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PubMed2006

Medicaid and family wealth transfer.

PURPOSE: This study examines whether the relationship between making familial wealth transfers and becoming a Medicaid recipient sheds light on the current debate about Medicaid estate planning, whereby some elders transfer their assets to their families to qualify for Medicaid. DESIGN AND METHODS: Using the Health and Retirement Study, we tracked a national sample of community-based elders who did not receive Medicaid at the 1993 baseline interview but became Medicaid recipients during a 10-year time period and examined wealth transfers for these new Medicaid beneficiaries. RESULTS: Among elders aged 70 or older who did not receive Medicaid in 1993, 16.4% became Medicaid recipients over 10 years. Among these new Medicaid recipients, 17.9% transferred their wealth to family members before receiving Medicaid benefits, with an average transfer amount of $8,507 during the 2 years prior to receiving Medicaid benefits. In addition, 15.2% of community-residing elders entered a nursing home during the 10-year period, and 26.3% of these were covered by Medicaid. Of these new Medicaid recipients living in nursing homes, 12.6% transferred wealth to their families in the mean amount of $4,112. IMPLICATIONS: Familial wealth transfers do occur before changes in Medicaid eligibility in a small, but nontrivial, number of cases, but the amount transferred is modest, especially among nursing home residents. This finding implies that policies to reduce Medicaid long-term-care expenditures by limiting such transfers may not be very effective.

Aged↗
PubMed1995

Introducing health insurance in Vietnam.

Like many other countries Vietnam is trying to reform its health care system through the introduction of social insurance. The small size of the formal sector means that the scope for compulsory payroll insurance is limited and provinces are beginning to experiment with ways of encouraging people to buy voluntary insurance. Methods of contracting between hospitals and insurance centres are being devised. These vary in complexity and there is a danger that those based on fee for service will encourage excessive treatment for those insured. It is important that the national and provincial government continue to maintain firm control over funding while also ensuring that a substantial and targeted general budget subsidy is provided for those unable to make contributions.

Developing Countries↗
PubMed1996

Ability to pay for health care: concepts and evidence.

In many developing countries people are expected to contribute to the cost of health care from their own pockets. As a result, people's ability to pay (ATP) for health care, or the affordability of health care, has become a critical policy issue in developing countries, and a particularly urgent issue where households face combined user fee burdens from various essential service sectors such as health, education and water. Research and policy debates have focused on willingness to pay (WTP) for essential services, and have tended to assume that WTP is synonymous with ATP. This paper questions this assumption, and suggests that WTP may not reflect ATP. Households may persist in paying for care, but to mobilize resources they may sacrifice other basic needs such as food and education, with serious consequences for the household or individuals within it. The opportunity costs of payment make the payment 'unaffordable' because other basic needs are sacrificed. An approach to ATP founded on basic needs and the opportunity costs of payment strategies (including non-utilization) is therefore proposed. From the few studies available, common household responses to payment difficulties are identified, ranging from borrowing to more serious 'distress sales' of productive assets (e.g. land), delays to treatment and, ultimately, abandonment of treatment. Although these strategies may have a devastating impact on livelihoods and health, few studies have investigated them in any detail. In-depth longitudinal household studies are proposed to develop understanding of ATP and to inform policy initiative which might contribute to more affordable health care.

Africa↗
PubMed1996

Willingness to pay for district hospital services in rural Tanzania.

This paper describes a study undertaken to investigate the willingness of patients and households to pay for rural district hospital services in north-western Tanzania. The surveys undertaken included interviews with 500 outpatients and 293 inpatients at three district level hospitals, interviews with 1500 households and discussions with 22 focus groups within the catchment areas of the primary health care programmes of these hospitals. Information was collected on willingness to pay fees for certain hospital services, willingness to become a member of a local insurance system, and exemptions for cost-sharing. The willingness to pay for district hospital services was large. Furthermore, most respondents favoured a local insurance system above user fee systems, a finding which applied at all places and in all the surveys. More female respondents were in favour of a local insurance scheme. The conditions needed for the introduction of a local insurance system are discussed.

Attitude to Health↗
PubMed1997

Sustaining malaria prevention in Benin: local production of bednets.

Through a Benin-Canada participatory research initiative which included both Benin and Canadian non-governmental organizations, a local capacity to produce and market bednets for the prevention of malaria was developed. The development process began following a community-based assessment of local needs and skills. All materials for the manufacture and distribution of the bednets were obtained locally with the exception of the netting which was imported from Canada. The sustainability of the enterprise is enhanced by the community's recognition of the importance of malaria and the culturally acceptable practice of bednet use.

Benin↗
PubMed1997

Primary health care in Turkey: a passing fashion?

The Alma-Ata Declaration has long been regarded as a watershed in the health policy arena. The global goal of the World Health Organization, 'Health for All by the Year 2000' through primary health care, has attracted many countries both in the developed and the developing world and commitments to this end have been made at every level. However, albeit this consensus on the paper, a common and explicit definition of the concept has not been reached yet. This paper aims at discussing various definitions of primary health care that emerged after the Declaration and also presenting a case study from Turkey, a country that advocates primary health care in her recent health policy reform attempts. After setting the conceptual framework for discussion the Turkish case is presented by using research carried out among Turkish policy-makers at different levels of the State apparatus. It has been concluded that application of primary health care principles as defined in the broad definition of the concept requires major changes or rather shake-ups in Turkey. These areas are outlined briefly at the end of the paper.

Comprehensive Health Care↗
PubMed1998

Informal payments for health care in the Former Soviet Union: some evidence from Kazakstan.

An important feature of the health care system of the Former Soviet Union (FSU) and Central and Eastern Europe is the presence of informal or under-the-table payments. It is generally accepted that these represent a significant contribution to the income of medical staff. Discussions with medical practitioners suggest that for certain specialities in certain hospitals a doctor might obtain many times his official income. Yet little empirical work has been done in this area. Informal payments can be divided into those paid to health care providers and those that go directly to practitioners. They can be further divided into monetary and non-monetary. The complexity of these payments make obtaining estimates using quantitative survey techniques difficult. Estimates on contributions to the costs of medicines in Kazakstan suggest that they may add 30% to national health care expenditure. Payments to staff are likely to add substantially to this figure, although few reliable statistics exist. Research in this area is important since informal payment is likely to impact on equity in access to medical care and the efficiency of provision. The impact of attempts to reform systems using Western ideas could be reduced unless account is taken of the effect and size of the informal payment system.

Financing, Personal↗
PubMed1998

User fees, self-selection and the poor in Bangladesh.

The widespread uncontrolled introduction of user fees in any developing country is likely to have a disastrous impact on poorer patients. Furthermore, traditional targeting schemes aimed at their exemption are often expensive, difficult to administer and ineffective at reaching those in greatest need. This research study examines how user fees can raise revenue and target poorer patients, under the right market conditions, without resorting to costly targeting schemes. The authors draw their findings from case studies of cost recovery in the health and population sectors in Bangladesh. The mechanism suggested in the paper is to use self-selection. It is argued that under certain market conditions poorer patients will choose the health-care option that is appropriate to their means. They will thus identify themselves as poor without having to be selected or tested by an independent authority. This self-selection allows the relevant authorities to cross-subsidize their market choice by over-charging the non-poor in other segments of the market.

Bangladesh↗
PubMed1998

Household health expenditures in Nepal: implications for health care financing reform.

His Majesty's Government of Nepal has embarked on an ambitious social welfare programme of increasing the accessibility of primary education and health care services in rural communities. The implications on the financing of health care services are substantial, as the number of health posts has increased twelve-fold from 1992 to 1996, from 200 to 2597. To strengthen health care financing, government policy-makers are considering a number of financing strategies that are likely to have a substantial impact on household health care expenditures. However, more needs to be known about the role of households in the current structure of the health economy before the government designs and implements policies that affect household welfare. This paper uses the Nepal Living Standards Survey, a rich, nationally-representative sample of households from 1996, to investigate level and distribution of household out-of-pocket health expenditures. Utilization and expenditures for different types of providers are presented by urban/rural status and by socioeconomic status. In addition, the sources of health sector funds are analyzed by contrasting household out-of-pocket expenditures with expenditures by the government and donors. The results indicate that households spend about 5.5% of total household expenditures on health care and that households account for 74% of the total level of funds used to finance the health economy. In addition, rural households are found to spend more on health care than urban households, after controlling for income status. Distributing health care expenditures by type of care utilized indicates that the wealthy, as well as the poor, rely heavily on services provided by the public sector. The results of this analysis are used to discuss the feasibility of implementing alternative health care financing policies.

Developing Countries↗
PubMed1998

The hidden cost of 'free' maternity care in Dhaka, Bangladesh.

We studied the cost and affordability of 'free' maternity services at government facilities in Dhaka, Bangladesh, to assess whether economic factors may contribute to low utilization. We conducted a questionnaire survey and in-depth interviews among 220 post-partum mothers and their husbands, selected from four government maternity facilities (three referral hospitals and one Mother and Child Health hospital) in Dhaka. Mothers with serious complications were excluded. Information was collected on the costs of maternity care, household income, the sources of finance used to cover the costs, and the family's willingness to pay for maternity services. The mean cost for normal delivery was 1275 taka (US$31.9) and for caesarean section 4703 taka (US$117.5). Average monthly household income was 4933 taka (US$123). Twenty-one per cent of families were spending 51-100% of monthly income, and 27% of families 2-8 times their monthly income for maternity care. Overall, 51% of the families (and 74% of those having a caesarean delivery) did not have enough money to pay; of these, 79% had to borrow from a money lender or relative. Surprisingly, 72% of the families said they were willing to pay a government-levied user charge, though this was less popular among low-income families (61%). 'Free' maternity care in Bangladesh involves considerable hidden costs which may be a major contributor to low utilization of maternity services, especially among low-income groups. To increase utilization of safer motherhood services, policy-makers might consider introducing fixed user charges with clear exemption guidelines, or greater subsidies for existing services, especially caesarean section.

Adolescent↗
PubMed1999

Unofficial fees in Bangladesh: price, equity and institutional issues.

The widespread collection of unofficial fees at health facilities is a common form of rent-seeking behaviour in Bangladesh. Typically, unofficial fees come in the form of cash payments for the performance of required services, for direct purchase of drugs and medical-surgical requisites, and for service access. Using observational and interview methods, this study explores linkages between official and unofficial fees at three Bangladesh health facility levels; primary care Thana Health Complexes, secondary or district hospitals, and medical college hospitals. The study estimates payment levels for different income classes and different payor types at these facilities, thereby highlighting potential equity, price and institutional questions associated with unofficial fees. Not only does the practice have clear income and equity effects, there also appear to be direct effects upon patient satisfaction, perception of quality, and the ability to pay for health services. The article concludes with a discussion of 'rent capture' processes at Bangladesh facilities and the effect of unofficial fees in six areas of health sector reform: displaced official policies, reduced merit goods production, upward income redistribution, distorted human resource development, growth of facility inefficiency, and obstruction of market reforms.

Bangladesh↗
PubMed2001

Is equity being sacrificed? Willingness and ability to pay for schistosomiasis control in China.

Decentralization of the health care system in China has led to an increasing need for income generation at all operational levels, both for curative services and for public health programmes. In general, people have accepted the costs of curative services, although the impact of charges on health-seeking behaviour has yet to be assessed. Public health programmes present particular problems in terms of revenue generation, however, because of the less direct impact of these activities on individual health and well-being. In this paper, we report the results of a cross-sectional study of willingness and ability to pay for schistosomiasis control. Questionnaires were administered to household heads of six representative villages in the Dongting Lake Region of Hunan Province, China. A total of 628 valid questionnaires were analyzed. The yearly mean household expenditure on schistosomiasis diagnosis and treatment was RMB 59.50 +/- 146.04 Yuan (US$1 = 8 RMB Yuan), accounting for 0.94% of the total yearly household income. Most household heads (514, 82%) thought schistosomiasis was the greatest health threat in their communities, but only 30.9% of them were willing to pay for screening, diagnosis and treatment of the infection. On the other hand, 72.3% of the respondents were willing to undertake volunteer work for control.

Adult↗
PubMed2001

Determining the full costs of medical education in Thai Binh, Vietnam: a generalizable model.

We summarize a model for determining the full cost of educating a medical student at Thai Binh Medical School in Vietnam. This is the first full-cost analysis of medical education in a low-income country in over 20 years. We emphasize policy implications and the importance of looking at the educational costs and service roles of the major health professions. In Vietnam fully subsidized medical education has given way to a system combining student-paid tuition and fees with decreased government subsidies. Full cost information facilitates resource management, setting tuition charges at a school and adjusting budget allocations between medical schools, teaching hospitals, and health centres. When linked to quality indicators, trends within and useful comparisons between schools are possible. Cost comparisons between different types of providers can assist policy-makers in judging the appropriateness of expenditures per graduate for nursing and allied health education versus physician education. If privatization of medical education is considered, cost analysis allows policy-makers to know the full costs of educating physicians including the subsidies required in clinical settings. Our approach is intuitively simple and provides useful, understandable new information to managers and policy-makers. The full cost per medical graduate in 1997 was 111 462 989 Vietnamese Dong (US$9527). The relative expenditure per Vietnamese physician educated was 2.8 times the expenditure in the United States when adjusted for GNP per capita. Preliminary findings suggest that, within Vietnam, the cost to educate a physician is 14 times the cost of educating a nurse. Given the direct costs of physician education, the lifetime earnings of physicians and the costs that physicians generate for the use of health services and supplies, it is remarkable that so little attention is paid to the costs of educating physicians. Studies of this type can provide the quantitative basis for vital human resource and health services policy considerations.

Budgets↗
PubMed2001

The effects of different kinds of user fee on prescribing costs in rural Nepal.

OBJECTIVES: (1) To estimate the cost of irrational prescribing, and (2) to compare the effect of three different kinds of user fee on prescribing costs, in rural Nepal. METHODS: A controlled before-after study was conducted in 33 government primary health care facilities in rural eastern Nepal during 1992-95. A fee per prescription (covering all drugs in whatever amounts) was regarded as the control against which two types of fee per drug item (covering a full course of treatment for each item) were compared. The average total cost to the patient for two drug items was the same in all fee systems. Total cost, expected cost (according to standard treatment guidelines) and wastage costs (total minus expected cost) per prescription were calculated from an average of 400 prescribing episodes per facility per year. The proportion of prescriptions conforming to standard treatment guidelines was calculated from 30 prescriptions per facility per year. RESULTS: 20-52% of total drug costs were due to inappropriate drug prescription. A fee per drug item, as compared with a fee per prescription, was associated with (1) significantly fewer drug items prescribed per patient, (2) significantly lower drug costs per prescription, (3) significantly lower wastage due to inappropriate drug prescription, and (4) a significantly greater proportion of prescriptions conforming to standard treatment guidelines. Average drug cost per prescription (which was 24-33 Nepali rupees [NRs] across districts and time) was 5.7 NRs (95% confidence interval 1.0 to 10.4) and 9.3 NRs (95% confidence interval 4.8 to 13.8) less with the two different item fees, respectively, than with the fee per prescription. CONCLUSION: The economic consequences of irrational prescribing are severe, particularly in association with charging a fee per prescription. Item fees in the public sector reduce irrational prescribing and associated costs.

Drug Costs↗
PubMed2001

Consumer out-of-pocket spending for pharmaceuticals in Kazakhstan: implications for sectoral reform.

What do consumers pay for pharmaceuticals in a transition economy, and who is hit hardest? Kazakhstan is in the midst of emerging from a Soviet Union state to a market economy. It has seen a significant dip in Gross Domestic Product and available revenues for health as a result. New sources of revenues, such as out-of-pocket payments, both formal and informal, have become widespread. In this paper we use the results of a 1996 Living Standards survey jointly sponsored by the World Bank and the Kazakhstan Government to examine patterns of prescribed pharmaceutical spending. We use a two-part regression model that is utilized to adjust for the skewness of non-spenders and heavy utilizers. Results suggest that upper-income groups spend more in absolute terms, but low-income groups pay a higher share of their income for pharmaceuticals. Pharmaceutical expenditure is positively related to poor health status, chronic illness and rural area residence. Our estimates suggest that on average people in rural areas spend 16% more than people in urban areas. The analysis shows that certain types of illnesses impose significant out-of-pocket burden for consumers - gynaecologic as well as intestinal and cardiac. The findings can be used for developing and designing a new 10-year World Bank-financed programme for restructuring the health sector. They also suggest the need for prioritizing rural care, as well as covering pharmaceuticals for specific types of care interventions and certain demographic groups.

Community Participation↗
PubMed2001

Cost recovery beds in public hospitals in Indonesia.

A policy of allowing public hospitals to provide some better quality, higher priced hospital beds for those able to pay was introduced as government policy in Indonesia after 1993. A study was conducted in 1998 in three public hospitals in East Java to investigate if the policy objective of cost-recovery was being achieved. Hospital revenue from these commercial beds was less than both the recurrent and total costs of providing them in all three hospitals, but exceeded recurrent costs minus staff salaries in two hospitals. One reason for the low cost-recovery ratios was that between 55% and 66% of the revenue was used as staff incentives, mostly to doctors. This was more than the maximum of 40% stipulated in the policy. The high proportions of total revenue going to staff were a result of hospital management having set bed fees too low. The policy may be contributing to the retention of doctors within public sector employment; however, it is not achieving its stated objective, especially over the longer term where full recovery of salaries and investment costs needs to be considered. Public hospitals that wish to invest in commercial beds need effective management and accounting systems so as to be able to monitor and control costs and set fees at levels that recoup the costs incurred. Further research is required to determine if this form of public-private mix has negative effects on equity and access for poorer patients.

Accounting↗