. As women take on the additional burden of care for those with HIV/AIDS an inevitable conclusion is that their resources, both social and economic, will not be adequate. These data indicate the need for additional research and stress the importance of appropriate support and relief programs for those responsible for informal care.     

Paying for hospital-based care of Kala-azar in Nepal: assessing catastrophic, impoverishment and economic consequences

Households obtaining health care services in developing countriesincur substantial costs, despite services generally being providedfree of charge by public health institutions. This constitutesan economic burden on low-income households, and contributesto deepening their level of poverty. In addition to the economicburden of obtaining health care, the method of financing thesepayments has implications for the distribution of householdassets. This effect on resource-poor households is amplifiedsince they have decreased access to health insurance. Recentliterature, however, ignores the importance of the method offinancing health care payments. This paper looks at the caseof Nepal and highlights the impact on households of paying forhospital-based care of Kala-azar (KA) by analysing the catastrophic,impoverishment and economic consequences of their coping strategies.The paper utilizes micro-data on a random selection of 50% ofthe KA-affected households of Siraha and Saptari districts ofNepal. The empirical results suggest that direct costs of hospital-basedtreatment of KA are catastrophic since they consume 17% of annualhousehold income. This expenditure causes more than 20% of KA-affectedhouseholds to fall below the poverty line, with the remaininghouseholds being pushed into the category of marginal poor;the poverty gap ratio is more than 90%. Further, KA incidencecan have prolonged and severe economic consequences for thehousehold economy due to the mechanisms of informal sector financingto which households resort. A heavy burden of loan repaymentscan lead households on a downward spiral that eventually becomesa poverty trap. In other words, the method of financing healthcare payments is an important ingredient in understanding theeconomic burden of disease.     

How do supply‐side factors influence informal payments for healthcare? The case of HIV patients in Cameroon

Direct out‐of‐pocket payments for healthcare continue to be a major source of health financing in low‐income and middle‐income countries. Some of these direct payments take the form of informal charges paid by patients to access the needed healthcare services. Remarkably, however, little is known about the extent to which these payments are exercised and their determinants in the context of Sub‐Saharan Africa. This study attempts therefore to shed light on the role of supply‐side factors in the occurrence of informal payments while accounting for the demand‐side factors. The study relies on data taken from a nationally representative survey conducted among people living with HIV/AIDS in Cameroon. A multilevel mixed‐effect logistic model is employed to identify the factors associated with the incidence of informal payments. Results reveal that circa 3.05% of the surveyed patients incurred informal payments for the consultations made on the day of the survey. The amount paid informally represents up to four times the official tariff. Factors related to the following: (i) human resource management of the health facilities (e.g., task shifting); (ii) health professionals' perceptions vis‐à‐vis the remunerations of HIV care provision; and (iii) reception of patients (e.g., waiting time) significantly influence the probability of incurring informal payments. Also of note, the type of healthcare facilities is found to play a role: informal payments appear to be significantly lower in private non‐profit facilities compared with those belonging to public sector. Our findings allude to some policy recommendations that can help reduce the incidence of informal payments. Copyright © 2014 John Wiley & Sons, Ltd.     

Health care-seeking behaviour and out-of-pocket payments in Tbilisi, Georgia

Based on a household survey conducted in Tbilisi, Georgia, in 2000, this paper examines current patterns of health care-seeking behaviour and the extent of out-of-pocket payments. Results show that health care services are a financial burden and that private (out-of-pocket) payment creates financial barriers to accessing health services. Members of the poorest households are less likely to seek care than people from more affluent households, and devote a higher share of household monthly expenditure to health care. Households have adopted various strategies to overcome these financial barriers, but the strategies are likely to contribute to both declining economic status and worsening health outcomes. The paper provides an evidence base to help direct future policy reform in Georgia. Government needs to: (1) prioritize public financing of services for the poor, in particular through amending the Basic Benefit Package so that it better reflects the needs of the poor; (2) promote the quality and utilization of primary care services; (3) address the issue of rational drug use; and (4) consider mobilizing out-of-pocket payments on a pre-paid basis through formal or community-based risk pooling schemes.     

Access to health care in a system transition: the case of Bulgaria

OBJECTIVE: Throughout the 1990s, the Soviet-style model in central and eastern Europe that provided free health services has been subject to radical reforms. Socio-economic inequalities have also increased but there is little information on inequalities in health care utilization. This paper examines the pattern of illness behaviour in Bulgaria, seeking evidence of inequalities in access to services and eliciting users' pathways to care. DESIGN: Analysis drew on a representative population survey in Bulgaria (1997). The financial determinants of service use were tested in a multivariate model adjusted first for age, and then for age, marital status and self-reported health. In-depth interviews with users and providers addressed pathways to care, use of connections and other informal strategies to obtain care. RESULTS: As expected, rates of illness vary with income, with highest rates among the poor. After adjustment for illness, consultation rates are relatively equal across income levels, with the exception of worse-off women who tend to consult more. For first contact, there are few differences according to income, with the better off preferring secondary level. Pathways slightly differ, with women more often treated in primary care. Private sector utilization is low. Qualitative research reveals well-established strategies to obtain more advanced care, including use of connections, informal payments and use of emergency services. CONCLUSIONS: An apparent lack of inequalities in access to care conceals a more complex picture in which income and gender influence the pathways taken through the system.     

Have out‐of‐pocket health care payments risen under free health care policy? The case of Sri Lanka

Compared to its neighbors, Sri Lanka performs well in terms of health. Health care is provided for free in the public sector, yet households' out‐of‐pocket health expenditures are steadily increasing. We explore whether this increase can be explained by supply shortages and insufficient public health care financing or whether it is rather the result of an income‐induced demand for supplementary and higher quality services from the private sector. We focus on total health care expenditures and health care expenditures for specific services such as expenses on private outpatient treatments and expenses on laboratory and other diagnostic services. Overall, we find little indication that limited supply of public health care per se pushes patients into the private sector. Yet income is identified as one key driver of rising health care expenditures, ie, as households get richer, they spend an increasing amount on private services suggesting a dissatisfaction with the quality offered by the public sector. Hence, quality improvements in the public sector seem to be necessary to ensure sustainability of the public health care sector. If the rich and the middle class increasingly opt out of public health care, the willingness to pay taxes to finance the free health care policy will certainly shrink.     

Analysing the importance of older people's resources for the use of home care in a cash‐for‐care scheme: evidence from Vienna

Older people of lower socioeconomic status (SES) are disproportionately affected by chronic conditions, yet less able to compensate health limitations through use of formal long‐term care (LTC) at home, a preferred type of care for most. Some, like older women and single people, are particularly vulnerable. Under the Austrian public cash‐for‐care scheme, which aims to incentivise care at home and empowerment of LTC users, this study analyses: (i) interdependencies between SES, gender and ‘informal’ or family care, and (ii) how these factors associate with the use of old age formal home care in Vienna. An adaptation of Arber and Ginn's theory is used to identify material resources (income), health resources (care needs) and informal caring resources (co‐residence and/or availability of family care). Gender aspects are also considered as a persistent source of inequalities. Administrative and survey data, collected by public authorities between 2010 and 2012 in Vienna, serve to compare home care use in old age (60+) to other support forms (residential and informal care) using logistic regression analysis. Results show a pro‐rich bias in home care use among single‐living people, with high‐income single people being less likely to move to a care home, while there are no significant income differences present for non‐singles. Second, traditional gender roles are salient: female care recipients co‐residing with a partner are more likely to use formal care than men, reflecting that men's traditional gender roles involve less unpaid care work than women's. In conclusion, in an urban setting, the Austrian cash‐for‐care scheme is likely to reinforce stratifications along gender and class, thus implementing the general policy objective of care at home, but more likely for those with higher income. A support mechanism promoting empowerment among all older people might contribute to unequal degrees of choice, especially for those with fewer resources to manage their way through a fragmented system of LTC delivery.     

疾病影响社会经济发展的主要途径

人类社会进步与文明发展的历史证明“健康就是财富”,一些可预防疾病对人类健康所造成的经济损失累计起来是相当巨大的,疾病减少了社会创造了财富,也降低了人们对收入,生活与经济增长的希望。疾病通过对人们健康状况与生命周期的影响疾病的外部效应与对社会的影响,制约着社会经济的发展,一次疾病可以使一个贫困的家庭变得更加穷困,甚至也可以使富人变为贫困者;因疾致贫,因病返贫成了当今社会发展中的一个特点,投资于卫生,加强对居民健康状况的保护与关照也就是对社会经济的发展的贡献,各国社会经济发展的历史证明,加强对卫生保障的投入,是许多发展中国家减少贫困促进经济发展的一个战略性措施。