Crowding-Out Effect of Out-of-Pocket Health Expenditures on Consumption Among Households in Mongolia.

BACKGROUND: High out-of-pocket (OOP) health expenditures are a common problem in developing countries. Studies rarely investigate the crowding-out effect of OOP health expenditures on other areas of household consumption. OOP health costs are a colossal burden on families and can lead to adjustments in other areas of consumption to cope with these costs. METHODS: This cross-sectional study used self-reported household consumption data from the nationally representative Household Socioeconomic Survey (HSES), collected in 2018 by the National Statistical Office of Mongolia. We estimated a quadratic conditional Engel curves system to determine intrahousehold resource allocation among 12 consumption variables. The 3-stage least squared method was used to deal with heteroscedasticity and endogeneity problems to estimate the causal crowding-out effect of OOP. RESULTS: The mean monthly OOP health expenditure per household was ₮64 673 (standard deviation [SD]=259 604), representing approximately 6.9% of total household expenditures. OOP health expenditures were associated with crowding out durables, communication, transportation, and rent, and with crowding in education and heating for all households. The crowding-out effect of ₮10 000 in OOP health expenditures was the largest for food (₮5149, 95% CI=-8582; -1695) and crowding-in effect was largest in heating (₮2691, 95% CI=737; 4649) in the lowest-income households. The effect of heating was more than 10 times greater than that in highest-income households (₮261, 95% CI=66; 454); in the highest-income households, food had a crowding-in effect (₮179, 95% CI=-445; 802) in absolute amounts. In terms of absolute amount, the crowding-out effect for food was up to 5 times greater in households without social health insurance (SHI) than in those with SHI. CONCLUSION: Our findings suggest that Mongolia's OOP health expenses are associated with reduced essential expenditure on items such as durables, communication, transportation, rent, and food. The effect varies by household income level and SHI status, and the lowest-income families were most vulnerable. SHI in Mongolia may not protect households from large OOP health expenditures.

Disparities in Depression Status Among Different Industries in Transition Economy: A Cross-Sectional Study of Mongolia.

Transition economies tend to rely on rapid growth of specific industries and hence often leads to disparities in health status among the working population. This study aims to determine the depression status in different industries and occupational groups in Mongolia, a country that is experiencing an economic transition. We conducted a cross-sectional survey between July and September 2018 in Ulaanbaatar, Mongolia. A total of 1784 employees from 22 private and public companies were enrolled in this study. The Patient Health Questionnaire-9 (PHQ-9) was used to determine the severity of depression. Prevalence of depression is evaluated using weighted analysis. The association between occupational groups (white, blue, and pink collars), industries, and PHQ-9 score was analyzed using linear regression. In multiple regression, the workers in the transportation, public administration, and education industries exhibited the highest depression scores (P < .001). Traditional variables such as age, sex, and marital status remained significant predictors in our model. Industrial types should not be overlooked in identifying depression in the working population. This is especially true for a transition economy like Mongolia. Analysis by industries is essential to promote stress management in the future among vulnerable groups in specific industries.

Willingness to pay for private health insurance among workers with mandatory social health insurance in Mongolia.

BACKGROUND: High out-of-pocket health expenditure is a common problem in developing countries. The employed population, rather than the general population, can be considered the main contributor to healthcare financing in many developing countries. We investigated the feasibility of a parallel private health insurance package for the working population in Ulaanbaatar as a means toward universal health coverage in Mongolia. METHODS: This cross-sectional study used a purposive sampling method to collect primary data from workers in public and primary sectors in Ulaanbaatar. Willingness to pay (WTP) was evaluated using a contingent valuation method and a double-bounded dichotomous choice elicitation questionnaire. A final sample of 1657 workers was analyzed. Perceptions of current social health insurance were evaluated. To analyze WTP, we performed a 2-part model and computed the full marginal effects using both intensive and extensive margins. Disparities in WTP stratified by industry and gender were analyzed. RESULTS: Only < 40% of the participants were satisfied with the current mandatory social health insurance in Mongolia. Low quality of service was a major source of dissatisfaction. The predicted WTP for the parallel private health insurance for men and women was Mongolian Tugrik (₮)16,369 (p < 0.001) and ₮16,661 (p < 0.001), respectively, accounting for approximately 2.4% of the median or 1.7% of the average salary in the country. The highest predicted WTP was found for workers from the education industry (₮22,675, SE = 3346). Income and past or current medical expenditures were significantly associated with WTP. CONCLUSION: To reduce out-of-pocket health expenditure among the working population in Ulaanbaatar, Mongolia, supplementary parallel health insurance is feasible given the predicted WTP. However, given high variations among different industries and sectors, different incentives may be required for participation.

Phase III, placebo-controlled, randomized, double-blind trial of tableted, therapeutic TB vaccine (V7) containing heat-killed M. vaccae administered daily for one month.

OBJECTIVE: Immunotherapy of tuberculosis (TB) to shorten treatment duration represents an unmet medical need. Orally delivered, tableted TB vaccine (V7) containing heat-killed Mycobacterium vaccae (NCTC 11659) has been demonstrated in prior clinical studies to be safe and fast-acting immune adjunct. METHODS: The outcome of Phase III trial of V7 containing 10 µg of hydrolyzed M. vaccae was evaluated in 152 patients randomized at 2:1 ratio: V7 (N = 100), placebo (N = 52). Both arms received conventional 1st or 2nd line TB drugs co-administered with daily pill of V7 or placebo. RESULTS: After one month mycobacterial clearance was observed in 68% (P < 0.0001) and 23.1% (P = 0.04) of patients on V7 and placebo. Stratified conversion rates in V7 recipients with drug-sensitive and multidrug-resistant TB were 86.7% and 55.6% vs 27.2% and 15% in placebo. Patients on V7 gained on average 2.4 kg (P < 0.0001) vs 0.3 kg (P = 0.18) in placebo. Improvements in hemoglobin levels, erythrocyte sedimentation rate and leukocyte counts were significantly better than in controls. Liver function tests revealed that V7 can prevent chemotherapy-induced hepatic damage. CONCLUSION: Oral M. vaccae is safe, can overcome TB-associated weight loss and inflammation, reduce hepatotoxicity of TB drugs, improve sputum conversion three-fold OR 3.15; 95%CI (2.3,4.6), and cut treatment length by at least six-fold. Longer follow-up studies might be needed to further substantiate our findings (Clinicaltrials.gov: NCT01977768).

Double-blind, placebo-controlled, 1:1 randomized Phase III clinical trial of Immunoxel honey lozenges as an adjunct immunotherapy in 269 patients with pulmonary tuberculosis.

AIM: Safer and shorter antituberculosis treatment (ATT) regimens represent the unmet medical need. PATIENTS & METHODS: The patients were randomly assigned into two arms: the first (n = 137) received once-daily sublingual honey lozenge formulated with botanical immunomodulator Immunoxel and the second (n = 132) received placebo lozenges along with conventional ATT. Immunoxel and placebo arms were demographically similar: 102 versus 106 had drug-susceptible TB; 28 versus 20 multidrug-resistant TB (MDR-TB); 7 versus 7 extensively drug-resistant TB (XDR-TB); and 22 versus 20 TB-HIV. The primary end point was sputum smear conversion. RESULTS: After 1 month 87 out 132 (65.9%) of Immunoxel recipients became sputum smear negative, whereas 32 out of 127 (25.2%) in placebo group had converted (p < 0.0001). Sputum clearance produced by Immunoxel was equally effective across all forms of TB. In the immunotherapy arm the average weight gain was 2 kg, but placebo recipients gained only 0.6 kg. Immunoxel reduced TB-associated inflammation as evidenced by defervescence and normalization of elevated leukocyte counts and erythrocyte sedimentation rate. No adverse effects were seen at any time. The liver function tests indicate that ATT-caused hepatotoxicity was counteracted by Immunoxel. These results are in agreement with prior 20 trials of Immunoxel conducted over the past 17 years. CONCLUSION: Immunoxel is affordable, safe, effective, fast-acting, commercially available immunotherapeutic intervention to supplement conventional TB chemotherapy. Clinicaltrials.gov ID: NCT01061593.