Why "free maternal healthcare" is not entirely free in Ghana: a qualitative exploration of the role of street-level bureaucratic power.

BACKGROUND: Ghana introduced a free maternal healthcare policy within its National Health Insurance Scheme (NHIS) in 2008 to remove financial barriers to accessing maternal health services. Despite this policy, evidence suggests that women incur substantial out-of-pocket (OOP) payments for maternal health care. This study explores the underlying reasons for these persistent out-of-pocket payments within the context of Ghana's free maternal healthcare policy. METHODS: Cross-sectional qualitative data were collected through interviews with a purposive sample of 14 mothers and 8 healthcare providers/administrators in two regions of Ghana between May and September 2022. All interviews were audio-recorded, transcribed and imported into the NVivo 14.0 software for analysis. An iteratively developed codebook guided the coding process. Our thematic data analysis followed the Attride-Sterling framework for network analysis, identifying basic, organising themes and global themes. RESULTS: We found that health systems and demand-side factors are responsible for the persistence of OOP payments despite the existence of the free maternal healthcare policy in Ghana. Reasons for these payments arose from health systems factors, particularly, NHIS structural issues - delayed and insufficient reimbursements, inadequate NHIS benefit coverage, stockouts and supply chain challenges and demand-side factors - mothers' lack of education about the NHIS benefit package, and passing of cost onto patients. Due to structural and system level challenges, healthcare providers, exercising their street-level bureaucratic power, have partly repackaged the policy, enabling the persistence of out-of-pocket payments for maternal healthcare. CONCLUSIONS: Urgent measures are required to address the structural and administrative issues confronting Ghana's free maternal health policy; otherwise, Ghana may not achieve the sustainable development goals targets on maternal and child health.

Catastrophic health expenditure and distress financing of breast cancer treatment in India: evidence from a longitudinal cohort study.

OBJECTIVE: To estimate the catastrophic health expenditure and distress financing of breast cancer treatment in India. METHODS: The unit data from a longitudinal survey that followed 500 breast cancer patients treated at Tata Memorial Centre (TMC), Mumbai from June 2019 to March 2022 were used. The catastrophic health expenditure (CHE) was estimated using households' capacity to pay and distress financing as selling assets or borrowing loans to meet cost of treatment. Bivariate and logistic regression models were used for analysis. FINDINGS: The CHE of breast cancer was estimated at 84.2% (95% CI: 80.8,87.9%) and distress financing at 72.4% (95% CI: 67.8,76.6%). Higher prevalence of CHE and distress financing was found among rural, poor, agriculture dependent households and among patients from outside of Maharashtra. About 75% of breast cancer patients had some form of reimbursement but it reduced the incidence of catastrophic health expenditure by only 14%. Nearly 80% of the patients utilised multiple financing sources to meet the cost of treatment. The significant predictors of distress financing were catastrophic health expenditure, type of patient, educational attainment, main income source, health insurance, and state of residence. CONCLUSION: In India, the CHE and distress financing of breast cancer treatment is very high. Most of the patients who had CHE were more likely to incur distress financing. Inclusion of direct non-medical cost such as accommodation, food and travel of patients and accompanying person in the ambit of reimbursement of breast cancer treatment can reduce the CHE. We suggest that city specific cancer care centre need to be strengthened under the aegis of PM-JAY to cater quality cancer care in their own states of residence. TRIAL REGISTRATION: CTRI/2019/07/020142 on 10/07/2019.

Willingness to pay for National Health Insurance Services and Associated Factors in Africa and Asia: a systematic review and meta-analysis.

Background: Universal health coverage (UHC) is crucial for public health, poverty eradication, and economic growth. However, 97% of low- and middle-income countries (LMICs), particularly Africa and Asia, lack it, relying on out-of-pocket (OOP) expenditure. National Health Insurance (NHI) guarantees equity and priorities aligned with medical needs, for which we aimed to determine the pooled willingness to pay (WTP) and its influencing factors from the available literature in Africa and Asia. Methods: Database searches were conducted on Scopus, HINARI, PubMed, Google Scholar, and Semantic Scholar from March 31 to April 4, 2023. The Joanna Briggs Institute's (JBI's) tools and the "preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 statement" were used to evaluate bias and frame the review, respectively. The data were analyzed using Stata 17. To assess heterogeneity, we conducted sensitivity and subgroup analyses, calculated the Luis Furuya-Kanamori (LFK) index, and used a random model to determine the effect estimates (proportions and odds ratios) with a p value less than 0.05 and a 95% CI. Results: Nineteen studies were included in the review. The pooled WTP on the continents was 66.0% (95% CI, 54.0-77.0%) before outlier studies were not excluded, but increased to 71.0% (95% CI, 68-75%) after excluding them. The factors influencing the WTP were categorized as socio-demographic factors, income and economic issues, information level and sources, illness and illness expenditure, health service factors, factors related to financing schemes, as well as social capital and solidarity. Age has been found to be consistently and negatively related to the WTP for NHI, while income level was an almost consistent positive predictor of it. Conclusion: The WTP for NHI was moderate, while it was slightly higher in Africa than Asia and was found to be affected by various factors, with age being reported to be consistently and negatively related to it, while an increase in income level was almost a positive determinant of it.

Exploring the financial burden due to additional mobility among cancer patients: A cross-sectional study based on National Sample Survey.

BACKGROUND: Cancer imposes a substantial economic burden due to treatment costs, supportive care, and loss of productivity. Besides all the affecting factors, major concerns lead to significant financial burdens of cancer treatment, bringing unwanted huge unbearable direct and indirect treatment costs. The aim was to explore the nature of additional mobility/travel required for accessing health care for cancer patients and also to assess financial burden due to additional mobility/travel costs for cancer treatment. METHODS: This study employed unit-level cross-sectional data from the 75th round (2017-18) of India's National Sample Survey (NSS). The primary analysis commenced with descriptive and bivariate analyses to explore mean health spending and out-of-pocket expenses. Subsequently, multivariable logistic regression models were utilized to estimate the associations between catastrophic health expenditure, distress financing, and the treatment location. RESULTS: The findings highlight distinct healthcare utilization patterns: inpatient treatments predominantly occur within the same district (50.4 %), followed by a different district (38.8 %), and a smaller share in other states (10.8 %). Outpatients largely receive treatment in the same district (65.5 %), followed by a different district (26.8 %), and around 8 % percent in other states. Urban areas show higher inpatient visits within the same district (41.8 %) and different districts (33.5 %). Outpatients, particularly those seeking treatment in other states, experience higher total expenditures, notably with higher out-of-pocket expenses. Distress financing is more common among inpatients (20.6 %) and combined inpatient/outpatient cases (23.9 %), while outpatients exhibit a lower rate (6.8 %). CONCLUSION: The findings collectively suggest the importance of developing local healthcare infrastructures to reduce the additional mobility of cancer patients. The policy should focus to train and deploy oncologists in non-urban areas can help bridge the gap in cancer care proficiency and reduce the need for patients to travel long distances for treatment.

Prevalence of internet addiction and psychological factors in adolescents during the covid-19 pandemic / Prevalência de dependência da internet e fatores psicológicos em adolescentes durante a pandemia de covid-19 / Prevalencia de la adicción a internet y factores psicológicos en adolescentes durante la pandemia de la covid-19

Addictive behaviors related to Internet are becoming more common and this tool has been essential once it enables home office, entertainment, homeschooling, and easy access to information. Despite the easiness brought by technology, the exaggerated use has affected users in different ways, including in the development of psychiatric disorders. This study aimed to assess internet addiction, depression, anxiety, attention-deficit/hyperactivity disorder (ADHD), attention, impulsivity, and stress in 48 adolescents (26 young women and 22 young men), aged from 15 to 18 years, with a mean age of 16.74 (0.61), mostly students of public schools, during COVID-19, to investigate correlations between these variables according to sex and sociodemographic aspects. To assess the factors, the Internet Addiction Test (IAT); the Swanson, Nolan, and Pelham Rating Scale (SNAP-IV) Questionnaire ; the Depression, Anxiety, and Stress scale for brazilian adolescents (EDAE-A); the Barratt Impulsiveness Scale (BIS-11); and a sociodemographic questionnaire were applied. The data collection was performed in schools located in southern Brazil. The results indicated that 12 out of 48 adolescents were considered addicted to the Internet. Moreover, Internet addiction was a predictor of depression in regression analysis (p<0.001). In addition, participants classified as more addicted to the Internet scored lower averages in general attention (p<0.035) and higher averages in behavioral symptoms of inattention and ADHD (p<0.050), stress (p<0.003), anxiety (p<0.016), and depression (p<0.015), with effect sizes ranging from moderate to high. Therefore, the intense internet use by adolescents might cause psychological consequences such as depression in adolescents. Family support and professional intervention might help in the reduction of symptoms and consequences of internet addiction as well as in its prevention.(AU)

A dependência de internet é cada vez mais comum, pois essa ferramenta tem se tornado imprescindível, uma vez que possibilita home office, entretenimento, educação domiciliar e fácil acesso às informações. No entanto, o uso exagerado da tecnologia afeta os usuários de diversas formas, inclusive no desenvolvimento de transtornos psiquiátricos. Este estudo visou avaliar a dependência de internet, depressão, ansiedade, hiperatividade, atenção, impulsividade e estresse em 48 adolescentes (26 meninas e 22 meninos) de 15 a 18 anos, com idade média de 16,74 (0,61), estudantes de escolas públicas do Sul do Brasil durante a covid-19, para investigar correlações entre as variáveis anteriores de acordo com gênero e aspectos sociodemográficos. Para avaliar, aplicou-se o Internet Addiction Test (IAT), um teste de atenção, escala SNAP IV, escala de depressão, ansiedade e estresse para adolescentes (EDAE-A), escala de impulsividade de Barratt e um questionário sociodemográfico. Os resultados indicaram que 12 adolescentes foram considerados viciados em internet, e que a dependência desta foi preditora da depressão na análise de regressão (p < 0,001). Ainda, os participantes classificados como adictos tiveram médias mais baixas em atenção geral (p < 0,035) e mais altas em sintomas comportamentais de desatenção e hiperatividade (p < 0,050), estresse (p < 0,003), ansiedade (p < 0,016) e depressão (p < 0,015), com efeitos que variaram de moderado a alto. Portanto, o uso intenso da internet por adolescentes pode ter consequências psicológicas, como a depressão. Bom apoio familiar e intervenção profissional podem ajudar na redução dos sintomas e consequências, bem como na prevenção da dependência.(AU)

La adicción a Internet es cada vez más habitual, puesto que esta herramienta es esencial para el trabajo remoto, el entretenimiento, la educación domiciliar y el fácil acceso a la información. Sin embargo, su uso exagerado afecta a la vida de las personas de diferentes maneras, incluso en el desarrollo de trastornos psiquiátricos. El objetivo de este estudio fue evaluar la adicción a Internet, depresión, ansiedad, hiperactividad, atención, impulsividad y estrés en 48 adolescentes (26 muchachas y 22 muchachos), de entre 15 y 18 años, con una edad promedio de 16,74 (0,61), en su mayoría estudiantes de escuelas públicas del Sur de Brasil, durante la pandemia de la COVID-19, para investigar las correlaciones entre las variables mencionadas según género y aspectos sociodemográficos. Para evaluar los factores, se aplicaron el Test de Adicción a Internet (TAI), un test de atención, la escala SNAP IV, la Escala de Depresión, Ansiedad y Estrés para adolescentes (EDAE-A), la escala de impulsividad de Barratt y un cuestionario sociodemográfico. Los resultados indicaron que 12 adolescentes fueron considerados adictos a Internet, además, la adicción a Internet fue un predictor de la depresión en el análisis de regresión (p<0,001). Igualmente, los participantes clasificados como más adictos a Internet tuvieron promedios más bajos en atención general (p<0,035), y más altos en síntomas conductuales de falta de atención e hiperactividad (p<0,050), estrés (p<0,003), ansiedad (p<0,016) y depresión (p<0,015), con efectos que varían de moderado a alto. Por lo tanto, el uso intenso podría producir consecuencias psicológicas como la depresión en los adolescentes. Tener un buen apoyo familiar e intervención profesional puede ayudar a reducir los síntomas y las consecuencias de la adicción a Internet, así como prevenirla.(AU)

Gasto de bolsillo en salud en la familia con diabetes-hipertensión durante la pandemia del covid-19 / Out-of-pocket health spending in the family with diabetes-hypertension during the covid-19 pandemic

Determinar el gasto de bolsillo en salud en las familias con diabetes mellitus y/o hipertensión arterial y el porcentaje del ingreso familiar durante la pandemia del Covid-19. Estudio de gasto de bolsillo en salud que incluyó muestreo consecutivo de 268 familias de México. El ingreso trimestral familiar se definió como la suma de ingresos de cada uno de los integrantes de la familia, el gasto en salud se definió como el total de erogaciones que tuvo la familia para cubrir los diferentes servicios de salud, y porcentaje de gasto en salud se definió como la relación del gasto total trimestral y el gasto corriente del hogar, valores expresados en pesos mexicanos. El promedio trimestral del gasto de bolsillo en salud en la familia con diabetes mellitus y/o hipertensión arterial en la dimensión consulta fue $975,82 y en la dimensión medicamentos $1,371.22; el gasto promedio total trimestral fue $3,133.08. El ingreso trimestral de la familia después de la pandemia del covid-19 fue $85,348.86 lo que representa 5,93% menos del ingreso trimestral antes de la pandemia. El gasto trimestral en salud fue $3,133.08, lo cual corresponde a 3,45% y 3,67% del ingreso trimestral familiar antes y después de la pandemia del Covid-19 respectivamente (AU)

Determine out-of-pocket health spending in families with diabetes mellitus and/or high blood pressure and the percentage of family income during the Covid-19 pandemic. Study of out-of-pocket health spending that included consecutive sampling of 268 families in Mexico. The quarterly family income was defined as the sum of income of each of the family members, health spending was defined as the total expenses that the family had to cover the different health services, and percentage of health spending. It was defined as the relationship between total quarterly expenditure and current household expenditure, values expressed in Mexican pesos. The quarterly average of out-of-pocket health expenditure in the family with diabetes mellitus and/or arterial hypertension in the consultation dimension was $975.82 and in the medication dimension $1,371.22; The average total quarterly expense was $3,133.08. The family's quarterly income after the covid-19 pandemic was $85,348.86, which represents 5.93% less than the quarterly income before the pandemic. The quarterly health expenditure was $3,133.08, which corresponds to 3.45% and 3.67% of the family's quarterly income before and after the Covid-19 pandemic respectively (AU)

Implementation of Systematic Financial Screening in an Outpatient Breast Oncology Setting.

PURPOSE: Implementation of routine financial screening is a critical step toward mitigating financial toxicity. We evaluated the feasibility, sustainability, and acceptability of systematic financial screening in the outpatient breast oncology clinic at a large, urban cancer center. METHODS: We developed and implemented a stakeholder-informed process to systematically screen for financial hardship and worry. A 2-item assessment in English or Spanish was administered to patients through the electronic medical record portal or using paper forms. We evaluated completion rates and mode of completion. Through feedback from patients, clinicians, and staff, we identified strategies to improve completion rates and acceptability. RESULTS: From March, 2021, to February, 2022, 3,500 patients were seen in the breast oncology clinic. Of them, 39% (n = 1,349) responded to the screening items, either by paper or portal, 12% (n = 437) preferred not to answer, and the remaining 49% (n = 1,714) did not have data in their electronic health record, meaning they were not offered screening or did not complete the paper forms. Young adults (18-39 years) were more likely to respond compared with patients 70 years or older (61% v 30%, P < .01). English-preferring patients were more likely to complete the screening compared with those who preferred Spanish (46% v 28%, P < .01). Non-Hispanic White patients were more likely to respond compared with Non-Hispanic Black patients and with Hispanic patients (46% v 39% v 32%, P < .01). Strategies to improve completion rates included partnering with staff to facilitate paper form administration, optimizing patient engagement with the portal, and clearly communicating the purpose of the screening. CONCLUSION: Systematic financial screening is feasible, and electronic data capture facilitates successful implementation. However, inclusive procedures that address language and technology preferences are needed to optimize screening.

Illnesses and hardship financing in India: an evaluation of inpatient and outpatient cases, 2014-18.

BACKGROUND: Progress towards universal health coverage requires strengthening the country's health system. In developing countries, the increasing disease burden puts a lot of stress on scarce household finances. However, this burden is not the same for everyone. The economic burden varies across the disease groups and care levels. Government intervention is vital in formulating policies in addressing financial distress at the household level. In India, even when outpatient care forms a significant proportion of out-of-pocket expenditure, government schemes focus on reducing household expenditure on inpatient care alone. Thus, people resort to hardship financing practices like informal borrowing or selling of assets in the event of health shocks. In this context, the present study aims to identify the disease(s) that correlates with maximum hardship financing for outpatients and inpatients and to understand the change in hardship financing over time. METHODS: We used two waves of National Sample Survey Organisation's data on social consumption on health- the 71st and the 75th rounds. Descriptive statistics are reported, and logistic regression is carried out to explain the adjusted impact of illness on hardship financing. Pooled logistic regression of the two rounds is estimated for inpatients and outpatients. Marginal effects are reported to study the changes in hardship financing over time. RESULTS: The results suggest that cancer had the maximum likelihood of causing hardship financing in India for both inpatients (Odds ratio 2.41; 95% Confidence Interval (CI): 2.03 - 2.86 (71st round), 2.54; 95% CI: 2.21 - 2.93 (75th round)) and outpatients (Odds ratio 6.11; 95% CI: 2.95 - 12.64 (71st round), 3.07; 95% CI: 2.14 - 4.40 (75th round)). In 2018, for outpatients, the hardship financing for health care needs was higher at public health facilities, compared to private health facilities (Odds ratio 0.72; 95% CI: 0.62 - 0.83 (75th round). The marginal effects model of pooled cross-section analysis reveals that from 2014 to 2018, the hardship financing had decreased for inpatients (Odds ratio 0.747; 95% CI:0.80 - -0.70), whereas it had increased for outpatients (Odds ratio 0.0126; 95% CI: 0.01 - 0.02). Our results also show that the likelihood of resorting to hardship financing for illness among women was lesser than that of men. CONCLUSION: Government intervention is quintessential to decrease the hardship financing caused by cancer. The intra-household inequalities play an important role in explaining their hardship financing strategies. We suggest the need for more financial risk protection for outpatient care to address hardship financing.

Progressivity of out-of-pocket costs under Australia's universal health care system: A national linked data study.

BACKGROUND: In line with affordability and equity principles, Medicare-Australia's universal health care program-has measures to contain out-of-pocket (OOP) costs, particularly for lower income households. This study examined the distribution of OOP costs for Medicare-subsidised out-of-hospital services and prescription medicines in Australian households, according to their ability to pay. METHODS: OOP costs for out-of-hospital services and medicines in 2017-18 were estimated for each household, using 2016 Australian Census data linked to Medicare Benefits Schedule (MBS) and Pharmaceutical Benefit Scheme (PBS) claims. We derived household disposable income by combining income information from the Census linked to income tax and social security data. We quantified OOP costs as a proportion of equivalised household disposable income and calculated Kakwani progressivity indices (K). RESULTS: Using data from 82% (n = 6,830,365) of all Census private households, OOP costs as a percentage of equivalised household disposable income decreased from 1.16% in the poorest decile to 0.63% in the richest decile for MBS services, and from 1.35% to 0.35% for PBS medicines. The regressive trend was less pronounced for MBS services (K = -0.06), with percentage OOP cost relatively stable between the 2nd and 9th income deciles; while percentage OOP cost decreased with increasing income for PBS medicines (K = -0.24). CONCLUSION: OOP costs for out-of-hospital Medicare services were mildly regressive while those for prescription medicines were distinctly regressive. Actions to reduce inequity in OOP costs, particularly for medicines, should be considered.

Willingness to pay for a National Health Insurance Scheme in The Gambia: a contingent valuation study.

In pursuit of universal health coverage, many low- and middle-income countries are reforming their health financing systems and introducing health insurance schemes. As part of these reforms, lawmakers in The Gambia enacted 'The National Health Insurance Bill, 2021'. The Act will establish a National Health Insurance Scheme (NHIS) that pays for the cost of healthcare services for its members. This study assessed Gambians' willingness to pay (WTP) for a NHIS. Using multistage sampling design with no replacement, head/co-head of households were presented with a hypothetical health insurance scheme from July to August 2020. Their WTP and factors influencing WTP were elicited using a contingent valuation method. Descriptive statistics were used to describe sample characteristics. Lopez-Feldman's modified ordered probit model and linear regression were applied to estimate respondents' WTP as well as identify factors that influence their WTP. More than 90% of the respondents-677 (94.4%) were willing to join and pay for the scheme. Half of these respondents-398 (58.8%) agreed to pay the first bid of US dollars (US$) 20.78 or Gambian dalasi (GMD) 1000. The average WTP was estimated at US$23.27 (GMD1119.82), whereas average maximum amount to pay was US$26.01 (GMD1251.16). Results of the two models together showed that gender, level of education and household income were statistically significant, with the latter showing negative influence on WTP. The study found that Gambians were largely receptive to the scheme and have stated their willingness to contribute. Our findings can inform policymakers in The Gambia and other sub-Saharan countries when establishing contribution rates and exemption criteria during social health insurance scheme implementation.

Robotic thoracic surgery in Canada: Are patients willing to pay out of pocket?

Robotic-assisted thoracoscopic surgery (RTS) is safe and effective, but is associated with high capital and operating costs that are not reimbursed by the Canadian government. Currently, patients have access to RTS only when it is supported by research or philanthropic funds. In a recent study, we assessed the extent of patient-reported satisfaction with RTS, whether patients would have been willing to pay out of pocket for it, and what factors were associated with patients' willingness to pay. Many patients (290 of 411 [70.56%]) stated that they would have paid the additional $2000 to supplement the government health care coverage to have access to RTS. Factors found to be significantly associated with participants' willingness to pay were an annual income of $60 000 or more (p = 0.034), private insurance coverage (p = 0.007), overall experience with RTS rated as 8 or higher out of 10 (p < 0.001), and overall postoperative postdischarge experience rated as satisfying or very satisfying (p = 0.004).

Disease-specific distress healthcare financing and catastrophic out-of-pocket expenditure for hospitalization in Bangladesh.

BACKGROUND: Financial risk protection and equity are two fundamental components of the global commitment to achieve Universal Health Coverage (UHC), which mandates health system reform based on population needs, disease incidence, and economic burden to ensure that everyone has access to health services without any financial hardship. We estimated disease-specific incidences of catastrophic out-of-pocket health expenditure and distress financing to investigate progress toward UHC financial risk indicators and investigated inequalities in financial risk protection indicators by wealth quintiles. In addition, we explored the determinants of financial hardship indicators as a result of hospitalization costs. METHODS: In order to conduct this research, data were extracted from the latest Bangladesh Household Income and Expenditure Survey (HIES), conducted by the Bangladesh Bureau of Statistics in 2016-2017. Financial hardship indicators in UHC were measured by catastrophic health expenditure and distress financing (sale/mortgage, borrowing, and family support). Concentration curves (CC) and indices (CI) were estimated to measure the pattern and severity of inequalities across socio-economic classes. Binary logistic regression models were used to assess the determinants of catastrophic health expenditure and distress financing. RESULTS: We found that about 26% of households incurred catastrophic health expenditure (CHE) and 58% faced distress financing on hospitalization in Bangladesh. The highest incidence of CHE was for cancer (50%), followed by liver diseases (49.2%), and paralysis (43.6%). The financial hardship indicators in terms of CHE (CI = -0.109) and distress financing (CI = -0.087) were more concentrated among low-income households. Hospital admission to private health facilities, non-communicable diseases, and the presence of chronic patients in households significantly increases the likelihood of higher UHC financial hardship indicators. CONCLUSIONS: The study findings strongly suggest the need for national-level social health security schemes with a particular focus on low-income households, since we identified greater inequalities between low- and high-income households in UHC financial hardship indicators. Regulating the private sector and implementing subsidized healthcare programmes for diseases with high treatment costs, such as cancer, heart disease, liver disease, and kidney disease are also expected to be effective to protect households from financial hardship. Finally, in order to reduce reliance on OOPE, the government should consider increasing its allocations to the health sector.

Willingness to pay for a National Health Insurance (NHI) in Saudi Arabia: a cross-sectional study.

BACKGROUND: Healthcare services in Saudi Arabia are provided free of charge to its citizens at the point of use. Recently, however, the government has realized that this model is unsustainable in the long run. Therefore, Saudi decision-makers are seeking to have a sustainable health system through the introduction of a contributory National Health Insurance that require making regular financial contributions from its members. OBJECTIVE: This study aims to explore the people's willingness to pay for a National Health Insurance system in Saudi Arabia. The study also aims to understand the factors affecting their willingness or unwillingness to pay NHI, such as, their demographic and socio-economic characteristics, the type of their usual health care provider, and their satisfaction with the current healthcare services. METHODS: A cross-sectional study design with Contingent Valuation (CV) technique was used to measure the value of National Health Insurance based on an individual's willingness to pay. The data were collected from 475 participants using an online survey via Google Forms between March 2021 and April 2021. Frequencies, logistic regression, and linear regression, were conducted to answer the research questions. RESULTS: The number of individuals who was willing to pay for NHI was higher than those who were not willing to pay (62.9, 95% CI = 58.4-67.3%) vs (37.1, 95% CI = 32.7-41.6%). A binomial test found this difference was statistically significant (p < 0.001). There was a significant association between the likelihood of paying for NHI and type of usual healthcare provider (OR = 3.129, 95% CI = 1.943-5.039, p < 0.001); as individuals using public health services were more likely to pay for NHI. Also, with satisfaction with health services (OR = 14.305, 95% CI = 3.240-63.153, p < 0.001), as individuals who were very satisfied with the healthcare services were more likely to pay for NHI. The median amount of money the people were willing to pay as a monthly contribution for NHI was 100 SAR (26.5 USD) with the average being 152 SAR (40 USD). There was a significant association between the maximum amount the participants were willing to pay and age, region, and education. Specifically, 30-39-year-olds were willing to pay more for NHI compared to participants aged 50 or older (ß = 103.55, 95% CI = 26.27- 199.29); participants from central region more than participants from northern region (ß = 70.71,95% CI = 2.14- 138.58); and participants with masters degree more than participants with PhDs (ß = 227.46, 95% CI = 81.59- 399.28). CONCLUSION: This study provided some evidence that more people were willing to pay for NHI than those who declined. Individuals who frequently used public health services and were very satisfied with these services were more willing to pay for NHI. Younger population, those with master's degree, and from the central region were willing to pay more amount of money for NHI. These results could help policy makers shape their decisions and anticipate problems that may arise with NHI implementation.

Willingness to Pay for National Health Insurance: A Contingent Valuation Study Among Patients Visiting Public Hospitals in Melaka, Malaysia.

BACKGROUND: The Malaysian public healthcare system is tax funded, with healthcare costs highly subsidized by the Government. The current health financing is not sustainable to cover all the healthcare resources. Introducing a national health insurance (NHI), a prepayment method, would protect the population from financial hardship by reducing out-of-pocket payment, minimizing the barrier to accessing health and achieving equitable healthcare. Studies on the willingness to pay (WTP) for NHI are available in different contexts; however, little was found in Malaysia. In addition, factors affecting the WTP for NHI have been less researched in the Malaysian context. OBJECTIVE: This study investigates the WTP for NHI and factors influencing it in Melaka, Malaysia. METHOD: Using the contingent valuation method, the researchers distributed a pre-tested self-administered questionnaire to 489 respondents in three leading public hospitals from 1 to 9 November 2019. Multi-stage sampling forms the selection of respondents. Respondents were presented with a hypothetical scenario on NHI and asked whether they would be willing to pay for NHI. Chi-square was used to examine the association between categorical independent variables and WTP for NHI, and binary logistic regression was applied to determine the variables with the most predictive effect towards WTP for NHI. RESULTS: Out of 462 usable responses, 344 respondents (74.5%) were willing to pay for NHI. The majority (51.3%) of the respondents were willing to pay 15 Malaysian Ringgit (3.70 US dollars) or more for the NHI scheme. Chi-square analysis revealed that age, marital status, education level, employment status, chronic diseases, and perception towards NHI were significantly associated with WTP for NHI. Binary regression analysis found that marital status and perception towards NHI have the most predictive effect on respondents' WTP for NHI. CONCLUSION: This study revealed that the majority of the respondents are willing to pay for NHI if implemented in Malaysia. The findings lay a foundation for implementing a future NHI framework in Malaysia and reference future health financing research.

Impact of Pain on Employment and Financial Outcomes Among Cancer Survivors.

PURPOSE: Although pain is a frequently reported symptom among individuals with cancer, there is limited information on the impact of pain on employment or financial outcomes. This study used nationally representative data to examine the role of pain levels on employment and financial outcomes. METHODS: We used data from the 2016-2017 Medical Expenditure Panel Survey Experiences with Cancer Survivorship Supplement to identify 1,213 adults diagnosed with cancer. Multivariable logistic regression analyses were used to examine association of pain levels and self-reported employment and financial outcomes. RESULTS: Approximately 43% of adults with a cancer history reported no pain, 29% mild pain, 18% moderate pain, and 10% severe pain over the past 7 days. Compared with those reporting no pain, individuals reporting any pain had significantly increased likelihood of adverse employment outcomes including early retirement, feeling less productive, and staying at a job because of concerns about losing insurance. Individuals with any pain (compared with no pain) also had significantly increased likelihood of adverse financial outcomes including borrowing money or going into debt, inability to cover medical costs, and worrying about paying medical bills. For both employment and financial outcomes, there were dose-response relationships, with worse outcomes generally associated with greater pain levels. CONCLUSION: Pain is frequently associated with adverse employment and financial outcomes among cancer survivors, and greater pain is associated with worse outcomes. Better assessment of pain severity among survivors and implementation of strategies to assist with employment and financial objectives may be important steps to enhance patient-centered care.

'If I don't work, I don't get paid': An Australian qualitative exploration of the financial impacts of acute myeloid leukaemia.

A cancer diagnosis can have significant financial impacts for patients, often resulting from unexpected out-of-pocket expenses and a reduced capacity to work. These financial implications have been well characterised quantitatively in common cancers. However, less is known about the lived experience of financial stress, particularly outside the United States and in rarer cancers. This study aimed to explore the perceived financial impact of acute myeloid leukaemia (AML)-a rare haematological malignancy where patients may be particularly vulnerable to financial stress due to the lengthy, specialised and centralised care. The findings provide insight into the patients' lived experience of the personal financial impact of the disease. This Australian qualitative study was undertaken with 11 adults in remission from AML and recruited from their treating hospital. Semi-structured interviews were transcribed, and data were managed using NVivo. Themes were identified through inductive and deductive analysis using open, axial and thematic coding. Four themes were identified: burden of AML-attributable costs (e.g. out-of-pocket parking and medication expenses); accommodating the AML-impact on paid work (e.g. early retirement and modifying job tasks); the consequence of financial strain from AML (e.g. using savings and accessing Government welfare) and concerns about the future and future familial financial burden (e.g. securing finances and worry about depleting financial resources). A reduction in or stopping work was perceived as the most burdensome to their current and future finances. The findings demonstrate people with AML experience financial difficulty even within a publically funded healthcare system. Opportunities exist for health services to alleviate some financial burden through reducing or abolishing parking fees for oncology patients and ensuring adequate access to social workers to facilitate access to Government welfare. Improving patients' financial difficulties contributes to improved quality of life, which is congruent to cancer survivorship.

Socio-Demographic Predictors of Willingness to Pay for Premium of National Health Insurance: A Cross-sectional Survey of Six Districts in Sierra Leone.

BACKGROUND: The government of Sierra Leone introduced Social Health Insurance Scheme as a measure to remove financial barriers that beset the people in accessing health to ensure universal coverage. Under this policy, the citizens were encouraged to subscribe to the scheme to avoid out of pocket payment for healthcare at the point of use. This study was conducted to find out the predictors of willingness among the people to pay for health insurance premium. METHODS: A cross-sectional study design was employed in six selected districts in Sierra Leone. Quantitative data was collected for this study through the use of semi-structured questionnaire with a sample size of 1185 respondents. Data was analysed into descriptive and inferential statistics using the contingent valuation model. Statistical analysis was run at 5% significant level using Stata version 14.0 software. RESULTS: The results showed that majority of the respondent are willing to join and pay a monthly premium of Le 10 000 (US$1.03) with an estimated mean contribution of about Le 14 089 (US$1.44) and the top five predictors of willingness to pay (WTP) were household monthly income, age, district of resident, gender, and educational qualification. CONCLUSION: The findings on predictors of WTP premium of Sierra Leone National Social Health Insurance (SLeNSHI), suggests that the socio-demographic characteristics of the population are important in premium design and payment. Efforts at improving the socio-economic statuses of the population could be helpful in premium design and payment.

Palliative care and catastrophic costs in Malawi after a diagnosis of advanced cancer: a prospective cohort study.

BACKGROUND: Inclusive universal health coverage requires access to quality health care without financial barriers. Receipt of palliative care after advanced cancer diagnosis might reduce household poverty, but evidence from low-income and middle-income settings is sparse. METHODS: In this prospective study, the primary objective was to investigate total household costs of cancer-related health care after a diagnosis of advanced cancer, with and without the receipt of palliative care. Households comprising patients and their unpaid family caregiver were recruited into a cohort study at Queen Elizabeth Central Hospital in Malawi, between Jan 16 and July 31, 2019. Costs of cancer-related health-care use (including palliative care) and health-related quality-of-life were recorded over 6 months. Regression analysis explored associations between receipt of palliative care and total household costs on health care as a proportion of household income. Catastrophic costs, defined as 20% or more of total household income, sale of assets and loans taken out (dissaving), and their association with palliative care were computed. FINDINGS: We recruited 150 households. At 6 months, data from 89 (59%) of 150 households were available, comprising 89 patients (median age 50 years, 79% female) and 64 caregivers (median age 40 years, 73% female). Patients in 55 (37%) of the 150 households died and six (4%) were lost to follow-up. 19 (21%) of 89 households received palliative care. Catastrophic costs were experienced by nine (47%) of 19 households who received palliative care versus 48 (69%) of 70 households who did not (relative risk 0·69, 95% CI 0·42 to 1·14, p=0·109). Palliative care was associated with substantially reduced dissaving (median US$11, IQR 0 to 30 vs $34, 14 to 75; p=0·005). The mean difference in total household costs on cancer-related health care with receipt of palliative care was -36% (95% CI -94 to 594; p=0·707). INTERPRETATION: Vulnerable households in low-income countries are subject to catastrophic health-related costs following a diagnosis of advanced cancer. Palliative care might result in reduced dissaving in these households. Further consideration of the economic benefits of palliative care is justified. FUNDING: Wellcome Trust; National Institute for Health Research; and EMMS International.

Catastrophic expenditure and impoverishment after caesarean section in Sierra Leone: An evaluation of the free health care initiative.

BACKGROUND: Utilizing surgical services, including caesarean sections, can result in catastrophic expenditure and impoverishment. In 2010, Sierra Leone introduced the Free Health Care Initiative (FHCI), a national financial risk protection program for the most vulnerable groups. Aim of this study was to investigate catastrophic expenditure and impoverishment related to caesarean section in Sierra Leone and evaluate the impact of the FHCI. METHODS: Women who delivered by caesarean section in nine hospitals were followed up with home visits one month after surgery, and data on medical and non-medical expenditures were collected. Individual income was estimated based on household characteristics and used to determine catastrophic expenditure and impoverishment for each patient. The impact of the FHCI was assessed by comparing actual expenditure with counterfactual expenditures had the initiative not existed. RESULTS: For the 1146 patients in the study, the median expenditure was 23 (IQR 4; 56) international dollars (Int$). Patients in the poorest quintile spent a median Int$ 59 (IQR 28; 76), which was significantly more than patients in the richest quintile, who spent a median Int$ 17 (IQR 2; 38, p<0.001). Travel (32.9%) and food (28.7%) were the two largest expenses. Catastrophic expenditure was encountered by 12.0% and 4.0% (10% and 25% threshold, respectively) of the women. Without the FHCI, 66.1% and 28.8% of the women would have encountered catastrophic expenditure. CONCLUSION: Many women in Sierra Leone face catastrophic expenditure related to caesarean section, mainly through food and travel expenses, and the poor are disproportionally affected. The FHCI is effective in reducing the risk of catastrophic expenditure related to caesarean section, but many patients are still exposed to financial hardship, suggesting that additional support is needed for Sierra Leone's poorest patients.