Few days back I was reading the article that will be posted here today. It is also a socio-economic study on the impact of snakebites on Bangladesh. It is a short study, one of the few done on this particular topic and almost at the end introduces the concept of: CATASTROPHIC HEALTH EXPENDITURES.
Any health expenditure that threatens a household's financial capacity to maintain its subsistence needs is termed as catastrophic
First I will summarize the article and then we can go further to explore this concept.
Please refer alway to the full article.
The impact of snake bite on household economy in Bangladesh
A. Basher et al. Dpt. of Medicine, Sir Salimullah Medical College, Dhaka, Bangladesh.
TROPICAL DOCTOR 2012: 1-3
DOI: 10.1258/td.2011.110137
The present study aims to assess the different types of costs for treatment of snakebite patients, to quantify household economic impact and to understand the coping mechanisms required to cover the cost for snakebite patients in Bangladesh.
The patients admitted to four tertiary level hospitals were interviewed using structured questionnaires including health-care-related expenditures and the way in which the expenditures were covered.
Introduction:
Delays in diagnosis and treatment are common and result in part from the burden of payment for the service providers and drug therapy. When indicated snake anti-venom is given(ASV). The ASV is not manufactured in Bangladesh and supplies to government hospitals are irregular.
Methods:
The study includes 83 patients admitted suffering from snakebites from June to October 2006. Adult members of the households involved were interviewed using structured questionnaires documenting history, clinical features, treatment-seeking behavior, health-care-related expenditures and the way in which these expenditures were covered.
Direct treatment cost as well as indirect cost (transport, attendant cost...) and opportunity cost (lost of wages) were also recorded. The authors conducted a survey on private pharmacy shops close to hospital in order to document market prices, availability of ASV.
Results:
Total of patients included in the study: 83. Around 70% male. The occupations were widely distributed, only 18% agricultural labour. Others were house wife (17%), businessman (16%)... even student 11%.
Almost 60% were living in katcha house (constructed from mud, stone and wooden beams). 65% had electricity, 30% radio, 42% tv, 68% used a sanitary latrine and most 95% were drinking water from a tube well.
The monthly income ranged from US$4.48 to US$1,194. Mean of US$ 44.7
Treatment-seeking behavior before hospital admission:
54% of patients went to traditional healers (ohza); 7% to unqualified doctors (quack doctors); others to private clinics, or registered doctors and 34% to government hospitals.
Hospital Treatment
From those 83 snakebite patients, 38 were suffering from venomous snakebite. 35 recieved the ASV. 7 required artificial respiratory support and 13.2% died.
Expenditure: (here the variation is very high between groups)
Household expenditure:
US$ 13.43 to 2,294 for venomous snakes
US$ 3.61 to 134 for non-venomous snakes
ASV cost:
From US$ 8.21 to US$ 13.43 per vial.
Coping mechanism:
Among the households, 74% spent from their savings and 61% borrowed money to cope with the cost.
Spend savings (73%) , loans (61%) , sell livestock (3.6%) and others like sell ornament, sell business and even land mortgage
DISCUSSION:
The importance of illness and health-care cost as major contributors to poverty have been increasingly recognized in recent years.
Health economist at the WHO have defined "catastrophic health expenditures" as expenditures for health care totaling 40% of a household income after basic subsistence.
In the study, the population had a median household income of US$ 50 per month.
The authors stress the need for the following in order to improve the care of snakebite cases:
1) The initiation of a country-wide training program for health-care service providers.
2) A mass awareness development program about first aid treatment of snakebite patients
3) The provision of a smooth supply of anti-snake venom to public hospitals.
4) The supply of logistics to enable proper diagnosis, especially in endemic zones
5) The setting up of proper ICU facilities, initially in all medical college hospitals and subsequently in major district hospitals.
I like the introduction of the concept of catastrophic health expenditures as it is something recognized internationally and a very graphic way to express it and also it allows us to quantify it. This is one of the very few studies that really measures some of those economic factors. The study is based on those patients reaching a tertiary level hospital in Dhaka the capital of Bangladesh. Rural population of the sample is only a 18% of a population sample that seems must include many inhabitants from the suburbia around the city.
CATASTROPHIC HOUSEHOLD EXPENDITURE FOR HEALTH
Any health expenditure that threatens a household's financial capacity to maintain its subsistence needs is termed as catastrophic.
WHO estimates that families who spend 50% or more of their non-food expenditure on health care are likely to be impoverished. However, there is no consensus on the catastrophic threshold and cut-off values ranging from 5-20% of the total household income have been reported in the literature.
Health expenditure has been also defined as catastrophic if a household's health expenditure exceeds 40% of income remaining after subsistence needs have been met.
In developing countries, high out-of-pocket payments, an absence of risk-pooling mechanisms in health financing systems and high levels of poverty can result in catastrophic health care expenditure. Other factors contributing are households headed by an elderly or disabled person, families with a low income and those who have a member with chronic disease.
Understanding household Catastrophic Health Expenditures: a Multi-country analysis
Ke Xu, David B. Evans, Kei Kawabata, Riadh Zeramdini, Jan Klavus,
Christopher J.L. Murray
Health Systems Performance Assessment: debates, methods and empiricism.
World Health Organization, 2003, Chapter 42
Catastrophic health expenditure is defined in relation to a household's capacity to pay. In this study health expenditure is defined as catastrophic when a household's out-of-pocket payments are greater or equal to 40% of its capacity to pay.
Household capacity to pay is defined as effective income remaining after basic subsistence needs have been met.
The poorer the household, the higher the shares of total income or consumption devoted to food.
Health expenditures requiring out-of-pocket payments include all categories of health-related expenses. Typically these include consultation fees, purchases of medication and hospital bills.
59 countries were analyzed with a wide range of results. (India in not included in the study!)
The triad of
- poverty,
- health service utilization
- absence of risk pooling mechanism
Catastrophic payments are the biggest problem when all three of these factors are strong. In other words, we would expect to see high rates of catastrophic spending in countries with high rates of poverty, groups excluded from financial risk protection mechanisms such as social insurance, and moderate to high levels of health care physical access and utilization.
At this point, snakebite accidents fit perfectly on: Affect mostly small agricultural, rural villages with low incomes, they do not have any type of financial risk protection and the accident demands the access and utilization of high level and costly health services (many times private health facilities), sometimes far from were the accidents took place.
It is important to recognize that the impact of out-of-pocket (OOP) payments is not fully captured by examining catastrophic spending. Many poor households will choose not to seek care rather than become impoverished. Making the users of health services pay OOP for the services they receive has a potential dual effect at the population level: impoverishing some households that choose to seek services and excluding other individuals from seeking health care.
These is also quite clear on snakebites. When asked, patients would choose to go directly to a hospital if treatment is free or much cheaper as first option instead of local healers.
Reduction of catastrophic health care expenditures by a community-based health insurance scheme in Gujarat, India: current experiences and challenges
Michael Kent Ranson, Health Policy Unit, London School of Hygiene and Tropical Medicine. UK.
Bulletin of the WHO 2002; 80: 613-621
Material wealth, health and the ability to cope with adverse health events are intimately related.
Community-based health insurance schemes allow many people's resources to be pooled to cover the costs of unpredictable health-related events. They protect individuals and households from the risk of catastrophic medical expenses in exchange for regular payments of premiums.
Prepayment (even in the absence of pooling) can facilitate access to expensive medical care, because it spreads cost over time and prevents people having to pay at the time of treatment.
Community-based health insurance allows pooling in settings where institutional capacity is too weak to organize nationwide risk-pooling, especially in low-income countries.
The Self Employed Women's Association was started by Ela Bhatt in Ahmedabad in 1972. "It is an organization of poor, self-employed women workers. There are women who earn a living through their own labor or small businesses. They do not obtain regular salaried employment with welfare benefits like workers in the organized sector. They are the unprotected labor force of India". (Would say the same for farmers!!!)
The Self Employed Women's Association's Integrated Social Security Scheme was set up in 1992. From an annual premium of 72.5 Rs, 30 Rs were dedicated to medical insurance. Women who pay this premium are covered to a maximum of 1200 Rs per year n case of hospitalization.
It is a reimbursement system. The SEWA ass. directly provides preventive and curative services through 95 health centers which are open to its members as well as non-members.
The author analyzes the changes occurred over from 1992 to 2002.
The aim of the study is to assess the impact of a community-based health insurance scheme on the medical indebtedness or impoverishment of their members.
For Materials, methods, statistical analysis etc. please refer to the original as it is quite extensive.
Results:
Between 1 July 1994 and 30 June 2000, 1930 claims for hospitalization were made. Mean age was 41 years. The leading causes for hospitalization were injuries, malaria, acute gastroenteritis and hysterectomy. Mean duration was 6.1 days (median=4days). Private-for-profit, government and private-non-profit hospitals cared for patients in 63.9%, 28.6% and 7.5% of claims, respectively.
Claims were rejected in 215 (11%) of 1927 cases.
The women who made claims were much poorer that the general population. The mean self-reported annual household income was 24,723 Rs (67.7 Rs/day), median 19,797 (54.2 Rs/day). 502 (27%) of claimants for whom income information was available fell below the poverty line. This value is within the wide range of estimates of the percentage of Gujarati households that are below the poverty line*.
*The poverty line values correspond to a total household expenditure estimated as enough to provide 2400 calories daily in rural areas and 2100 calories daily in urban areas, plus some basic non-food items. The poverty line in 1999-2000 was an income of 254 rupees per person per month's income. The author considered a household to be below the poverty line if its reported yearly income was below 13, 716 Rs (254 Rs per person per month x 12 months x 4,5 household members).
The median spent on the 1712 hospitalizations for which the cost was reimbursed was 1387 rupees and the median amount reimbursed was 1200 rupees.
47% of the claims were reimbursed full.
Between 1 July 1994 and 30 June 2000, 1930 claims for hospitalization were made. Mean age was 41 years. The leading causes for hospitalization were injuries, malaria, acute gastroenteritis and hysterectomy. Mean duration was 6.1 days (median=4days). Private-for-profit, government and private-non-profit hospitals cared for patients in 63.9%, 28.6% and 7.5% of claims, respectively.
Claims were rejected in 215 (11%) of 1927 cases.
The women who made claims were much poorer that the general population. The mean self-reported annual household income was 24,723 Rs (67.7 Rs/day), median 19,797 (54.2 Rs/day). 502 (27%) of claimants for whom income information was available fell below the poverty line. This value is within the wide range of estimates of the percentage of Gujarati households that are below the poverty line*.
*The poverty line values correspond to a total household expenditure estimated as enough to provide 2400 calories daily in rural areas and 2100 calories daily in urban areas, plus some basic non-food items. The poverty line in 1999-2000 was an income of 254 rupees per person per month's income. The author considered a household to be below the poverty line if its reported yearly income was below 13, 716 Rs (254 Rs per person per month x 12 months x 4,5 household members).The median spent on the 1712 hospitalizations for which the cost was reimbursed was 1387 rupees and the median amount reimbursed was 1200 rupees.
47% of the claims were reimbursed full.
Expenditures on hospitalizations meant that an additional of 107 (6.6%) households fell below the poverty line. Reimbursement by the SEWA prevented 56 of this households (3.4% of 1632 claimants who were reimbursed) from falling below the poverty line (paired t-statistic=7.6, p<0.001), i.e. the fund significantly reduced the percentage of hospitalizations that would have resulted in impoverishment by 52%.
On average, claimants received reimbursement almost four months after hospital discharge, the lag time appeared to be longer for claimants who lived in rural areas and significantly for those who worked as farmers or agricultural laborers. This figures were substantially reduced on the last two years of the study: the 98 days between discharge and reimbursement broke down to 55 days.
Discussion
The SEWA Medical insurance Fund successfully included the poor. This reflects the commitment of the SEWA to target self-employed, poor women. This is probably due to the fact that it charges a flat-rate premium that is fairly low (currently 72.5 Rs, a 0,4% of median annual household income among claimants in this study). Studies of community-based health insurance have found that the cost of membership is an important determinant of participation.
This is challenging as low premiums that target a population for which the frequency of illness, and thus hospitalization, may be relatively high. A community-based health scheme that aims to strictly target the poor could improve equity and financial viability by seeking subsides from government or donor agencies. Subsides may, however, not be sufficiently reliable or sustainable. Alternatively, a socially oriented community-based health scheme could seed to broaden membership to include wealthier populations, but would ensure equity by indexing premiums to income and enabling equal (or better) access to care among the poor. For voluntary community-based health insurance schemes, this would require a high degree of social solidarity among members.
Even after claimants received reimbursement, cost relating to hospitalization were still catastrophic for some members. Some women may have paid the uncovered balance out of their savings, many undoubtedly had to borrow, sell capital, work more or forego spending.
On average, claimants received reimbursement almost four months after hospital discharge, the lag time appeared to be longer for claimants who lived in rural areas and significantly for those who worked as farmers or agricultural laborers. This figures were substantially reduced on the last two years of the study: the 98 days between discharge and reimbursement broke down to 55 days.
Discussion
The SEWA Medical insurance Fund successfully included the poor. This reflects the commitment of the SEWA to target self-employed, poor women. This is probably due to the fact that it charges a flat-rate premium that is fairly low (currently 72.5 Rs, a 0,4% of median annual household income among claimants in this study). Studies of community-based health insurance have found that the cost of membership is an important determinant of participation.
This is challenging as low premiums that target a population for which the frequency of illness, and thus hospitalization, may be relatively high. A community-based health scheme that aims to strictly target the poor could improve equity and financial viability by seeking subsides from government or donor agencies. Subsides may, however, not be sufficiently reliable or sustainable. Alternatively, a socially oriented community-based health scheme could seed to broaden membership to include wealthier populations, but would ensure equity by indexing premiums to income and enabling equal (or better) access to care among the poor. For voluntary community-based health insurance schemes, this would require a high degree of social solidarity among members.
Even after claimants received reimbursement, cost relating to hospitalization were still catastrophic for some members. Some women may have paid the uncovered balance out of their savings, many undoubtedly had to borrow, sell capital, work more or forego spending.
The lag time between discharge and reimbursement was much higher than the SEWA stated goal of 30 days, at is was certainly too long for women who had to borrow at high rates of interest to pay for their hospitalization. Some proposals to remedy that as well as to help women to submit the claims.
CONCLUSIONS:
This study is one of the few that have investigated the impact of a community-based health insurance scheme on use of health care and the financial burden of medical expenses.
In India, spending related to hospitalization is often catastrophic for household finances. The study shows that community-based health insurance schemes can effectively protect poor households from the uncertain risk of medical expenses, and they can be implemented in areas where institutional capacity is too weak to organize mandatory, nationwide risk-pooling.
We need studies on the impact of the snakebite accident on the life / economy of the victims, particularly in India. Maybe we should start thinking on ways to help coping with this stressful situation through a kind of risk pooling for rural population. Need to investigate what has been done till now. Many more patients will go to hospitals if they could afford it, at the same time we need to guarantee good services able to deal properly with snakebites.
ॐ लोकाः समस्ताः सुखिनो भवन्तु ॥
Om Lokah Samasthah Sukhino Bhavantu
May all beings everywhere be happy and peaceful
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