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PubMed2002

Assessing the cost and willingness to pay for voluntary HIV counselling and testing in Kenya.

OBJECTIVE: Voluntary counselling and testing (VCT) should be an important component in a country's HIV/AIDS prevention and care strategy. However, the high cost of VCT raises concerns about the affordability of VCT in low-income countries. This study was designed to assess the costs of VCT and to identify potential ways of introducing VCT more affordably. METHODOLOGY: An economic evaluation was performed of VCT services in two rural health centres in Thika District and an urban health centre in Nairobi, Kenya. A contingent valuation study was also performed among VCT clients. Estimates were developed regarding the national cost of offering VCT services in Kenya. RESULTS: VCT added US dollars 6800 per year to the average cost of providing services at each of these three health centres. The evaluation revealed that the incremental cost, from the government's perspective, of adding VCT is approximately 16 dollars per client. The estimated incremental cost per client is significantly less than a previous cost estimate in Kenya which estimated a cost per client of 26 dollars. The difference in cost estimates is in part attributable to the emphasis of this project on integrating VCT services into existing health centres, rather than creating stand-alone sites. The cost of VCT services might be further reduced to as little as 8 dollars per client if a government health worker could perform the counselling. A contingent valuation study indicated that most VCT clients would be willing to pay at least 2 dollars for the service. However, if the full cost of the service were charged to the client, less than 5% of clients indicated they were willing and able to pay for the service. CONCLUSIONS: Integrating services into existing health centres can significantly reduce the cost of VCT. Additional cost reductions may be feasible if health centre staff are hired to perform the counselling. Furthermore, it appears that some level of cost recovery from VCT clients is feasible and can contribute to sustainability, although it is very unlikely that the full cost of the service could be recovered from the clients. The national provision of VCT in all Kenyan health centres is likely to be an affordable option, although additional operational research is required to determine the most appropriate way of scaling up VCT services throughout the country.

AIDS Serodiagnosis↗

PubMed2002

Paying for reproductive health services in Bangladesh: intersections between cost, quality and culture.

In 1997 a consortium of non-governmental organizations (NGOs) in Bangladesh began to implement health sector reform measures intended to expand access to and improve the quality of family planning and other basic health services. The new service delivery model entails higher costs for clients and requires that they take greater initiative. Clients have to travel further to get certain services, and they have to pay more for them than they did under the previous door-to-door family planning model. This paper is based on findings from a qualitative study looking at client and community reactions to the programme changes. It examines a number of barriers to access and constraints to cost recovery, including gender, class and ideas about entitlements, the role of government and obligations among people. The NGOs want to maximize cost recovery while making the basic services they offer accessible to most people. The findings suggest that this requires more than the establishment of an appropriate pricing structure. Attitudes related to charging and paying for services must also change, along with the institutional policies and practices that support them.

Attitude to Health↗

PubMed2002

Ministry of Health user fees, equity and decentralization: lessons from Honduras.

Decentralization is commonly championed as a means for achieving equity. To date, however, there has been little discussion of the mechanisms underlying this relationship, and several of the few empirical investigations that have addressed the topic have found the converse; that decentralization has exacerbated inequalities. This article examines the performance and equity in financing of the Honduras Ministry of Health's (MOH) decentralized user fee system. The MOH of Honduras established a national user fee policy in 1989. It provided a framework of rules and regulations and decentralized administration of the system to the regional offices. A survey conducted under the auspices of this study provided detailed information about the structures and operations of MOH user fee systems. The survey revealed that the systems vary markedly by region, creating horizontal inequities, and that they have numerous other shortcomings. The average price of a consultation is low, US dollars 0.16, and revenues have consistently equalled just 2% of MOH expenditures. The systems' administrative costs are equal to 67% of their revenues. Eliminating the user fee systems in all but the national and regional hospitals would actually save money and/or enable the MOH to provide more care. Average consultation prices are highest in health posts, intermediate in centres and lowest in the national hospitals, thereby encouraging the inappropriate use of the MOH's pyramidal referral system and fostering MOH inefficiency. Fee levels and exemption practices are horizontally and vertically inequitable. The likelihood of paying for an ambulatory visit is highest at a health post, 89%, and lowest at a hospital, 49%. Individuals from the poorest one-fifth of households are the most likely to have to pay for care. Honduras' experience demonstrates that a decentralized user fee system is not necessarily equitable, and that, more generally, the gains that can be realized from decentralizing user fee systems are not automatic. They must be anticipated, planned for and cultivated by a well-designed and well-implemented initiative that is not a single, one-time event, but rather a dynamic, on-going enterprise.

Ambulatory Care Facilities↗

PubMed2002

Willingness to pay for treated mosquito nets in Surat, India: the design and descriptive analysis of a household survey.

For willingness to pay (WTP) studies to have an appropriate impact on policy making, it is essential that the design and analysis are undertaken carefully. This paper aims to describe and justify the design of the survey tool used to assess hypothetical WTP for treated mosquito nets (TMN) in rural Surat, India and report its findings. Results from qualitative work were used as an input for developing the WTP questionnaire. A total of 1200 households belonging to 80 villages in rural Surat were selected for the study. A bidding format was used to elicit WTP values, using three different starting bids. The scenario was constructed in a way to reduce the possibility of respondents acting strategically. The response rate was 100%. About 79% of the respondents were willing to buy TMNs and the mean WTP was Rs57. Descriptive results of economic and other taste and preference variables are also presented, which include preventive measures used by households and treatment seeking behaviour for malaria. It is observed that WTP as well as demographic variables and prevention methods differ significantly across arms of the trial. This paper suggests that policy-makers could use the evidence following further analysis, along with information on costs of implementation, to ascertain the levels of subsidy that may be needed at different levels of coverage.

Adult↗

PubMed2002

Equitable financing, out-of-pocket payments and the role of health care reform in Colombia.

For a health care system to be considered equitable in its financing, the financial burden of contributions has to be progressive or at least proportional. Out-of-pocket financing takes a larger proportion of poor than of non-poor households' income. To remedy this regressive burden, among other goals, Colombia launched a health care reform based on social insurance as a means to reduce health care financing through out-of-pocket payments, and to reduce financial barriers to access. This paper analyzes the evolution of regressivity in out-of-pocket financing from 1984 to 1997, in order to detect if the 1993 health care reform had an impact on such regressivity. The Kakwani index of progressivity was estimated using three national household surveys. Kakwani indices showed a constant trend towards more regressivity (-0.126 in 1984, to -0.3498 in 1997) when using income to build the index, but a trend towards progressivity (-0.0092 in 1984, to 0.0026 in 1997) when using expenses. Our findings suggest that there was a progressive impact of the reform on out-of-pocket financing when household expenses are used to build the Kakwani index; however, due to issues of comparability between surveys, the findings are not conclusive.

Colombia↗

PubMed1991

User charges for health care: a review of recent experience.

This paper reviews recent experiences with increases in user charges and their effect on the utilization of health care. Evidence from several countries of differences in utilization between rich and poor is presented, and recent accounts of sharp, and often sustained, drops in utilization following fee increases, are presented and discussed. Fee income, appropriately used, represents a small but significant additional resource for health care. Recent national experiences appear to have concentrated on achieving cost recovery objectives, rather than on improving service quality and health outcomes. Appraisal of financing changes must be linked to probable health outcomes. Successful large-scale experience in linking these two is in short supply.

Developing Countries↗

PubMed1994

Community financing of drug supplies in rural Nepal: evaluating a 'fee per item' drug scheme.

A new programme in rural Nepal was evaluated in which users partly fund the supply of additional drugs needed at health posts. Patients are charged a fee per item prescribed (FPI scheme). The scheme is administered by the District Public Health Office (DPHO). This scheme is compared with two established schemes: one charges patients a fee per prescription ('fee-per-script' or FPS scheme) and is administered by independently paid NGO (non-governmental organization) staff; the other uses local shops as a means of supplying drugs. The new scheme was associated with a rise in average daily attendance from nine to thirty-two patients a day (a 240% increase) when compared to a similar period the previous year. Fewer drugs were prescribed in the FPI scheme (average per patient 1.8 vs. 2.4, Chi square P <0.001). The average cost of a drug from the user's perspective was approximately 12% lower in the FPI scheme. These factors combined to make the average cost to the patient of a prescription half that of one in the FPS scheme. The new scheme was 24% cheaper to run on a 'cost per patient' basis when compared with the FPS scheme. However, the overall subsidy needed for the scheme to operate was higher because of the big increase in attendance. One-off stocktakes of ten essential drugs were used to assess the availability of drugs for patient use. The proportion of these drugs that were in low supply or absent was 24% in the FPI scheme. This was similar in the other two schemes. The government DPHO did not perform all the administrative tasks required. These tasks need to be simplified and different methods for involving DPHO staff in drug scheme management need to be explored. The rapid turnover of senior staff, however, will remain a major impediment. This preliminary evaluation shows that an FPI scheme promotes a more rational use of resources, compared to an FPS scheme. Administration of the scheme may, however, prove to be more difficult. A simple field-based comparative assessment of drug supply schemes can give a valuable insight into the strengths and weaknesses of a new programme.

Financing, Government↗

PubMed2003

The impact of the 1997-98 East Asian economic crisis on health and health care in Indonesia.

This article identifies the effects of the 1997-98 East Asian economic crisis on health care use and health status in Indonesia. The article places the findings in the context of a framework showing the complex cause and effect relationships underlying the effects of economic downturns on health and health care. The results are based on primary analysis of Indonesian household survey data and review of a wide range of sources from the Indonesian government and international organizations. Comparisons are drawn with the effects of the crisis in Thailand. The devaluation of the Indonesian currency, the Rupiah, led to inflation and reduced real public expenditures on health. Households' expenditures on health also decreased, both in absolute terms and as a percentage of overall spending. Self-reported morbidity increased sharply from 1997 to 1998 in both rural and urban areas of Indonesia. The crisis led to a substantial reduction in health service utilization during the same time period, as the proportion of household survey respondents reporting an illness or injury that sought care from a modern health care provider declined by 25%. In contrast to Indonesia, health care utilization in Thailand actually increased during the crisis, corresponding to expansion in health insurance coverage. The results suggest that social protection programmes play a critical role in protecting populations against the adverse effects of economic downturns on health and health care.

Economics↗

PubMed2003

Who buys insecticide-treated nets? Implications for increasing coverage in Nigeria.

OBJECTIVES: To investigate the determinants of purchase of insecticide-treated nets (ITNs) and explore the policy implications of the findings for ITN programmes. METHODS: Two surveys were conducted 1 month apart in three villages. The first survey was used to determine stated willingness to pay (WTP) and respondent practices regarding untreated nets and ITNs. The second survey was accompanied by actual sales of ITNs. Pre-tested interviewer-administered questionnaires using three contingent valuation method (CVM) question formats, namely the bidding game (BG), binary with follow up (BWFU) and a structured haggling technique (SH), were administered to different sub-samples of the respondents. The nets were sold at a price of 350 Naira (US dollars 1 = 110 Naira). Bivariate analysis and logistic regression were used to investigate the factors that explain actual WTP. FINDINGS: While 15/158 (9.5%), 21/166 (12.7%) and 35/144 (24.3%) of the respondents in the BG, BWFU and SH stated WTP amounts that were equal to or greater than the price of the net, 19.6%, 24.7% and 24.3% of respondents actually purchased the nets in the three groups respectively. Lower socioeconomic groups were less likely to purchase the nets, while households with a recent attack of malaria and those that stated higher WTP amounts were more likely to purchase nets. Stated WTP was positively associated with actual WTP (p < 0.01). Increased distance of the respondents to the ITNs sales point decreased net purchases (p < 0.05). CONCLUSIONS: Stated WTP was a good predictor of actual WTP. ITNs distribution strategies that will decrease time and travel costs to households are needed to increase net coverage. Also, ITNs financing mechanisms are needed that will ensure that lower socioeconomic groups and those at greater risk of malaria are protected. Governments and donors should take the lead to ensure that ITNs programmes are equitable.

Adult↗

PubMed2003

Using willingness to pay to investigate regressiveness of user fees in health facilities in Tanzania.

The study uses data from the Tanzania Human Resources Development Survey (1994) on willingness to pay (WTP) for desired quality of health care at lower-level health facilities to assess potential regressiveness of user fees - a disproportionately higher negative effect of user fees on utilization of health services among the poor compared with the rich. Despite reports of extensive bypassing of the lower-level health facilities in Tanzania, the WTP for quality health care at these health facilities is surprisingly large. WTP was lower among the poor, female and elderly respondents. Almost one-quarter of the poorest 40% of the population was not willing to pay even when the quality of services met their expectations. The results suggest that: the utilization of health services at lower-level health facilities can be increased by improving the quality of care; and the implementation of uniform user charges in the public facilities may be regressive, adversely affecting utilization among the poor, women and the elderly. An effective system of exemptions and waivers will be required for the very poor who may not be able to pay even when quality of services is improved. The findings of the study have policy implications for the Tanzanian government's recent attempts to expand cost-sharing through community health funds at lower-level health facilities, being introduced since 1998.

Adult↗

PubMed2003

Costs of near-miss obstetric complications for women and their families in Benin and Ghana.

This paper estimates the total cost to women and their families associated with a spontaneous vaginal delivery and five types of 'near-miss' obstetric complication in Benin and Ghana, and assesses affordability in relation to household cash expenditure. A retrospective evaluation of costs was carried out among 121 mothers in three hospitals in Ghana. A prospective evaluation of costs was undertaken among 420 pregnant women in two hospitals in Benin. Information was collected on the cost of travel to the facilities and of direct medical and non-medical costs incurred during their stay in hospital. In Benin, costs ranged from an average of 15 US dollars for a spontaneous delivery to 256 US dollars for a near-miss complication caused by dystocia. In Ghana, average costs ranged from 18 US dollars for a spontaneous vaginal delivery to 115 US dollars for a near-miss complication caused by haemorrhage. Medical costs accounted for the largest share of total costs, mainly drugs and medical supplies in Ghana and costs of the delivery and any surgical intervention in Benin. Payments associated with a spontaneous vaginal delivery amounted to at least 2% of annual household cash expenditure in both countries. In the case of severe obstetric complications, costs incurred reached a high of 34% of annual household cash expenditure in Benin. The economic burden of hospital-based delivery care in Ghana and Benin is likely to deter or delay women's use of health services. Should a woman develop severe obstetric complications while in labour, the relatively high costs of hospital care could have a potentially catastrophic impact on the household budget.

Benin↗

PubMed2004

Differential willingness of household heads to pay community-based health insurance premia for themselves and other household members.

OBJECTIVE: This study compares household heads' willingness-to-pay (WTP) for community-based health insurance (CBI) for themselves with their WTP for other household members, in order to provide information for policy makers on setting the premium and choosing the enrollment unit. METHOD: A random sample of 698 heads of households was interviewed in the northwest of Burkina Faso and a bidding game approach was used to elicit WTP. Factors associated with differences in WTP were identified, including characteristics of the household head and of the household. RESULTS: Mean WTP by the heads of households for insurance for themselves (3575 CFA) was twice their mean WTP per capita for the household as a whole (1759 CFA). The old have a lower WTP than the young, females have lower WTP than males, the poor have a lower WTP than the rich, and that those with less schooling have a lower WTP than those with more years of schooling. CONCLUSION: The differences in household heads' WTP for insurance for themselves and their WTP to insure their households as a whole need to be considered when setting the insurance premium. WTP information can assist decision makers with the complex problem of choosing the enrollment unit and setting the premium.

Burkina Faso↗

PubMed2005

Does use of tobacco or alcohol contribute to impoverishment from hospitalization costs in India?

The study investigates the association between tobacco and alcohol use, and the potential risk of impoverishment from borrowing and distress selling of assets for meeting costs of hospitalization in India. Data from the fifty-second round of the National Sample Survey, a representative survey of 120,942 households across India, were used to investigate the likelihood and the levels of borrowing and distress selling of assets to cover hospitalization expenditures among regular users of tobacco and/or alcohol, non-users from households where there was use, and non-users from households with no use. The data were analyzed by bivariate comparisons and multivariate logistic and ordinary least square regression. The study found a higher risk of borrowing/distress selling during hospitalization for individuals who use tobacco (OR 1.35, p<0.05), who were non-users but belong to households that use tobacco (OR 1.38, p<0.05), and non-users from households that use both tobacco and alcohol (OR 1.51, p<0.05), even after controlling for socio-economic and demographic factors. The same groups also met a higher percentage of hospitalization expenditures through borrowing/distress selling of assets. The adjusted population-attributable risk proportion of borrowing/distress selling to meet hospital expenditures for tobacco and alcohol use was 16%. The study suggests that there is an association between use of tobacco and alcohol, and impoverishment through borrowing and distress selling of assets due to costs of hospitalization. While reduction of poverty is the overarching goal of developing countries and multilateral development organizations, very little is mentioned about control of tobacco and alcohol in the framework of development. It might be necessary to include strategies for control of tobacco and alcohol in the larger framework of poverty reduction.

Adolescent↗

PubMed2005

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

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

Adolescent↗

PubMed2005

Out-of-pocket payments for under-five health care in rural southern Tanzania.

Catastrophic payments and fairness in financial contributions for health care are becoming increasing concerns for many governments. Out-of-pocket financing for health care is common in many developing countries, including Tanzania. As part of the Multi-Country Evaluation of the Integrated Management of Childhood Illness (MCE-IMCI), the objective of this paper is to explore the determinants of variation and the level of out-of-pocket payments for child health care in rural Tanzania, with and without IMCI, using data from two household surveys conducted in 1999 and 2002. We analyzed data for 833 visits to health providers for 764 children who had been sick in the 2 weeks prior to the survey and who had sought care at a 'Western' or formal health care provider. We found evidence that IMCI was associated with lower out-of-pocket costs at government facilities (Tshs.3.5 compared with Tshs.6.9 without IMCI) and in NGOs (Tshs.95.1 compared with Tshs.267.3). Out-of-pocket payments were on average Tshs.110.1 when care was sought at government primary health care facilities running a cost-sharing scheme, about 15 times higher than in those not part of the scheme (p<0.0001). Those who visited NGO facilities paid about 30 times more than those seeking care at government facilities not operating the cost-sharing scheme (p<0.0001). In conclusion, there is no doubt that health care financing mechanisms and equitable access to government facilities have a major impact on household economic burden related to under-five illness. Increasing access to IMCI-based care, however, offers an additional opportunity to reduce out-of-pocket payments, mainly through more rational use of medicines. Increasing access to IMCI-based care would not only improve inequities in financial contributions, but also in health, an important consideration for its own sake.

Child Health Services↗

PubMed2006

Financing mental health services in low- and middle-income countries.

Mental disorders account for a significant and growing proportion of the global burden of disease and yet remain a low priority for public financing in health systems globally. In many low-income countries, formal mental health services are paid for directly by patients out-of-pocket and in middle-income countries undergoing transition there has been a decline in coverage. The paper explores the impact of health care financing arrangements on the efficient and equitable utilization of mental health services. Through a review of the literature and a number of country case studies, the paper examines the impact of financing mental health services from out-of-pocket payments, private health insurance, social health insurance and taxation. The implications for the development of financing systems in low- and middle-income countries are discussed. International evidence suggests that charging patients for mental health services results in levels of use which are below socially efficient levels as the benefits of the services are distributed according to ability to pay, resulting in inequitable access to care. Private health insurance poses three main problems for mental health service users: exclusion of mental health benefits, limited access to those without employment and refusal to insure pre-existing conditions. Social health insurance may offer protection to those with mental health problems. However, in many low- and middle-income countries, eligibility is based on contributions and limited to those in formal employment (therefore excluding many with mental health problems). Tax-funded systems provide universal coverage in theory. However, the quality and distribution of publicly financed health care services makes access difficult in practice, particularly for rural poor communities.

Developing Countries↗

PubMed2006

Beliefs about informal payments in Albania.

Informal payments for health care are a growing concern in Albania and other transitional economy countries. Recent international studies have shown that informal payments can have negative effects on health care access, equity and health status by causing people to forgo or delay seeking care, or sell assets to pay for care. Many countries are putting in place reforms meant to reduce informal payments. In order to be successful, such policies need to consider people's attitudes and beliefs about the practice. This study collected data from 222 citizens in Albania regarding intentions, past behaviours, attitudes and beliefs about informal payments. Comparing people who intend to make informal payments with people who do not intend to make payments, the study found differences in attitudes as well as beliefs about the consequences of making informal payments, in perceptions about what others think and in control beliefs, but no difference in moral beliefs or demographic characteristics. People who intend to make informal payments the next time they seek care are more likely to believe they will get faster and better quality care than non-intenders, but also think they must pay to receive any care at all. People who do not intend to make informal payments are more likely to report that they have connections with medical personnel, which may be substituting for informal payments. The study has implications for educational campaigns accompanying policy reforms. Campaigns which focus on anti-corruption messages are unlikely to be effective, as moral beliefs do not appear to influence intention.

Adult↗

PubMed2006

Detecting changes in financial protection: creating evidence for policy in Estonia.

Ninety-four per cent of the Estonian population is covered by public health insurance, but private expenditure has been increasing quickly both in real terms and as a percentage of total health expenditure. To date, little attention has been given to the impact this could have on the population's financial protection. Out-of-pocket payments, which account for the bulk of the private expenditure in many low- and middle-income countries, can push people into poverty and more generally represent too high a burden for some households. It is therefore very important that governments monitor the impact of out-of-pocket payments on health. Using an example from Estonia, this paper aims to illustrate that, if household budget survey data are available, monitoring a population's financial protection is not a complex undertaking. Further, by combining simple statistical analyses of these data with a good knowledge of a country's health system, it is possible to give a fairly detailed diagnostic of the nature of the population's coverage limitation. This allows for the presentation of easily interpretable results that can raise awareness among policy-makers and help to target adequate policy responses. Using Estonian household budget surveys from 1995, 2001 and 2002, we show that the proportion of households who spend more than 20% of their capacity to pay on health increased from 3.4% in 1995 to 7.4% in 2002 and that in 2002, 1.3% of the population fell into poverty because of health payments. Logistic regression helps in identifying the population most at risk: elderly patients who belong to poor households and spend high amounts on medicines. This study, which can be replicated, did raise awareness among policy-makers about the changes in financial protection over the years in Estonia.

Data Collection↗