The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) after four years of implementation - is it making an impact on quality of inpatient care and financial protection in India?

BACKGROUND: India launched a national health insurance scheme named Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) in 2018 as a key policy for universal health coverage. The ambitious scheme covers 100 million poor households. None of the studies have examined its impact on the quality of care. The existing studies on the impact of AB-PMJAY on financial protection have been limited to early experiences of its implementation. Since then, the government has improved the scheme's design. The current study was aimed at evaluating the impact of AB-PMJAY on improving utilisation, quality, and financial protection for inpatient care after four years of its implementation. METHODS: Two annual waves of household surveys were conducted for years 2021 and 2022 in Chhattisgarh state. The surveys had a sample representative of the state's population, covering around 15,000 individuals. Quality was measured in terms of patient satisfaction and length of stay. Financial protection was measured through indicators of catastrophic health expenditure at different thresholds. Multivariate adjusted models and propensity score matching were applied to examine the impacts of AB-PMJAY. In addition, the instrumental variable method was used to address the selection problem. RESULTS: Enrollment under AB-PMJAY was not associated with increased utilisation of inpatient care. Among individuals enrolled under AB-PMJAY who utilised private hospitals, the proportion incurring catastrophic health expenditure at the threshold of 10% of annual consumption expenditure was 78.1% and 70.9% in 2021 and 2022, respectively. The utilisation of private hospitals was associated with greater catastrophic expenditure irrespective of AB-PMJAY coverage. Enrollment under AB-PMJAY was not associated with reduced out-of-pocket expenditure or catastrophic health expenditure. CONCLUSIONS: AB-PMJAY has achieved a large coverage of the population but after four years of implementation and an evidence-based increase in reimbursement prices for hospitals, it has not made an impact on improving utilisation, quality, or financial protection. The private hospitals contracted under the scheme continued to overcharge patients, and purchasing was ineffective in regulating provider behaviour. Further research is recommended to assess the impact of publicly funded health insurance schemes on financial protection in other low- and middle-income countries.

Assessing catastrophic health expenditure and impoverishment in adult asthma care: a cross-sectional study of patients attending six public health clinics in Klang District, Malaysia.

BACKGROUND: In Malaysia, asthma is a common chronic respiratory illness. Poor asthma control may increase out-of-pocket payment for asthma care, leading to financial hardships Malaysia provides Universal Health Coverage for the population with low user fees in the public health system to reduce financial hardship. We aimed to determine out-of-pocket expenditure on outpatient care for adult patients with asthma visiting government-funded public health clinics. We examined the catastrophic impact and medical impoverishment of these expenses on patients and households in Klang District, Malaysia. METHODS: This is a cross-sectional face-to-face questionnaire survey carried out in six government-funded public health clinics in Klang District, Malaysia. We collected demographic, socio-economic profile, and outpatient asthma-related out-of-pocket payments from 1003 adult patients between July 2019 and January 2020. Incidence of catastrophic health expenditure was estimated as the proportion of patients whose monthly out-of-pocket payments exceeded 10% of their monthly household income. Incidence of poverty was calculated as the proportion of patients whose monthly household income fell below the poverty line stratified for the population of the Klang District. The incidence of medical impoverishment was estimated by the change in the incidence of poverty after out-of-pocket payments were deducted from household income. Predictors of catastrophic health expenditure were determined using multivariate regression analysis. RESULTS: We found the majority (80%) of the public health clinic attendees were from low-income groups, with 41.6% of households living below the poverty line. About two-thirds of the attendees reported personal savings as the main source of health payment. The cost of transportation and complementary-alternative medicine for asthma were the main costs incurred. The incidences of catastrophic expenditure and impoverishment were 1.69% and 0.34% respectively. The only significant predictor of catastrophic health expenditure was household income. Patients in the higher income quintiles (Q2, Q3, Q4) had lower odds of catastrophic risk than the lowest quintile (Q1). Age, gender, ethnicity, and poor asthma control were not significant predictors. CONCLUSION: The public health system in Malaysia provides financial risk protection for adult patients with asthma. Although patients benefited from the heavily subsidised public health services, this study highlighted those in the lowest income quintile still experienced financial catastrophe and impoverishment, and the risk of financial catastrophe was significantly greater in this group. It is crucial to ensure health equity and protect patients of low socio-economic groups from financial hardship.

Out-of-pocket expenditures and catastrophic expenditures on inpatient care among households of an urban village in Delhi.

Background: Out-of-pocket expenditure (OOPE) for inpatient care has been known to cause maximum impoverishment. It can have debilitating consequences for urban poor households. It is necessary to study inpatient care costs and the related factors among the households of an urban village to determine their vulnerability to catastrophic expenditure and to protect them from it. Objective: The study aimed to calculate the mean OOPE on inpatient care, and catastrophic health expenditure among households of an urban village in Delhi. Design: This was a cross-sectional study conducted over 18 months among urban village households of Delhi who have been residing for the last 1 year. Methods: A sample size of 188 was calculated based on another study, and households were selected using systematic random sampling. A pre-designed, pre-tested, semi-structured, and interviewer-administered questionnaire in Hindi was used to elicit and record relevant information. Data were recorded and coded, and analysis was done using licensed SPSS v.26 software. Tables were generated for relevant data, and cross-tables were used to assess statistical association with chi-square or Fisher exact tests, as required. A p-value of 0.05 was considered statistically significant. Results: The mean annual OOPE borne by a household on inpatient care was INR 6870.3 (SD ± 30,580.6), where 93.3% of OOPE was incurred while seeking treatment from public facilities. The OOPE on inpatient care had a statistically significant association with households having joint family, members from vulnerable population, and belonging to Delhi. Conclusion: The households of an urban village of Aliganj, Delhi, have high OOPE on inpatient care (60.6%) and catastrophic health expenditure (75.6%).

Determinants of tuberculosis: an example of high tuberculosis burden in the Saharia tribe.

Tuberculosis (TB) is a significant public health problem among the Saharia community, an underprivileged tribal group in the west-central part of India. There are several challenges for India's TB control program to curtail TB in the Saharia tribe. Malnutrition, poor health sector facilities, lower socio-economic status, and substance abuse are interconnected and synergistic factors contributing to a high burden of TB in the Saharia tribe. In this review, efforts are made to collate the findings of previous studies discussing the causes of high burden of TB in the Saharia tribe, social gaps for mitigating these preventable risk factors of TB in the Saharia tribe, and the plausible solutions for closing these gaps. The concept of Health in All Policies and intersectoral co-ordination is needed for the reduction of TB in the Saharia tribe and to make India TB-free by the year 2025.

The Effect of Iran Health Transformation Plan on Equity in Health Financing: A Systematic Review.

Background: Achieving financial goals is one of the health systems goals, especially for those in low- and middle-income countries. Since financing equity, is an objective of Health Transformation Plan (HTP) implementation in Iran, this study examined this plan toward improving equity in healthcare Financing, using four payment indices: Out-of-Pocket Payment (OOP), Catastrophic Health Expenditure (CHE), Fair financial Contribution Index (FFCI) and Impoverishing Health Expenditure (IHE). Methods: Articles published in English on equity in financing related to HTP were searched and retrieved in the Web of Science, Scopus, PubMed, and Embase databases between Jan 2014 and Dec 2020, following PRISMA guidelines. Overall, 1319 papers were retrieved initially, and 31 were selected for analysis. Results: After implementation of HTP, OOP index has decreased between patients and households. No consistent trend was evident for CHE. HTP reforms have a limited effect on the FFCI. The one study on IHE has shown an upward trend for this index. In general, in the early years of HTP, there was a higher downward trend in equity in financing indicators than in subsequent years. Conclusion: HTP has made significant accomplishments in equity, such as the financial protection of patients in healthcare centers, but fail to achieve this plan goals, significantly reduced its value. Therefore, it is necessary for managers and health policy makers around the world, with scientific and principled solutions, to prevent loss of their reform plans positive achievements.

Trends of Private Drugs' Sales and Costs Incurred by Patients on Anti-tuberculosis Drugs in Selected Districts of Jharkhand (2022): Results From Sub-national TB-Free Certification.

BACKGROUND: The government of India is committed to eliminating tuberculosis (TB) by 2025 under the National Tuberculosis Elimination Programme which provides free investigations and treatment as well as incentives for nutritional support during their treatment course. Many TB patients prefer to seek treatment from the private sector which sometimes leads to financial constraints for the patients. Our study aims to find the burden of TB patients in the private sector and the expenses borne by them for their treatment. METHODOLOGY: Sales data of rifampicin-containing formulation drug consumption in the private sector of six districts of Jharkhand was collected from Clearing and Forwarding agencies. Based on the drug sales data, the total incurring costs of the drugs, total number of patients, and cost per patient seeking treatment from the private sector were calculated for the year 2015-2021. ANOVA and the post hoc test (Tukey honestly significant difference (HSD)) were applied for analysis. RESULTS:  There was a marked difference amongst all the districts in relation to all the variables namely total costs, cost per patient, and total private patients seeking treatment from the private sector which was statistically significant (p < 0.001). East Singhbhum had the highest out-of-pocket expense and private patients as compared to all six districts. Lohardaga showed the sharpest decline in total private patients from 2015 to 2021. The average cost borne by private patients in 2015 was INR 1821 (95% CI 1086 - 2556) which decreased to INR 1033 (95% CI 507 - 1559) in 2021. CONCLUSION: From the study, it was concluded that the purchase of medicines for TB treatment from the private sector is one of the essential elements in out-of-pocket expenditure (OOPE) borne by TB patients. Hence, newer initiatives should be explored to foresee the future OOPE borne by the patients and decrease OOPE-induced poverty.

Scourge of out-of-pocket expenditure on health: A study on its burden and predictors in a rural community of West Bengal.

Introduction: Globally, one-third of current health expenditure had been out-of-pocket expenditure (OOPE). The health system financing of almost all low- and middle-income countries including India rely heavily on out-of-pocket (OOP) payments for health care. OOPE on health payments is particularly hard on any community, especially the poor leading to incomplete or even no treatment during their ill health. This study estimated OOPE among residents of a rural community in West Bengal and explored the associated factors with high OOP expenses. Methods: A community-based cross-sectional study was conducted in a rural community in Singur, West Bengal from June 2019 to February 2020. The study was done among 398 villagers selected from 15 clusters or villages. Households were randomly selected in each village. All members of the selected households were interviewed. SPSS was used for data analysis both for descriptive and inferential statistics. Results: Only 14.6% of morbid persons had catastrophic expenditure. The incidence of catastrophic expenditure was higher among those who opted for private practitioners and or ayurveda, yoga and naturopathy, unani, siddha, and homeopathy (AYUSH) facilities. There was zero catastrophic expenditure for the unqualified sector. There was an increasing trend of OOP payments among the lower socioeconomic groups. Again, low-income individuals had a higher share in cumulative expenditure (Gini coefficient of 0.35). Most of the participants (78.4%) had no health insurance coverage. Conclusion: Promotion for higher utilization of public health facilities may reduce the burden of OOP expenses. Government health insurance schemes must be widened with the inclusion of coverage of outpatient services. Integrating AYUSH services in the public sector is another option to reduce OOP expenses.

Financial impact of oral cancer treatment on the households in rural India.

Background: Oral cancer ranks second and accounts for over 20% of all cancers reported in India. Like management of all other cancers, oral cancers bring a heavy financial burden to their families. This study analyzes the financial burden on families during the management of oral cancer at Kasturba Hospital, Sewagram, a government-aided tertiary health care facility in central India. Methods: The hospital-based cross-sectional study was conducted in the cancer unit of a government-aided tertiary hospital of central India. A total of 100 patients with oral cancer being treated in the hospital were included in the study. Information regarding cost incurred on management of oral cancer was inquired from a close family member or a caregiver of the study subjects. Results: The out-of-pocket expenditure on treatment of oral cancer was approximately INR 100,000 (USD 1363). It has been found that 96% of families experienced catastrophic health expenditure as a result of treatment. Conclusion: Although India aims for universal health coverage, it is important to protect cancer patients from catastrophic health expenditure.

Billing the Insured: An Assessment of Out-of-Pocket Payment by Insured Patients in Ghana.

Background: The Ghana National Health Insurance Scheme was introduced in 2003 to provide financial protection to the population. While the Scheme has made strides in improving access to healthcare there have been a few challenges including out of pocket charges to insured patients with weak client power. The study investigated the catastrophic nature of the out-of-pocket charges, the factors affecting the charges and the client power. Methodology: We used primary data collected in 3 administrative regions: Greater Accra, Ashanti and the Northern regions, within the period April and June 2022 to compute catastrophic expenditure of the out-of-pocket healthcare expenditure on household expenditure on food and non-food. In addition, multivariate logistic regressions and a linear regression were run to examine the incidence of the practice and client power. Results: The results showed that on average the insured paid out-of-pocket charges with a probability of 66%. The probability was highest (80%) in the Greater Accra, followed by Ashanti region (66.6%) and (52.9%) in the Northern region. The out-of-pocket charges were found to be catastrophic with incidence rate between 48.2% and 26.1% for the 5% and 20% thresholds; the overshoots ranged between 34.1% and 26.9% for the thresholds; the poor were more disadvantaged than the rich. Patients reported the out-of-pocket charges to the NHIA with probability of 1.9%, but the NHIA did not respond to 81% of the reported cases. Knowledge of the benefit list is likely to motivate the insured to report out-of-pocket charges, while cordial relationship between the NHIA staff and the insured deters providers from charging out-of-pocket. Conclusion: The out-of-pocket charges occur extensively across health facilities and is impoverishing. A close collaboration between the NHIA and the insured is needed to reduce the incidence and hold providers accountable.

Pre-treatment delay and out of pocket expenses by notified new tuberculosis patients in an Indian mega city.

BACKGROUND: Study was carried out to find out delay from onset of symptoms and out of pocket expenditure (OOPE) until initiation of anti-TB treatment (ATT) by new Tuberculosis (TB) patients registered in public health facilities in Bengaluru. METHODS: Notified patients (N = 228) selected purposively were interviewed at initiation of ATT regarding number and type of facilities visited and delay in initiating ATT. OOPE was elicited separately for in- and out-patient visits, towards consultation, purchase of medicines, diagnostic tests, transportation, hospitalization and food. Dissaving or money borrowed was ascertained. RESULTS: Two-thirds of participants were 15-44 years of age and 56% were males, mean annual household income was $4357. About 75% first visited a private health facility; 68% and 87% respectively were diagnosed and started on ATT in public sector after visiting an average of three facilities and after a mean delay of 68 days; the median delay was 44 days. Of mean OOPE of $402, 54% was direct medical expenditure, 5% non-medical direct and 41% indirect. OOPE was higher for Extra-pulmonary TB compared to PTB and when number of health facilities visited before initiating treatment was >3 compared to those who visited ≤3 and when the time interval between onset of symptoms and treatment initiation (total delay) was >28 days compared to when this interval was ≤28 days. About 20% suffered catastrophic expenditure; 34% borrowed money and 37% sold assets. CONCLUSION: Concerted efforts are needed to reduce delay and OOPE in pre-treatment period and social protection to account for indirect expenditure.

Catastrophic expenditure and treatment attrition in patients seeking comprehensive colorectal cancer treatment in India: A prospective multicentre study.

Background: Although colorectal cancer is increasing in India, the cost of comprehensive treatment and its consequences for patients and households are unknown. This study aimed to describe catastrophic expenditure and treatment attrition in patients with a treatment plan for colorectal cancer. Methods: A prospective, multicentre, cohort study was conducted in five tertiary hospitals in India from December 2020 to March 2022. Consecutive patients with a new treatment plan for colorectal cancer were followed-up for six months. The total cost of treatment was reported, including out-of-pocket payments (OOPP, paid by patients at the time-of-service use) and covered by third parties (insurance, public funds). The primary outcome was catastrophic expenditure, defined as OOPPs greater than 25% of patient's annual household income and the secondary outcome was treatment attrition, defined as unplanned interruption of the treatment course not recommended by the clinical team. Findings: Of 226 patients included, 20 died within six months of being offered a treatment plan and four were lost to follow-up. The median total cost of colorectal cancer treatment was 407,508 Indian Rupees (INR/5340 USD), to which the biggest contributor was the patient's OOPP (median 330,277 INR/4328 USD). Surgery and anaesthesia costs (median 85,944 INR/1126 USD) were higher than radiotherapy (median 55,525 INR/728 USD) and chemotherapy (median 14,780 INR/194 USD). The overall catastrophic expenditure rate was 90.1% (182/202) and the treatment attrition rate was 9.4% (19/202). Patients with treatment attrition made lower OOPPs than those who completed treatment (median 205,926 vs 349,398 INR, p < 0.01) but had a similar risk of catastrophic expenditure (OR 0.23, 95%CI 0.03-2.28, p = 0.186). Interpretation: Most treatment costs for colorectal cancer were paid out-of-pocket by patients and catastrophic expenditure was common. Treatment attrition rates at tertiary centres were low, suggesting greater attrition at previous stages of care. Better financial protection may allow more patients to receive comprehensive cancer treatment while avoiding household financial catastrophe. Funding: This research was funded by the National Institute for Health Research (NIHR) (NIHR 16.136.79) using UK aid from the UK Government to support global health research, by the India Institute of the University of Birmingham and by the Global Challenges program of the University of Birmingham. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK government.

Assessing equity of access and affordability of care among South Sudanese refugees and host communities in two districts in Uganda: a cross-sectional survey.

BACKGROUND: The vast majority of refugees are hosted in low and middle income countries (LMICs), which are already struggling to finance and achieve universal health coverage for their own populations. While there is mounting evidence of barriers to health care access facing refugees, there is more limited evidence on equity in access to and affordability of care across refugee and host populations. The objective of this study was to examine equity in terms of health needs, service utilisation, and health care payments both within and between South Sudanese refugees and hosts communities (Ugandan nationals), in two districts of Uganda. METHODS: Participants were recruited from host and refugee villages from Arua and Kiryandongo districts. Twenty host villages and 20 refugee villages were randomly selected from each district, and 30 households were sampled from each village, with a target sample size of 2400 households. The survey measured condition incidence, health care seeking and health care expenditure outcomes related to acute and chronic illness and maternal care. Equity was assessed descriptively in relation to household consumption expenditure quintiles, and using concentration indices and Kakwani indices (for expenditure outcomes). We also measured the incidence of catastrophic health expenditure- payments for healthcare and impoverishment effects of expenditure across wealth quintiles. RESULTS: There was higher health need for acute and chronic conditions in wealthier groups, while maternal care need was greater among poorer groups for refugees and hosts. Service coverage for acute, chronic and antenatal care was similar among hosts and refugee communities. However, lower levels of delivery care access for hosts remain. Although maternal care services are now largely affordable in Uganda among the studied communities, and service access is generally pro-poor, the costs of acute and chronic care can be substantial and regressive and are largely responsible for catastrophic expenditures, with service access benefiting wealthier groups. CONCLUSIONS: Efforts are needed to enhance access among the poorest for acute and chronic care and reduce associated out-of-pocket payments and their impoverishing effects. Further research examining cost drivers and potential financing arrangements to offset these will be important.

Multimorbidity, healthcare use and catastrophic health expenditure by households in India: a cross-section analysis of self-reported morbidity from national sample survey data 2017-18.

BACKGROUND: The purpose of this research is to generate new evidence on the economic consequences of multimorbidity on households in terms of out-of-pocket (OOP) expenditures and their implications for catastrophic OOP expenditure. METHODS: We analyzed Social Consumption Health data from National Sample Survey Organization (NSSO) 75th round conducted in the year 2017-2018 in India. The sample included 1,13,823 households (64,552 rural and 49,271 urban) through a multistage stratified random sampling process. Prevalence of multimorbidity and related OOP expenditure were estimated. Using Coarsened Exact Matching (CEM) we estimated the mean OOP expenditure for individuals reporting multimorbidity and single morbidity for each episode of outpatient visits and hospital admission. We also estimated implications in terms of catastrophic OOP expenditure for households. RESULTS: Results suggest that outpatient OOP expenditure is invariably lower in the presence of multimorbidity as compared with single conditions of the selected Non-Communicable Diseases(NCDs) (overall, INR 720 [USD 11.3] for multimorbidity vs. INR 880 [USD 14.8] for single). In the case of hospitalization, the OOP expenditures were mostly higher for the same NCD conditions in the presence of multimorbidity as compared with single conditions, except for cancers and cardiovascular diseases. For cancers and cardiovascular, OOP expenditures in the presence of multimorbidity were lower by 39% and 14% respectively). Furthermore, around 46.7% (46.674-46.676) households reported incurring catastrophic spending (10% threshold) because of any NCD in the standalone disease scenario which rose to 63.3% (63.359-63.361) under the multimorbidity scenario. The catastrophic implications of cancer among individual diseases was the highest. CONCLUSIONS: Multimorbidity leads to high and catastrophic OOP payments by households and treatment of high expenditure diseases like cancers and cardiovascular are under-financed by households in the presence of competing multimorbidity conditions. Multimorbidity should be considered as an integrated treatment strategy under the existing financial risk protection measures (Ayushman Bharat) to reduce the burden of household OOP expenditure at the country level.

Financial risk of emergency abdominal surgery: a cross sectional study from Ethiopia.

BACKGROUND: The Lancet Commission on Global Surgery suggested six indicators every country should use to measure their surgical systems. One of these indicators, catastrophic expenditure (CE), is defined as money paid for service which amounts to more than 10% of the patient's total annual expenditure, or more than 40% of annual non-food household expenditure. Ethiopian Ministry of Health has set a target of 100% protection from CE by 2030. However, so far there is lack of studies that assess financial risk of surgery. METHODS: Using a cross sectional study design, financial risk assessment was carried out on 142 patients from Yekatit 12 and Zewditu Memorial hospitals in Addis Ababa, Ethiopia from May 15 to September 15, 2021. RESULTS: Appendectomy (69.0%), emergency laparotomy (26.1%) and cholecystectomy (4.9%) resulted in mean direct medical expenditures of 111.7USD, 200.70USD and 224.60USD, respectively. Medications and imaging accounted for 60.8 and 13.9% of total treatment cost. By applying the two definitions of catastrophic expenditure, 67.6 and 62.7% of patients sustained CE, respectively Overall rates of CE across procedures were 67.3 and 59.1% for appendectomy, 70.2 and 70.2% for laparotomy, 57.0 and 71.2% for cholecystectomy. Thirty-five (24.6%) patients had some form of insurance, with Community Based Health Insurance being the most common form (57%). Insured patients were less likely to sustain CE with both definitions (AOR 0.09, p = 0.002 and AOR 0.10, p = 0.006 respectively). CONCLUSION AND RECOMMENDATIONS: Substantial proportion of patients undergoing emergency abdominal surgery sustain CE in Addis Ababa. Medications and imaging take major share of total cost mainly because patients have to acquire them from private set ups. Policy makers should work on availing medications and imaging in public hospitals as well as expand insurance and other forms of surgical care financing to protect patients from CE.

Comparative Analysis on Communicable and Non-Communicable Diseases on Catastrophic Spending and Impoverishment in Tanzania.

The question of whether communicable or non-communicable diseases have higher economic effects on households is rarely explored from the global to local level despite of their significant contribution in increasing household catastrophic spending and impoverishment. To shed light into this, therefore, this paper comparatively examines the economic effects of communicable and non-communicable diseases in Tanzania by the use of Tanzania Panel Survey data of 2019/2020 which has been used to analyze different parameters to provide needful information. The empirical analysis employed probit, two-stage residual inclusion (2SRI), and control function approachf (CFA) helpful in controlling endogeneity issues. Findings showed that, comparatively, non-communicable diseases have higher economic effects in endangering households into catastrophic spending and impoverishment comparing to communicable diseases. Conclusively, neglecting developing countries to fights against multiplicative effects of these diseases alone will result in killing their economies since most of these countries depend on donors and household as a means of healthcare financing. However, this paper recommends for global initiatives in reducing the burden of disease by funding on palliative care costs and enhancing the availability of affordable health insurance schemes to reduce household economic burden.

Role of publicly funded health insurance in financial protection of the elderly from hospitalisation expenditure in India-findings from the longitudinal aging study.

BACKGROUND: The elderly face a greater burden of illnesses than other age groups and have a more frequent need of healthcare, including in-patient hospitalisations. Catastrophic expenditure on hospitalisation of the elderly poses a significant challenge to India's aim of achieving Universal Health Coverage (UHC). India has implemented a policy of Publicly Funded Health Insurance (PFHI) to provide free inpatient care by empanelling private and public hospitals. The existing studies have examined the performance of PFHI in financial protection of the elderly. METHODS: This study utilised the Longitudinal Ageing Study in India (LASI) Wave 1, conducted in 2017-18. LASI is a large-scale nationally representative survey collecting data on elderly health including illness burden, healthcare use and out of pocket expenditure (OOPE). It covered a sample 72,250 individuals aged 45 or above. Financial Protection was measured in terms of Catastrophic Health Expenditure (CHE). Multivariate analysis was conducted to find effect of PFHI on OOPE-quantile and logistic models were applied for OOPE and CHE respectively. For robustness, Propensity Score Matching (PSM) model was applied. RESULTS: Of the hospitalisations, 35% had taken place in public hospitals. The mean OOPE for a hospitalisation in public sector was Indian Rupees (INR) 8276, whereas it was INR 49,700 in private facilities. Incidence of CHE was several times greater for using private hospitals as compared to public hospitals. Multi-variate analyses showed that enrolment under PFHI was not associated with lower OOPE or CHE. PSM model also confirmed that PFHI-enrolment had no effect on OOPE or CHE. Use of private facilities was a key determinant of OOPE, irrespective of enrolment under PFHI. CONCLUSIONS: This was the first study in India to examine the performance of PFHI in the context of catastrophic hospitalisation expenditure faced by the elderly. It found that PFHI was not effective in financial protection of the elderly. The ongoing reliance on a poorly regulated private sector seems to be a key limitation of PFHI policy. Governments need to find more effective ways of protecting the elderly from catastrophic health expenditure if the goal of UHC has to be realized.

Has Ebola delayed progress on access to routine care and financial protection in Sierra Leone? Evidence from a difference-in-differences analysis with propensity score weighting.

INTRODUCTION: Covid-19 has highlighted the need to understand the long-term impact of epidemics on health systems. There is extensive evidence that the Ebola epidemic of 2014-16 dramatically reduced coverage of key reproductive, maternal, newborn, child and adolescent health (RMNCAH) indicators during the period of acute crisis in Sierra Leone. However, less is known about the longer lasting effects, and whether patients continue to be deterred from seeking care either through fear or cost some years after the end of the epidemic METHODS: We analysed nationally representative household surveys from before (2011) and after (2018) the Ebola epidemic to estimate the coverage of 11 indicators of access to RMNCAH, and affordability of care. We used a differences-in-differences analysis, exploiting the variation in epidemic intensity across chiefdoms, to identify the effect of epidemic intensity on access and affordability outcomes, with propensity score weighting to adjust for differences in underlying characteristics between chiefdoms. RESULTS: 13537 households were included across both datasets. Epidemic intensity was associated with a significant stalling in progress (-12.2 percentage points, 95% CI: 23.2 to -1.3, p = 0.029) in the proportion of births attended by a skilled provider. Epidemic intensity did not have a significant impact on any other indicator. CONCLUSION: While there is evidence that chiefdoms which experienced worse Ebola outbreaks had poorer coverage of attendance of skilled providers at birth than would have otherwise been expected, more broadly the intensity of the epidemic did not impact on most indicators. This suggests the measures to restore both staffing and trust were effective in supporting the health system to recover from Ebola.

Out Of Pocket Expenditure On Thalassemia Major And Its Implications On The Household Economics.

BACKGROUND: Pakistan faces a considerable burden of disease with regard to inherited blood disorder, i.e., Thalassemia Major. Its economic implications are least studied before, particularly when it comes to ascertaining a household's out of pocket expense on treating the disease. This study was carried out to understand the current estimate of Out-of-pocket expenditure (OOP) expense and its implications on the household and livelihood, while seeking treatment for a child suffering from thalassemia. Methods: It was a descriptive cross-sectional study of 3 months' duration. Patients were selected from Fauji Foundation Hospital (FFH) and Pakistan Institute of Medical Sciences (PIMS), through. The descriptive quantitative analysis and inferential analysis was carried through purposive sampling. RESULTS: Treatment expense of entitled patients from FFH hospital (a public hospital which offers entitlement to the families of retired army personnel) was compared with that of non-entitled patients coming to PIMS (a public sector general hospital). Total expense incurred on treatment by the end of the month was PKR. 5000-10,000 (USD31-62) in FFH, while at PIMS, the total expense incurred on treatment by the end of the month was around PKR 80,000 (USD500). Around 37% families having an average monthly income of PkRs25000 (USD150) only, sold their livelihoods, 31% compromised on their children's education expenses and 23% percent curtailed the health expenses of the other children. CONCLUSIONS: The out-of-pocket expenditure on treating TM is quite high and compels the families to borrow money and sell or mortgage their property, which puts a great deal monetary pressure given their socio-economic status. A practical solution would be to cover these families under the health safety net supported by the government.

Catastrophic health expenditure due to hospitalisation for COVID-19 treatment in India: findings from a primary survey.

OBJECTIVE: The COVID-19 pandemic has caused widespread illness and a significant proportion of the infected required hospitalisation for treatment. People in developing countries like India were vulnerable to high hospitalisation costs. Despite its crucial importance, few primary studies are available on this aspect of the pandemic. This study was aimed at finding out the out of pocket expenditure (OOPE) and incidence of catastrophic expenditure on hospitalisation of persons infected with COVID-19. A primary survey of 492 randomly selected hospitalisations of individuals tested positive for COVID-19 in high-burden districts during August to November 2020 was carried out telephonically in Chhattisgarh state of India. RESULTS: Public hospitals accounted for 69% of the hospitalisations for COVID-19 treatment. Mean OOPE per hospitalisation was Indian Rupees (INR) 4871 in public hospitals and INR 169,504 in private hospitals. Around 3% of hospitalisations in public hospitals and 59% in private hospitals resulted in catastrophic expenditure, at a threshold of 40% of non-food annual household expenditure. Enrolment under publicly or privately funded health insurance was not effective in curtailing OOPE. Multivariate analysis showed that utilisation of private hospitals was a key determinant of incurring catastrophic expenditure.

Economic burden associated with stroke in India: insights from national sample survey 2017-18.

OBJECTIVE: To estimate the out-of-pocket (OOP) expenditure and catastrophic expenditure due to stroke-related hospitalization and determine associated predictors. METHODS: Secondary analysis of household-based survey conducted by National Sample Survey Organization from June 2017 to 2018. RESULTS: A total of 1152 and 407 individuals reported stroke-related hospitalization and outpatient care, respectively, in the survey. Stroke-related hospitalization rate in India is 46 per 100,000 persons. The mean and median expenditure per episode of stroke-related hospitalization was INR 40,360 (US$ 539.75) and INR 17,140 (US$ 229.22), respectively, with significant OOP hospitalization expenditure across wealth quintiles (p < 0.001). About 29% (25-34%) of households seeking stroke treatment in public medical institutions experienced catastrophic expenditure. 37% (34-40%) of households resorted to distress health financing due to stroke-related hospitalization. Medicines accounted on an average 38% and 73% of public sector hospitalization and outpatient care, respectively. Patients treated in a private facility, hospitalized for over 7 days, within the poorest wealth quintiles had higher odds of incurring catastrophic expenditure. CONCLUSION: Economic burden associated with stroke-related hospitalization is substantial in India. The publicly funded health insurance scheme should cover expenses on stroke-related medicines to reduce OOP expenditure of patients seeking treatment in public sector facilities.