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

Background:Missed 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.Method:Totally 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.Results:Among 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 5100 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[CZ]: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).Conclusion:Interventions 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 payments and economic consequences from tuberculosis care in eastern China:income inequality

Background:Despite the availability of free tuberculosis(TB)diagnosis and treatment,TB care still generates substantial costs that push people into poverty.We investigated out-of-pocket(OOP)payments for TB care and assessed the resulting economic burden and economic consequences for those with varying levels of household income in eastern China.Methods:A cross-sectional study was conducted among TB patients in the national TB programme networks in eastern China.TB-related direct OOP costs,time loss,and coping strategies were investigated across households in different economic strata.Analysis of Variance was used to examine the differences in various costs,and Kruskal-Wallis tests were used to compare the difference in total costs as a percentage of annual household income.Results:Among 435 patients,the mean OOP total costs of TB care were USD 2389.5.In the lower-income quartile,OOP payments were lower,but costs as a percentage of reported annual household income were higher.Medical costs and costs prior to treatment accounted for 66.4 and 48.9%of the total costs,respectively.The lower the household income was,the higher the proportion of medical costs to total costs before TB treatment,but the lower the proportion of medical costs patients spent in the intensive phase.TB care caused 25.8%of TB-affected households to fall below the poverty line and caused the poverty gap(PG)to increase by United States Dollar(USD)145.6.Patients in the poorest households had the highest poverty headcount ratio(70.2%)and PG(USD 236.1),but those in moderately poor households had the largest increase in the poverty headcount ratio(36.2%)and PG(USD 177.8)due to TB care.Patients from poor households were more likely to borrow money to cope with the costs of TB care;however,there were fewer social consequences,except for food insecurity,in poor households.Conclusions:Medical and pretreatment costs lead to high costs of TB care,especially among patients from the poorest households.It is necessary to train health system staff in general hospitals to promptly identify and refer TB patients.Pro-poor programmes are also needed to protect TB patients from the medical poverty trap.

Acupuncture price in forty-one metropolitan regions in the United States: An out-of-pocket cost analysis based on Ok Copay.com

Few studies have focused on the cost of acupuncture treatments although acupuncture has become popular in the United States(U.S.). The purpose of the current study was to examine the out-of-pocket costs incurred from acupuncture services based on an online website, Ok Copay.com. We examined descriptive statistics(range, median and 20% intervals) for the cost of acupuncture "first-time visits"and "follow-up visits" in 41 metropolitan regions in the U.S. The acupuncture prices of 723 clinics throughout 39 metropolitan regions were included, except for Birmingham, Alabama and Detroit, Michigan as there was no online data available at the time of the study for these two regions. The cost range for a first-time acupuncture visit was $15–400;the highest median was $150 in Charleston, South Carolina,while the lowest was $45 in St. Louis, Missouri. The top 10 cities for the highest median were:Baltimore, Washington, D.C., New York, San Francisco, San Jose, Boston, Atlanta, Seattle, Portland and Indianapolis, with the median $120, while the median for all 723 clinics was $112. For the follow-up visits,the cost range was $15–300;the highest median was $108 in Charleston, South Carolina, and the lowest$40 in Miami, Florida. The 10 cities with highest median follow-up acupuncture visit costs were: New York, Baltimore, New Orleans, Washington, D.C., Philadelphia, San Francisco, San Jose, Seattle, Boston and Atlanta, with the median $85, while for all 723 clinics the median price was $80. The estimation of the average gross annual income of each acupuncturist from the regions studied was $95,760, while the total annual cost of patients seeking acupuncture services in the U.S. was about $3.5 billion in 2018.

A cross-sectional study to assess the out-of-pocket expenditure of families on the health care of children younger than 5 years in a rural area

Objective:This study aimed to estimate the out-of-pocket expenditure of families on the health care of children younger than 5 years in a rural area of Kancheepuram district.Methods:A cross-sectional descriptive study was performed in a rural area of Kancheepuram district for 5 months.All households with at least one child younger than 5 years were eligible for the study,and 153 households were selected for the fi nal study.A semistructured and pretested schedule was used to obtain information about various study variables during home visits.Ethics approval was obtained before the start of the study.Data were entered into Microsoft Excel,and statistical analysis was done with IBM SPSS Statistics version 23.Frequency distributions were calculated for all the variables.Results:The fi ndings indicate that most children younger than 5 years were males(62.7%).The maximum out-of-pocket expenditure was for accidents/trauma and in cases of fever/malaria.Further,96 households(53.1%)preferred private-sector health care for their ailments.Conclusion:The fi ndings indicate that 93 of the children younger than 5 years(60.8%)had experienced one episode of illness in the previous 3 months.Further,the maximum out-of-pocket expenditure was for accident/trauma cases,and overall the largest share was for buying medica-tions for the treatment.

Impact of payment source, referral site, and place of residence on outcomes after allogeneic transplantation in Mexico

BACKGROUND The impact of social determinants of health in allogeneic transplant recipients in low-and middle-income countries is poorly described.This observational study analyzes the impact of place of residence,referring institution,and transplant cost coverage(out-of-pocket vs government-funded vs private insurance)on outcomes after allogeneic hematopoietic stem cell transplantation(alloHSCT)in two of Mexico's largest public and private institutions.AIM To evaluate the impact of social determinants of health and their relationship with outcomes among allogeneic transplant recipients in Mexico.METHODS In this retrospective cohort study,we included adolescents and adults≥16 years who received a matched sibling or haploidentical transplant from 2015-2022.Participants were selected without regard to their diagnosis and were sourced from both a private clinic and a public University Hospital in Mexico.Three payment groups were compared:Out-of-pocket(OOP),private insurance,and a federal Universal healthcare program“Seguro Popular”.Outcomes were compared between referred and institution-diagnosed patients,and between residents of Nuevo Leon and out-of-state.Primary outcomes included overall survival(OS),categorized by residence,referral,and payment source.Secondary outcomes encompassed early mortality,event-free-survival,graft-versus-host-relapse-free survival,and non-relapse-mortality(NRM).Statistical analyses employed appropriate tests,Kaplan-Meier method,and Cox proportional hazard regression modeling.Statistical software included SPSS and R with tidycmprsk library.RESULTS Our primary outcome was overall survival.We included 287 patients,n=164 who lived out of state(57.1%),and n=129 referred from another institution(44.9%).The most frequent payment source was OOP(n=139,48.4%),followed by private insurance(n=75,26.1%)and universal coverage(n=73,25.4%).No differences in OS,event-free-survival,NRM,or graft-versus-host-relapse-free survival were observed for patients diagnosed locally vs in another institution,nor patients who lived in-state vs out-of-state.Patients who covered transplant costs through private insurance had the best outcomes with improved OS(median not reached)and 2-year cumulative incidence of NRM of 14%than patients who covered costs OOP(Median OS and 2-year NRM of 32%)or through a universal healthcare program active during the study period(OS and 2-year NRM of 19%)(P=0.024 and P=0.002,respectively).In a multivariate analysis,payment source and disease risk index were the only factors associated with overall survival.CONCLUSION In this Latin-American multicenter study,the site of residence or referral for alloHSCT did not impact outcomes.However,access to healthcare coverage for alloHSCT was associated with improved OS and reduced NRM.

Health status and health systems financing in the MENA region:roadmap to universal health coverage

Background:Since the declaration of the Millennium Development Goals(MDGs)in 1990,many countries of the Middle East and North Africa(MENA)region made some improvements in maternal and child health and in tackling communicable diseases.The transition to the global agenda of Sustainable Development Goals brings new opportunities for countries to move forward toward achieving progress for better health,well-being,and universal health coverage.This study provides a profile of health status and health financing approaches in the MENA region and their implications on universal health coverage.Methods:Time-series data on socioeconomics,health expenditures,and health outcomes were extracted from databases and reports of the World Health Organization,the World Bank and the United Nations Development Program and analyzed using Stata 12 statistical software.Countries were grouped according to the World Bank income categories.Descriptive statistics,tables and charts were used to analyze temporal changes and compare the key variables with global averages.Results:Non-communicable diseases(NCDs)and injuries account for more than three quarters of the disabilityadjusted life years in all but two lower middle-income countries(Sudan and Yemen).Prevalence of risk factors(raised blood glucose,raised blood pressure,obesity and smoking)is higher than global averages and counterparts by income group.Total health expenditure(THE)per capita in most of the countries falls short of global averages for countries under similar income category.Furthermore,growth rate of THE per capita has not kept pace with the growth rate of GDP per capita.Out-of-pocket spending(OOPS)in all but the high-income countries in the group exceeds the threshold for catastrophic spending implying that there is a high risk of households getting poorer as a result of paying for health care.Conclusion:The alarmingly high prevalence of NCDs and injuries and associated risk factors,health spending falling short of the GDP and GDP growth rate,and high OOPS pose serious challenges for universal health coverage.Using multi-sector interventions,countries should develop and implement evidence-informed health system financing roadmaps to address these obstacles and move forward toward universal health coverage.

A Comparison between Canadian and Indian Healthcare Focusing on Financing

Healthcare is significant for a person’s comfort as well as the economic benefit of a country. Irrespective of ability, everyone should have access to health care while anyone is sick. This paper aims to compare Canadian and Indian health care highlighting the financing system and people’s benefits. In Canada, universal health care means everyone, including citizens, permanent residents, and visitors, can have health care from the government. Canadian healthcare pays the doctors based on the services they provide the patients. In India, 80% of health financing comes from private sources through out-of-pocket and private insurance. In India, government-paid doctors can do private practice beyond their office hours;any patient can go to any doctor without the general practitioner’s (GP) referral as the GP system does not exist there. The healthcare agents are aggressively eager to make money, forgetting quality service to the patients. On the other hand, in Canada, the insurance system plays a supportive role in making payments and ensuring quality healthcare.

Maternity or catastrophe: A study of household expenditure on maternal health care in India

Using data from 60th round of the National Sample Survey, this study attempts to measure the incidence and intensity of ‘catastrophic’ maternal health care expenditure and examines its socio-economic correlates in urban and rural areas separately. Additionally, it measures the effect of maternal health care expenditure on poverty incidence and examines the factors associated with such impoverishment due to maternal health care payments. We found that maternal health care expenditure in urban households was almost twice that of rural households. A little more than one third households suffered catastrophic payments in both urban and rural areas. Rural women from scheduled tribes (ST) had more catastrophic head counts than ST women from urban areas. On the other hand, the catastrophic head count was greater among illiterate women living in urban areas compared to those living in rural areas. After adjusting for out-of-pocket maternal health care expenditure, the poverty in urban and rural areas increased by almost equal percentage points (20% in urban areas versus 19% in rural areas). Increasing education level, higher consumption expenditure quintile and higher caste of women was associated with increasing odds of impoverishment due to maternal health care expenditure. To reduce maternal health care expenditure induced poverty, the demand-side maternal health care financing programs and policies in future should take into consideration all the costs incurred during prenatal, delivery and postnatal periods and focus not only on those women who suffered catastrophic expenditure and plunged into poverty but also those who forgo maternal health care due to their inability to pay.

Economic costs of hospitalized diarrheal disease in Bangladesh:a societal perspective

Background:Diarrheal diseases are a major threat to human health and still represent a leading cause of morbidity and mortality worldwide.Although the burden of the diarrheal diseases is much lower in developed countries,it is a significant public health problem in low and middle-income countries like Bangladesh.Though diarrhea is preventable and managed with low-cost interventions,it is still the leading cause of morbidity according to the patient who sought care from public hospitals in Bangladesh indicating that significant resources are consumed in treating those patients.The aim of the study is to capture the inpatients and outpatient treatment cost of diarrheal disease and to measure the cost burden and coping mechanisms associated with diarrheal illness.Methods:This study was conducted in six randomly selected district hospitals from six divisions(larger administrative units)in Bangladesh.The study was performed from the societal perspective which means all types of costs were identified,measured and valued no matter who incurred them.Cost analysis was estimated using the guideline proposed by the World Health Organization for estimating the economic burden of diarrheal diseases.The study adopted quantitative techniques to collect the household and hospital level data including structured and semi-structured questionnaires,observation checklists,analysis of hospital database,telephone interviews and compilation of service statistics.Results:The average total societal cost of illness per episode was BDT 5274.02(US$67.18)whereas the average inpatient and outpatient costs were BDT 8675.09(US$110.51)and BDT 1853.96(US$23.62)respectively.The cost burden was significantly highest for poorest households,21.45%of household income,compared to 4.21%of the richest quintile.Conclusions:Diarrheal diseases continue to be an overwhelming problem in Bangladesh.The economic impact of any public health interventions(either preventive or promotive)that can reduce the prevalence of diarrheal diseases can be estimated from the data generated from this study.

Financial burden of seeking diabetes mellitus care in India:Evidence from a Nationally Representative Sample Survey

Background:Diabetes mellitus(DM)is a major public health concern in India,and entails a severe burden in terms of disability,death,and economic cost.This study examined the out-of-pocket health expenditure(OOPE)and financial burden associated with DM care in India.Methods:The study used data from the latest round of the National Sample Survey on health,which covered 555,115 individuals from 113,823 households in India.In the present study,data of 1216 individuals who sought inpatient treatment and 6527 individuals who sought outpatient care for DM were analysed.Results:In India,10.04 per 1000 persons reported having DM during the last 15 days before the survey date,varying from 6.94/1000 in rural areas to 17.45/1000 in urban areas.Nearly 38%of Indian households with diabetic members experienced catastrophic health expenditure(at the 10%threshold)and approximately 10%of DM-affected households were pushed below the poverty line because of OOPE,irrespective of the type of care sought.48.5%of households used distressed sources to finance the inpatient costs of DM.Medicines constituted one of the largest proportion of total health expenditure,regardless of the type of care sought or type of healthcare facility visited.The average monthly OOPE was over 4.5-fold and 2.5-fold higher for households who sought inpatient and outpatient care,respectively,from private health facilities,compared with those treated at public facilities.Notably,the financial burden was more severe for households residing in rural areas,those in lower economic quintiles,those belonging to marginalised social groups,and those using private health facilities.Conclusion:The burden of DM and its associated financial ramifications necessitate policy measures,such as prioritising health promotion and disease prevention strategies,strengthening public healthcare facilities,improved regulation of private healthcare providers,and bringing outpatient services under the purview of health insurance,to manage the diabetes epidemic and mitigate its financial impact.

Effects of the Resident Basic Medical Insurance Reform on Household Consumption in China

This paper investigates the causal relationship between the Urban and Rural Resident Basic Medical Insurance(URRBMI)reform and household consumption in urban China using data from the Chinese Household Income Project survey and employing combination of the propensity score matching and difference-in-differences methods.The results yield three conclusions.First,the reform affected both the amount and share of household consumption.Specifically,the reform led to an increase in total household consumption,encompassing both medical and nonmedical expenditures.Among these,the proportion of medical consumption increased,while the proportion of nonmedical consumption reduced.Second,the impact of the URRBMI reform varied across consumption categories within nonmedical expenditure.Specifically,consumption for education and entertainment industries are positively impacted by the URRBMI reform in terms of both quantity and proportion.Third,low-income households benefit more from the URRBMI reform compared to middle-and high-income households.The main channels through which the URRBMI reform affects household consumption were the price effect and the crowding out effect on precautionary savings.

Tuberculosis care strategies and their economic consequences for patients: the missing link to end tuberculosis

Background:While investment in the development of Tuberculosis(TB)treatment strategies is essential,it cannot be assumed that the strategies are affordable for TB patients living in countries with high economic constraints.This study aimed to determine the economic consequences of directly observed therapy for TB patients.Methods:A cross-sectional cost-of-illness analysis was conducted between September to November 2015 among 576 randomly selected adult TB patients who were on directly observed treatment in 27 public health facilities in Addis Ababa,Ethiopia.Data were collected using interviewer-administered questionnaire adapted from the Tool to Estimate Patients’Costs.Mean and median costs,reduction of productivity,and household expenditure of TB patients were calculated and ways of coping costs captured.Eta(η),Odds ratio and p values were used to measure association between variables.Results:Of the total 576 TB patients enrolled,43%were smear-positive pulmonary TB(PTB),17%smear-negative PTB,37%Extra-PTB and 3%multi-drug resistant TB cases.Direct(Out-of-Pocket)mean and median costs of TB illness to patients were$123.0(SD=58.8)and$125.78(R=338.12),respectively,and indirect(loss income)mean and median costs were$54.26(SD=43.5)and$44.61(R=215.6),respectively.Mean and median total cost of TB illness to patient were$177.3(SD=78.7)and$177.1(R=461.8),respectively.The total cost had significant association with patient’s household income,residence,need for additional food,and primary income(P<0.05).Direct costs were catastrophic for 63%of TB patients,regardless of significant difference between gender(P=0.92)and type of TB cases(P=0.37).TB patients mean productivity and income reduced by 37 and 10%,respectively,compared with pre-treatment level,while mean household expenditure increased by 33%and working hours reduced by 78%due to TB illness.Income quartile categories were directly correlated with catastrophic costs(η=0.684).Conclusion:Despite the availability of free-of-charge anti-TB drugs,TB patients were suffering from out-of-pocket payments with catastrophic consequences,which in turn were hampering the efforts to end TB.TB patients in resource-limited countries deserve integrated patient-centered care with comprehensive health insurance coverage,financial incentives,and nutrition support to reduce catastrophic costs and retain them in care.Such countries should induce home-based directly observed therapy programs to reduce costs due to attending health facilities,intensify home treatment of critically-ill patients with impaired mobility,and reduce the spread of TB due to patients traveling to seek care.

Burden of chronic illness and associated disabilities in Bangladesh:Evidence from the Household Income and Expenditure Survey

Objective: The purpose of this study was to investigate the distribution of chronic illness and associated disability, out-of-pocket payment (OOPP), and other related factors using survey data from Bangladesh. Methods: This study analyzed Bangladesh Household Income and Expenditure Survey data that include socio-economic and demographic data, such as consumption, expenditures, and assets, along with information regarding chronic illness and disability. Multiple linear regression models were used to identify factors significantly associated with OOPP. Furthermore, a binary Logistic regression model was employed to assess the association of the explanatory variables with disability status. Results: A higher prevalence of chronic illness was found for those with chronic gastritis (18.70%), and 41.92%of the population had at least one side disability. The average OOPP healthcare expenditure for chronic illness was estimated to be US$7.59. Higher OOPP was found among the upper 2 wealth quintiles. Overall OOPP health expenditure was significantly higher among individuals with an associated disability (P<0.001). The likelihood of having an associated disability was higher among those individuals with a lower education level (OR=2.36, 95%CI:1.95-4.06), those who not earning an income (OR=2.85, 95%CI:2.53-3.21), those who did not seek care (OR=1.73, 95%CI:1.57-1.90), those who sought care from a pharmacy (OR=8.91, 95%CI:7.38-10.74), and those in the lowest wealth quintile (OR=7.21, 95%CI:6.41-8.12). Conclusions: The high OOPP illustrates the necessity of financial risk protection for the population at low socio-economic status. Therefore, we recommend that the government strengthen the healthcare system with appropriate support directed to the rural and elderly populations.

The Risks and Dynamics of Health Care Expenditures in Urban China： An Illustration in Kunshan City

This paper examines the individual financial risk of health care expenditures over time in urban China, .using longitudinal health expenditure data from 2005 to 2007 in Kunshan City, Jiangsu Province, China. We find that the stochastic process of log total health care expenditures is well represented by the sum of an AR（3） process and white noise process. Simulating this model, we find that the urban health insurance system protects enrollees from the risk of catastrophic health care expenditures by bearing the majority of the health care expenditures. However, out-of-pocket health care expenditures represents a considerable risk to an individual＇s financial status.