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PubMed1991

The financing of long term care in Ireland.

Major changes are proposed for the financing and regulation of the nursing home sector in Ireland. For the first time the payment of public subvention is to be related explicitly to the means and dependency of old people. More detailed proposals have, however, yet to be worked out. This paper reviews the proposed developments and makes concrete recommendations with respect to the means testing of income and assets. The issue of consumer sovereignty is also considered. Finally, the necessity for a co-ordinated and integrated policy with respect to the financing, regulation and organisation of public and private care is stressed, particularly as a means of improving the quality of service provision.

Activities of Daily Living↗
PubMed1991

Policy and implementation of user fees in Jamaican public hospitals.

User fees and other forms of copayment for health care are becoming of increasing interest to policymakers in developing countries. As indigenous populations continue to expand in response to current and historically high fertility, and government resources become constrained due to macroeconomic circumstances, publicly provided health care is being squeezed financially. Most developing countries have committed their governments to either providing for all health care or at least ensuring that all citizens have access to health care regardless of ability to pay. This has translated in most contexts into blanket coverage for the entire population financed and generally provided by the government. Recent periods of slow growth, high debt burdens and restricted spending on high recurrent cost sectors, such as health care under International Monetary Fund and other donor agreements have reduced many developing countries' budgets and often the real value of health expenditures. The costs of inputs (personnel, drugs and consumables), however, have not declined and quality or quantity have been necessarily reduced. At the same time, options for financial relief outside the tax system have become of increasing interest to financially constrained governments. User charges are straightforward, easily understood and can in theory be profitable in the short term. From a fairness perspective, they also charge those who actually use the health system. Their major drawback for policymakers is the potential for undermining equity in the health system.

Budgets↗
PubMed1996

Costs, effects and cost-effectiveness analysis of a mobile maternal health care service in West Kiang, The Gambia.

The costs, effects and cost-effectiveness of a new mobile maternal care service offered in The Gambia at a government-run health centre in Karantaba were compared with the usual pattern of maternal care offered (at Ngayen Sanjal). Routinely collected data were supplemented by research on time allocation of staff by activity, use of drugs, medical consumables and vehicles, out-of-pocket payments by patients and a range of effectiveness indicators. To account for a differential effect on hospital referrals, maternity care at the main referral hospital was assessed. In 1991, the annual total cost of maternity care at Karantaba was US$64 800 compared with US$25 300 at Ngayen Sanjal. The largest proportion of this difference was attributed to training. Whilst average cost/attendance was higher at Karantaba, the marginal cost of expanding the service to other villages was lower than the marginal cost at Ngayen Sanjal. Incremental cost-effectiveness of the mobile service at Karantaba was calculated according to best and worst case scenarios which showed that the extra cost/extra death averted per year ranged between US$459 and US$2134. Using discounted life years gained reduced the figures to US$42.9 and US$206.3. Various suggestions are offered for reducing the cost of the new service, and a number of methodological points are raised for discussion.

Catchment Area, Health↗
PubMed1996

The willingness to pay for health changes, the human-capital approach and the external costs.

In this paper, the relationship between willingness to pay for health changes, the human-capital approach, and the costs that should be included in a cost-benefit analysis of a health care programme are analysed. The costs that should be included are defined as the change in consumption minus the change in production of the individual that receives a health care programme. The size of these external costs differs depending on the institutional arrangements in society. It is shown that the net production version of the human-capital approach is an estimation of the external costs. The human-capital approach can thus be given a theoretical foundation in cost-benefit analysis if it is used to estimate the external costs.

Attitude to Health↗
PubMed1996

Health care and income distribution in Finland.

This paper examines the effects of health care on income redistribution in Finland. In contrast to earlier studies in this area, the redistributive effect is analysed with noncash transfers from health care utilisation included in household income. Distributional consequences of changing health care financing towards one system or another are analysed in terms of municipality provided public services and sickness insurance based public services. Our results show that, overall, the public health care system distributed income from the rich to the poor. The poorest one-third of the population financed only about one-third of the public health care services they utilised. The distributional implications were, however, markedly different depending on the definition of income used. Whereas health care financing had only a marginal redistributive effect, the effect was substantially increased as noncash transfers from health care utilisation were taken into account.

Data Collection↗
PubMed1996

Is community financing necessary and feasible for rural China?

The collapse of the Cooperative Medical System (CMS) in China after the agricultural reforms of the early 1980s caused serious concern and doubt about the viability of community financing of basic health care for the low-income population. This paper examines the rise and fall of China's community financing schemes and ascertains the need for and feasibility of community financing. Of the Chinese rural population, 90% now pay out-of-pocket for their health services. Both the problems with the fee-for-service system on the one hand and the observed advantages of the existing community financing schemes on the other indicate the necessity and desirability of revitalizing community financing as a major rural health care reform strategy. However, the feasibility of the community financing approach depends on adequate financial and social resources. Our study found that there are multiple potential funding sources for health care in rural areas, including households, village welfare funds, local enterprises, and the government. We designed several illustrative benefit packages and estimated their costs. It appears that a basic benefit package with high co-insurance would be affordable if funds could be mobilized from multiple sources. More importantly, community financing would require governmental promotion and support.

China↗
PubMed1990

Health care expenditure patterns for adolescents.

Health care expenditure patterns are described using a sample of 2,767 adolescents aged 10 to 18 years from the National Medical Care Utilization and Expenditure Survey. Average total per capita health care expenditures were $525. Average out-of-pocket expenses were $151 in 1988 dollars. The burden of out-of-pocket expenses was distributed unevenly among the families of adolescents. The 10% of adolescents with the highest expenses accounted for 65% of all out-of-pocket expenses. The presence of health insurance coverage greatly reduced the risk of incurring burdensome out-of-pocket expenses. Health policy interventions to improve health insurance coverage of adolescents are discussed.

Adolescent↗
PubMed1982

The role of support in relation to recovery from breast surgery.

The relationship between support and short-term recovery from breast surgery was examined retrospectively in 151 female breast cancer patients who were 3-12 months postoperative. Subjects were interviewed regarding the extent to which 3 forms of support (social, professional, financial) were available. Two indices, representing physical recovery and psychological adjustment, were generated. Patient characteristics (age, education, prior health status, and life stress following surgery) and clinical indicators of disease severity (stage, type of mastectomy, adjunct therapy, and time elapsed since surgery) were controlled. Social and professional support were significantly positively related to psychological adjustment. Financial support was significantly positively related to physical recovery. Implications of these findings for future research are discussed.

Adult↗
PubMed1983

Allocation of family resources for health care in rural Haiti.

A household survey of 230 episodes of infant and child illness in rural Haiti was analyzed to identify sociocultural and environmental factors that determine allocation of family resources for health care. The analysis tested the hypothesis that expenditures of time and money would vary according to expectations about the prognosis for the disease in question, the age and sex of the child, the household composition and family structure, and seasonal fluctuations in weather and financial resources. The results show that these factors are significant predictors of resource allocation, although they do not always produce the kind of influence that was hypothesized. The findings emphasize the importance of cultural and ecological variables, as well as of purely medical and economic factors, in understanding family response to illness. The importance of nonmonetary resources (such as the free time available to adult family members) in that response is also indicated. The study has methodological and practical implications for Haiti and other areas.

Adolescent↗
PubMed1984

Economic evaluation in primary health care: the case of Western Kenya community based health care project.

This paper describes the methodology and presents preliminary results of an economic appraisal of a community based health care project in Kenya. Community health workers, trained for 12 weeks and deployed in two locations in Kenya's Western Province, act as first contact providers of basic health care and promoters of selected health, sanitation and nutrition practices. A Cost Benefit Analysis has been undertaken using the Willingness to Pay approach to compare the costs of the project and its benefits. The benefits are in the form of more easily accessible basic health care and are measured as consumer surplus accruing to the community. Gain in consumer surplus is consequent on the fall of average user costs and rise in utilisation of the project established points of first contact with primary health care. The argument for the economic viability of the project is validated by the large Net Present Value and Benefit Cost Ratio obtained for the whole of the project area and for the two locations separately. Although the evaluation technique used faces the problem of valuation of community time, aggregation of health care services at all points of first contact and the partial nature of cost benefit analysis evaluations, the results are strongly in favour of decentralisation of primary health care on similar lines in the rest of the country.

Community Health Services↗
PubMed1986

Health care financing in Kenya: a simulation of welfare effects of user fees.

This paper examines the efficiency and equity effects of introducing user fees in public health facilities in Kenya. These effects are studied with the aid of a simulation technique. It is found that through their favourable effects on quality of medical services, the user fees in public clinics would yield welfare gains. However, these gains might involve unacceptable equity trade-offs. Thus, in general, the net welfare effects of user charges on medical services is ambiguous. More specifically, if the user fees were imposed across the board in government health facilities, the equity trade-offs would be large, and for that reason, the user fees would be socially and politically unacceptable. But, if the user charges are restricted to government hospitals, the attendant equity problem would not be too difficult to manage.

Developing Countries↗
PubMed1987

Prolonged unemployment and depression in older workers: a longitudinal study of intervening variables.

In this study, unemployed blue-collar workers over the age of 45 (N = 51) filled out a questionnaire in 1975 and in 1977. It was shown that prolonged unemployment or re-unemployment leads to depression, reduced hope, and financial problems, although none of these factors leads to prolonged unemployment. Being employed or retired leads to a reduction of depression and financial problems. Problems associated with the daily hassles of unemployment, such as financial problems and disappointed hope play a role in the development of depression with prolonged unemployment. Potential third variables that could cause both unemployment and depression--such as internal/external control, passivity, sickness, and age--do not affect the effect of unemployment on depression.

Depression↗
PubMed1987

Alleviating depression in the unemployed: adequate financial support, hope and early retirement.

Results of a longitudinal study on older blue-collar workers in the Federal Republic of Germany (Soc. Sci. Med. 25, 173-178, 1987) showed that people who retired out of unemployment improve in depression similar to those people who found a job. Furthermore, financial problems and disappointed hope were important in the development of depression in the unemployed. These results are relevant for measures to alleviate depression in the unemployed in three areas: early retirement and an increase of financial unemployment compensation are recommended. Furthermore, all those programs (like counseling or therapeutic programs) that increase hope to find a job without increasing the chances to find a job have to be viewed with skepticism because they might actually turn out to be dysfunctional.

Depression↗
PubMed1992

Is paying for health care culturally acceptable in Sub-Sahara Africa? Money and tradition.

In 1987 UNICEF launched the so-called Bamako Initiative, which has as its main objective to improve the sustainability of primary health care in Africa by making people pay for it. The question is raised whether paying for health care is culturally acceptable in African communities. The author argues that 'money' is not a new phenomenon in Africa and that paying for goods and services does not need to conflict with existing traditions of reciprocity in the field of health care. Money is an artifact which is culturally incorporated in a creative manner to satisfy specific needs. Cultural objections to paying for health care, therefore, are unlikely to exist, but how payment should be realised in an effective and just way is another question.

Africa↗
PubMed1995

Health care reforms in Russia: the example of St Petersburg.

This paper describes the changes being introduced into the Russian health care system, particularly the introduction of a compulsory social health insurance system which is paralleled by encouragement of independent health insurance. An example of the implementation of these changes is provided by the early developments in St Petersburg. The effects of the likely changes on health care providers and users are discussed. It is argued that in the light of these reforms, as well as change in other countries, a revision is necessary in the perspectives adopted by geographers of health care to compare national health systems.

Ambulatory Care Facilities↗
PubMed1996

Seasonal variations of household costs of illness in Burkina Faso.

This paper assesses the seasonal variations of the time and financial costs of illness for rural households in Burkina Faso. It is based on a multiple round survey of 566 households, which included a time allocation study. The economic parameters of households which influence health seeking behavior changed substantially between the dry and rainy seasons: revenues fell in the rainy season and were exceeded by expenditures. Household production was at its peak in the rainy season resulting in significantly higher opportunity costs of time. At the same time illness perception changed: in the rainy season, significantly fewer illness episodes were perceived, and of those, the proportion perceived as severe decreased over-proportionally. Households shifted their healer choice in the rainy season away from high cost treatment, such as the hospital and dispensary, to low cost home treatment. For all these reasons, households incurred significantly fewer costs of illness in the rainy season (27% of dry season costs). Household health care expenditures were reduced to 1/6 of dry season levels, the time costs incurred by healthy household members to tend to the sick was reduced to 1/5 and the time costs of work incapacity due to sickness fell to about 1/2 of dry season levels. The authors stress the need to carry out research in all relevant seasons when studying health seeking behavior and the household costs of illness in order to avoid serious seasonal bias. They suggest policy options to increase health care utilization in the rainy season by reducing the financial and time costs of access to health care. Finally, the authors put forward a hypothesis to be tested by future research: They argue that the cognitive (changes in illness perception) and behavioral changes (different health care seeking) reflect the high opportunity costs of time and the low availability of cash households face during the rainy season. The paper discusses the negative implication that untreated illness has on the health status of household members.

Adolescent↗
PubMed1996

Household strategies to cope with the economic costs of illness.

The authors examine the strategies rural households in Burkina Faso used to cope with the costs of illness in order to avert negative effects for household production and assets. They use information from 51 qualitative interviews, a household time allocation study and a household survey. Both surveys use the same sample of n = 566 households. The authors analyze these strategies along four dimensions: the type of behavior, the sequence in which strategies employed, the level at which strategies are negotiated, i.e. the household level, the non-household extended kin level or the community level, and finally the success of strategies in protecting household production and assets. A taxonomy of 11 distinct types of coping behavior is developed which have the effect of either avoiding costs by 'ignoring' disease, or of minimizing the impact of costs on the household once illness is perceived. Intra-household labor substitution was the main strategy to compensate for any labor lost to illness. However, labor substitution did not eliminate production losses in the majority of households struck with severe illness of a productive member. Only wealthy household were able to fully compensate labor losses by hiring labor or by investing in equipment to enhance productivity. Sales of livestock was the main strategy to cope with the financial costs of health care. None of the households studied fell into calamity. However, the households' ability to avert the loss of production and/or assets was very varied and depended on household size, composition and assets, on the type and duration of illness and on clustering of crises (e.g. several repetitive or simultaneous illnesses or concurrent seasonal stress). Coping with the costs of illness largely occurred at the level of the household. Inter-household transfers of resources played only a small role. The authors develop the concept of risk households and suggest several policies with the potential to strengthen the ability of households to cope with the economic costs of illness.

Adolescent↗