Transcript Presentation Title

Catastrophic expenditure under “free
care” policy in low-income country:
A case study from Liberia
Hong Wang, MD; PhD
Abt Associates Inc.
1st Global Symposium on Health Systems Research
November 18, 2010
Background
 Many low-income countries adopted “free care” policy,
in order to achieve MDG goals, as well as universal
coverage.
 A defined basic package of healthcare services, or
selected priority services are provided free of charge at
the point of services.
 This policy may reduce financial barrier of utilizing
defined services. However, little is known about its
impact on prevention of catastrophic expenditure,
which is another goal (concept of fairness) of health
financing policy (WHO, 2000).
Objectives
 Analyzing catastrophic expenditure status
under “free care” policy in Liberia.
 Specifically, following three issues will be
examined
 Does catastrophic expenditure still exist?
 Who bears catastrophic expenditure?
 What are the impacts on people’s daily living?
Liberia “free care” policy
 National Health Plan (2006): Remove user fees for all Basic
Package of Health Services (BPHS) in public facilities”
 BPHS includes range of services in the following priority areas
 Maternal and Newborn health
 Child Health
 Adolescent, Sexual and Reproductive Health
 Disease prevention, control and management
 Mental Health
 Essential Emergency Treatment
 Targets all population
 Government and Donors are main funding sources for free care
Methods
 Data source: A household survey in 2008, N=2528
 Source: Health Financing Studies (HFS), conducted by Liberia Institute for
Statistics and Geo-information service (LISGIS)
 Definition of catastrophic expenditure
 Spending over 10%-20% household expenditure on healthcare (WB)
 Analysis
 Incidence and intensity analysis: Does catastrophic expenditure exist?
 Headcount and mean positive overshot (MPO)
 Determinant analysis: Who bear the catastrophic expenditure?
 Logistic regression analysis (Catastrophic=1)
 Household consumption analysis: What are the impacts?
 Fractional logit model (% of expenditure)
Table 1. Basic characteristics of interviewed households in Liberia (2008)
Variables
Percentage/Mean
Residence
Urban
Household monthly expenditure (LD)
Household consumption
Foods
Education
Clothes
Fuel
Health
Other
Health status
Fraction of family members was ill in the the last month
Health facility in the area
Public health facility
NGO
Private health facility
No health facility
S.D.
33.1%
7301
47.1%
5508
37.4%
23.2%
22.9%
4.8%
2.9%
8.9%
22.8%
21.8%
19.4%
6.3%
6.3%
10.0%
46.6%
49.9%
39.8%
12.3%
12.6%
35.3%
49.0%
32.8%
33.2%
47.8%
Figure 1. Incidence and intensity of catastrophic expenditure
50%
% of Healthcare expenditure in total expenditure
0
Total catastrophic overshoot: Healthcare
expenditure shares exceeding threshold.
Mean positive overshoot (MPO)=
O / No. of HHs exceeding threshold.
MPO=8.6%
Headcount: Proportion HHs
exceeding threshold
Headcount=12%
Catastrophic threshold
Z=10%
20%
% of household, ranked by decreasing the share of healthcare
expenditure in total expenditure
Table 2. Logistic regression (OR): determinants of incuring catastrophic
health payment in Liberia (2008)
Variables
OR
Robust SE
Sig
Residence (ref: rural)
3.06
0.53
***
Urban
Household living standards (ref: richest quintile)
2nd richest
2.25
0.64
***
Middle
2.52
0.72
***
2nd poorest
3.24
0.92
***
Poorest
4.50
1.30
***
Health facility in the area (ref: public health
Private health facility
2.06
0.47
***
No health facility
1.96
0.38
***
NGO
0.45
0.17
**
% of family members was ill in last month
1.75
0.28
* significant at 0.1; ** significant at 0.05; *** significant at 0.01
The estimated values are after controling for socio-economic variables
***
Table 3. Marginal effects of catasytrophic healthcare payment on
household consumption patterns (%)
Catagories of
OOP healthcare payment share in total consumption
10%
25%
consumptions
Foods
-2.45%
-12.51%
(13.8%)*
(2.92%)***
Education
-5.14%
(1.25%)***
-5.24%
-3.20%
Clothes
-8.63%
(0.99%)***
-11.06%
(1.77%)***
Fuel
-0.77%
-0.84%
(0.34%)**
-0.69%
Robust standard errors in parentheses
* significant at 10%; ** significant at 5%; *** significant at 1%
The estimated values are after controling for socio-economic status
Discussion
 Though “free care” policy may serve certain specific
health and political purposes, its function on financial
risk protection is limited
 Catastrophic expenditure of healthcare is still an unsolved
social problem, which affects daily living significantly
 Without appropriate target strategy, catastrophic
expenditure will proportionally affect more to the poor
than to the rich
 Financing is only one of HSS efforts. Service availability
also played a critical role in financial risk protection.
Policy implications
 What is role of “free care” policy in universal
coverage?
 How to reduce catastrophic expenditure, in addition
to “free care” policy?
 How to target to the poor to reduce inequity in health
financing?
 How to reduce catastrophic expenditure, in addition
to health financing strategy?
Thank you
Contact information:
Hong Wang, MD, PhD
[email protected]