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PubMed1997

China's health care sector in transition: resources, demand and reforms.

Economic development and reforms have had profound impacts on China's health care sector. As a result, the health care sector in China is in transition. This report reviews the major changes, and the possible policy response to these changes in China's health care sector. It discusses resource availability in the Chinese health sector, and analyses the trend of household demand for health care goods and services. This study also examines the trade and investment situations in China's health sector and investigates the major forces that are driving the transition in health care and comments on the potential policy responses.

China↗
PubMed1997

Patients' willingness to pay for autologous blood donation.

Most cost-effectiveness analyses of autologous blood donation show very small health benefits for a substantial increase in resource utilization. However, these analyses do not consider the psychological benefits of peace of mind to patients participating in the program. In order to quantitate these benefits, we employed contingent valuation methodology to measure the willingness of patients undergoing elective surgery, to pay for autologous blood donation. The internal consistency of patient responses was investigated through correlations of willingness-to-pay values with risk perceptions and patient characteristics. Two hundred and thirty-five patients completed the self-administered questionnaire which included demographic, willingness-to-pay and risk perception questions. Median population willingness to pay for autologous blood donation was approximately $900 per patient. In multivariate analysis, willingness to pay varied significantly with dread of allogenic transfusion, perceived risk of requiring a blood transfusion and income. Patients who participate in autologous blood donation programs value the procedure highly and state they are willing to pay significant amounts out of pocket to assure themselves of available autologous blood. Willingness to pay correlated significantly with factors expected to influence value decisions.

Attitude to Health↗
PubMed1997

Under-the-counter payments for health care: evidence from Bulgaria.

Against a background of falling revenues and increasing expectations, health care systems in central and eastern Europe are facing increasing budgetary gaps. There is extensive anecdotal evidence that these gaps are being filled by informal or 'under-the-table' payments. These are important because of their implications for estimates of future funding requirements, for equity, and for the possible perverse incentives they introduce for those providing and managing health services. There is, however, relatively little information on either their scale or how they are perceived in these countries. We report the results of a small survey from Bulgaria that begins to address these issues. Data were collected by means of an interviewer-administered household survey in which those who had used state-provided health services in the preceding 2 years were identified. The survey took place throughout Bulgaria in 1994. One thousand people were approached and 706 (70.6%) provided information suitable for analysis; 42.9% had paid for services that were officially free. Payments had been for a wide range of services and to differing groups, including medical, nursing and ancillary staff. Payments to individuals during consultations were between 3% and 14% of average monthly income but the average cost of an operation was 83% of mean monthly income. There were large differences in the amounts paid by individuals. Most people were in favour of both official user fees and health care reform, except among the old, the poor, and those in poor health. Despite certain limitations, this study gives some indication of the scale of informal payments in Bulgaria. Several possibilities exist to address them. Contrary to what is often argued, there seems to be a popular willingness for them to be converted into formal co-payments. Before this can be done, there is a need for more research on the impact that this would have on equity and affordability.

Attitude to Health↗
PubMed1998

Effects of user charges on the use of prescription medicines in different socio-economic groups.

This study examined the sensitivity towards increases in user charges for different types of drugs and among different socio-economic groups. It was based on responses by 2008 consumers of prescription drugs to a self-administered postal questionnaire sent to a random sample of 8000 inhabitants in Uppsala County in Sweden. The questionnaire included a question about whether the respondents would use fewer prescription drugs if the user charges increased by a specific amount. The increase in user charges was varied between 9 and 150% in five different subsamples. Logistic regression analysis was used to estimate the probability that a respondent would reduce consumption of prescription drugs as a function of the size of the user charges increase, socio-economic characteristics and the type of drug used. Results showed that the price sensitivity decreased with increasing age, income, education and self-rated health status. Price sensitivity was highest for antitussives and lowest for climacteric drugs. If the user charges doubled, 40% of antitussives users would reduce their consumption whereas only 11% of climacteric drugs users would reduce their consumption. It is concluded that sensitivity to increases in user charges varied greatly between different types of drugs and between socio-economic groups. The young, those with poor health status, low education and low income are most likely to decrease consumption of prescription drugs when user charges increase.

Attitude to Health↗
PubMed1999

The willingness of families caring for victims of stroke to pay for in-home respite care--results of a pilot study in Taiwan.

This contingent survey was designed to investigate the willingness of family caregivers of stroke victims to pay for in-home respite care. Between September 1996 and December 1996, a designated family member from each family of 174 vascular accident patients hospitalized in the Taipei Metropolitan Area, including two medical centers, received the first interview during preparation and planning for discharge of the patient from the hospital, and follow up interview in their own homes at the end of the second month after the patient was discharged from the hospital. A willingness to pay for in-home respite care was measured as the percentage of monthly family income which would be sacrificed to receive the respite care. Logistic regressions were used to perform multivariate analysis. The willingness to pay for respite care ranged from US$ 363 to 2182, and 42.5% of the family caregivers interviewed indicated a willingness to pay at least 50% of monthly family income for respite care. Family income was strongly associated with the amount of money that family caregivers were willing to pay for respite care. After results were adjusted for the effect of variance in income level, the degree of dependence of patients on the caregiver was significantly associated with the percentage of monthly family income for respite care. The more severe the physical dysfunction of patient, the higher the willingness to pay for in-home respite care utilization. Initially, respite care could be provided to families caring for patients with severe dysfunction, and then the scope enlarged to include caregivers taking care of patients with mild dysfunction.

Caregivers↗
PubMed1999

Constraints on the retreat from a welfare-orientated approach to public health care in Malaysia.

Both in its articulation of values and through incremental changes, the Malaysian government has signalled a change in attitude towards the welfare approach which had hitherto characterized public health care policy. This change envisions an end to reliance upon the state for the provision and financing of health services and the fostering of a system of family-based welfare. In the future citizens should finance their own health care through savings, insurance or as part of their terms of employment. While the state will still accept a degree of responsibility for those unable to pay for their health care, it wishes to share this burden with the corporate sector and non-government organizations as part of a national policy of the 'Caring Society'. In this article the retreat from a commitment to a welfare model of public health care is documented and some of the serious obstacles to such a policy are discussed. It is concluded that the government's aspirations for reforming the welfare model will need to be tempered by both practical and political considerations. Moreover, the socio-economic consequences of the Asian currency crisis of 1997 are likely to increase the need for government welfare action.

Financing, Personal↗
PubMed1997

The economic impact of psoriasis increases with psoriasis severity.

BACKGROUND: Psoriasis treatments are known to be costly, but little is known about the financial impact of psoriasis and the way in which it relates to the severity of the disease. OBJECTIVE: This study was performed to obtain an estimate of the treatment costs faced by patients with psoriasis. METHODS: A total of 578 anonymous mail surveys were distributed to patients with psoriasis; 318 surveys were returned (55%). Psoriasis severity was assessed with the previously validated Self-Administered Psoriasis Area Severity Index (SAPASI). RESULTS: The total and out-of-pocket expenses to care for psoriasis were correlated with psoriasis severity (r = 0.26, p = 0.0001). There were no sex (p = 0.9) or racial (p = 0.4) differences in total expenditures. Severity was correlated with how bothersome to the patient was the cost of treatment (r = 0.30, p = 0.0001), the time required for treatment (r = 0.38, p = 0.0001), and the time lost from work (r = 0.23, p = 0.0001). Lower quality of life at work and in money matters also correlated with severity of psoriasis. Higher family income was associated with less time spent caring for psoriasis and less interference with work around the home. CONCLUSION: As expected, the expenses caring for psoriasis are greater for patients with more severe disease. These costs and other financial implications are associated with lower quality of life for patients with more severe psoriasis.

Absenteeism↗
PubMed1993

Estate planning for veterinarians.

A veterinarian has many tools from which to choose in forming an estate plan. This article defines the tools and explains the major concepts of which veterinarians should be aware in planning for the use and disposal of their assets. Augmented estates, probate and taxable estates, intestacy rules, trusts, and methods of ownership of property are examined as they relate to the practitioner. Included are possible options to consider with a qualified estate planner.

Financing, Personal↗
PubMed1988

Payor mix of trauma patients at a rural-metropolitan regional trauma center: a three-year experience.

The development of a statewide trauma system will depend on designation of community hospitals as trauma centers. The financial impact of such designation will be a prime concern. The payor mix of trauma patients will be one of the deciding factors as to whether hospitals will agree to accept designation. A three-year review of payor class on discharge for 2,605 trauma and 55,041 nontrauma admissions to a nonuniversity teaching hospital is presented. Sixty-four percent of all trauma admissions had third-party payor insurance coverage, compared with 72% of all nontrauma admissions (P less than .00001). Twenty-seven percent of trauma admissions were for penetrating injury. Sixty-eight percent of patients admitted for blunt trauma had third-party coverage, while 50% of those admitted for penetrating trauma had third-party coverage. Total commercial insurance coverage was higher for trauma patients than for nontrauma admissions. The payor class mix for trauma patients presented may be representative of similar institutions in a similar geographic setting and may offer assistance to hospitals considering the financial impact of trauma center designation.

Adolescent↗
PubMed2002

Altruistic willingness to pay in community-based sales of insecticide-treated nets exists in Nigeria.

The objective of this study was to determine whether households who are willing to pay for insecticide-treated nets (ITNs) for themselves are prepared to contribute for the ITNs to be purchased for the indigent community members who cannot afford the nets. This was in the framework of community-based and directed sales for ITNs. The study was conducted in four malaria holoendemic communities in south-eastern Nigeria. Contingent valuation method was used to determine the altruistic willingness to pay (WTP) from randomly selected household heads or their representatives, which was elicited using an open-ended question. Theoretical validity was assessed using the Tobit model. Median altruistic WTP ranged from $0.11 to $0.21 across the four communities (95 Naira = $1). However, using a pooled data from the four communities, the mean was $0.34. In Tobit estimation, altruistic WTP varied significantly with two of the communities; the respondents were resident in, sex, marital status and the amount of savings of the respondent. It also varied significantly with the respondents' WTP for their own ITNs and average monthly household expenditures to treat malaria (p<0.05). Altruistic WTP will exist in community-based and directed sales of ITNs. Thus there can be intra-community subsidisation by the rich for the poor who may not be able to pay for the nets. Community mobilisation and sensitisation should be used to encourage able households to actually pay at least the amounts they have stated.

Adult↗
PubMed2002

The contingent ranking method--a feasible and valid method when eliciting preferences for health care?

The Contingent Ranking Method--a feasible and valid method when eliciting preferences for health care? The objective of the study was to determine the feasibility and validity of the contingent ranking method, when eliciting preferences and measuring willingness to pay for health care. A measurement experiment based on ranking data is reported. Marginal willingness to pay for alleviation of rheumatoid arthritis symptoms that may be the outcome of a treatment with a novel anti-rheumatic agent, cA2 (now called TNF-alpha blockade) was calculated. The estimated marginal willingness to pay value was 650 DKK ($93). With regard to the health status variables and income variable the signs of the coefficients were, as expected, positive. The contingent ranking method is a feasible and valid method for eliciting preferences and determining willingness to pay estimates.

Aged↗
PubMed2002

Understanding household demand for indoor air pollution control in developing countries.

More than 2 billion people rely on solid fuels and traditional stoves or open fires for cooking, lighting, and/or heating. Exposure to emissions caused by burning these fuels is believed to be responsible for a significant share of the global burden of disease. To achieve widespread health improvements, interventions that reduce exposures to indoor air pollution will need to be adopted and consistently used by large numbers of households in the developing world. Given that such interventions remain to be adopted by large numbers of these households, much remains to be learned about household demand for interventions designed (in part at least) to reduce indoor air pollution. A general household framework is developed that identifies in detail the determinants of household demand for indoor air pollution interventions, where demand for an intervention is expressed in terms of willingness to pay. Household demand is shown to be a combination of three terms: (1) the direct consumption effect; (2) the child health effect; and (3) the adult health effect. While micro-level data are not available to estimate directly this model, existing data and information are used to estimate just the health effects component of household demand. Based on such existing information, it might be concluded that household demand should seemingly be strong given that willingness to pay, based on existing information, is seemingly large compared to costs for common interventions like improved stoves. Given that household demand is not strong for existing interventions, this analysis shows that more clearly focused research on household demand for interventions is needed if such interventions are going to be demanded (i.e. adopted and used) by large numbers of households throughout the developing world. Four priority areas for future research are: (1) improving information on dose-response relationships between indoor air pollution and various health effects (e.g. increased mortality and morbidity risks); (2) improving information on impacts from interventions in terms of air pollution reductions and also cooking times, fuel use, and heat intensities; (3) improving information on household shadow values for improved health, with separate information for adult and child health; and (4) considering more directly household information, and its adequacy, for their ability to evaluate the relationships between fuel use and health.

Adult↗
PubMed2002

An analysis of private health insurance purchasing decisions with national health insurance in Taiwan.

The Taiwanese health insurance industry is just over 30 years old. Originally private and domestic, the industry underwent substantial institutional changes when it opened to foreign competition between 1987 and 1994 and when the Taiwanese government established national health insurance (NHI) coverage in 1995. Congruent with these changes, rapid growth occurred in the Taiwanese demand for private health insurance. In order to better understand the recent performance of the Taiwanese health insurance industry, the structure of the NHI system is described and then household decisions to purchase private health insurance are analyzed using a two-part (hurdle) model on 1998 Survey of Family Income and Expenditure data. Logistic and OLS regressions are used to examine the factors influencing the probability and amount of private health insurance purchased. Generally, factors affecting the probability of having insurance also influence the amount of insurance coverage purchased. Higher income and education levels are associated with increased probabilities and larger quantities of private insurance purchases. Married females, the employed, and household heads working in state-run enterprises are more likely to purchase private insurance than their counterparts. The probability of private insurance purchases varies by region, with northern Taiwanese households having higher odds of owning private insurance than non-northern households. Compared to those in rural villages, households in cities and towns are more likely to have private insurance. The likelihood of private insurance purchase also tends to rise with advancing age and larger family sizes. In addition, one important implication in the private health insurance market is highlighted. There is no complementarity between the public and private systems.

Adult↗
PubMed2002

Dutch GPs' perceptions: the influence of out-of-pocket costs on prescribing.

The aim of this study was to explore the impact of out-of-pocket costs on Dutch general practitioners' prescribing. A qualitative study using focus groups was conducted. An open-ended topic guide was used to elucidate the influence of out-of-pocket costs on decision making for the treatment of dyspepsia, hay fever, hormone replacement therapy, and hypertension. A total of 21 Dutch GPs from University Departments of General Practice participated in four separate focus groups. These discussions were held between November 1998 and March 1999. Each discussion was tape-recorded and transcribed verbatim. From this transcription, key factors and issues were identified. GPs reported that they do not generally take out-of-pocket costs into account. Fully reimbursed drugs were usually prescribed and GPs felt that most patients were highly motivated and thus willing to pay for their medication. The patient charges were seen to be low and not likely to affect patients' willingness to pay. GPs felt that patients need not have to pay for their medication. They adjusted their drug choice in order to avoid co-payment and were willing to agree to a patient's demand for a reimbursed prescription. GPs describe their prescribing as not influenced by out-of-pocket costs. GPs seem inclined to avoid co-payment for patients when patients have financial difficulties and the disease is perceived as severe. They chose fully reimbursed drugs.

Attitude of Health Personnel↗
PubMed2002

Investigating starting-point bias: a survey of willingness to pay for insecticide-treated nets.

The objective of this study was to investigate the existence of starting-point bias in the bidding game contingent valuation elicitation technique when determining the willingness to pay (WTP) for insecticide-treated nets (ITNs) and ITNs re-treatment in rural Nigeria. Of all existing contingent techniques, the bidding game most closely mimics the normal price taking behaviour in local markets in Nigeria. Three different starting-points (low, medium and high) were used to determine WTP for large and small ITNs, and for ITNs re-treatment, respectively. The respondents were randomly assigned to any of the starting-points and a pre-tested interviewer-administered questionnaire used to elicit WTP. Non-parametric tests and the Tobit model were used to analyse the data for evidence of starting-point bias. Plots of respondents' cumulative density functions by starting-points were also examined to show the pattern of responses. The non-parametric tests showed no statistically significant differences between the three starting points in WTP for large ITNs (p = 0.262) and for ITNs re-treatment (p = 0.412). However, there was a statistical significant difference in WTP for small ITNs (p = 0.045). Nevertheless, in this instance, the high starting point group had a lower mean WTP than the low group, and also had the lowest median WTP amongst the three groups. However, using the conditional WTP (only males), there were no differences among the three starting-points for all goods. The multiple regression analyses using the Tobit model confirmed the results of the non-parametric tests. The plots of cumulative densities were also similar for the three starting-points for the three products. However, the high starting-point group had those more willing to pay higher amounts for large and small nets. There was no conclusive evidence of starting-point bias. Future research is required in order to gain a deeper understanding on factors determining peoples' valuation of goods and services, reasons for any type of starting-point bias, and how the bidding game can be improved.

Adult↗
PubMed2003

The impact of public voluntary health insurance on private health expenditures in Vietnam.

As a financing mechanism with the potential to raise additional funds for health services, whilst improving access to services amongst the poor, non-profit health insurance has become increasingly attractive to health policy-makers. Using data from a household survey in Vietnam, out of pocket health expenditure are compared between members and eligible non-members of the government-implemented voluntary health insurance scheme. Expenditures are analysed for individuals who sought care during their most recent illness. Using an endogenous dummy variable model to control for bias resulting from self-selection into the scheme, we find that health insurance reduces average out-of-pocket expenditures by approximately 200%. Whilst income inelastic, health expenditures are found to be significantly influenced by an individuals level of income, irrespective of insurance status. Despite this, insurance reduces expenditures significantly more for the poor than for the rich.

Cost Sharing↗
PubMed2003

A comparison of the reliability of the take-it-or-leave-it and the bidding game approaches to estimating willingness-to-pay in a rural population in West Africa.

The test-retest reliability of the bidding game and the take-it-or-leave-it (TIOLI) approaches to eliciting willingness-to-pay (WTP) are compared. A random sample of households in the Nouna area of Burkina Faso were interviewed twice with an interval of around 4-5 weeks. One thousand one hundred and eight individuals were asked their individual WTP for community-based health insurance. Three hundred and forty eight of these individuals were household heads who were in addition asked about their WTP for health insurance for the whole household. Median and the mean WTP were higher in the test than in the retest. Despite these differences both methods displayed moderate to good reliability (kappa values ranged from 0.467 to 0.621, Spearman correlations ranged from 0.653 to 0.701 and Pearson correlations ranged from 0.593 to 0.675). There was some evidence that the bidding game was more reliable than the TIOLI method. This study is based on larger sample size than previous studies and also is one of the first studies of the reliability of WTP in a developing country.

Adult↗