Background: In Vietnam, problems of high out-of-pocket payments for health, leading to catastrophic health expenditure and resulting impoverishment for vulnerable groups, has been at focus in the past decades. Since the beginning of the 1990’s, the Vietnamese government has launched a series of social health insurance reforms to increase prepayment in the health sector and thereby better protect the population from the financial consequences of health problems. Objective: The objective of this thesis is to contribute to the discussion in Vietnam on how large the problems of catastrophic health expenditure are in the population as a whole and in a special subgroup; the elderly households, and to assess important aspects on health insurance as a means to reduce the problems. Methods: Catastrophic health expenditure has been estimated, using an established and common method, from two different data sources; the Epidemiological Field Laboratory for Health Systems Research (FilaBavi) in the Bavi district, and Vietnam Household Living Standards Survey (VHLSS) 2010. Results from two cross-sectional analyses and a panel study have been compared, to gain information on whether the estimates of catastrophic health spending may be overestimated when using cross-sectional data. Then, the size of the problem for one group, the elderly households; hypothesized to be particularly vulnerable in this context, has been estimated. The question of to what extent a health insurance reform; the Health Care Funds for the Poor (HCFP), has offered protection for the insured against health spending is being assessed in another study over the period 2001 – 2007, using propensity score matching. The value that households attach to health insurance has also been explored through a willingness to pay (WTP) study. Results: Comparing results from two cross-sectional studies with a panel study over a full year in which the respondents were interviewed once every month, the estimates of catastrophic spending vary largely. The monthly estimates in the panels study are half as large as the cross-sectional estimates; the latter also having a recall period of one month. Among the elderly households, catastrophic health spending and impoverishment are found to be problems three times as large as for the whole population. However, household health care expenditure as a percentage of total household expenditure was affected by the HCFP, and significantly reduced for the insured. In the study of household WTP for health insurance, it was iiifound that households attach a low value to this insurance form; WTP being only half of household health expenditure. Conclusions: Cross-sectional studies of catastrophic spending with a monthly recall period are likely to be affected by recall bias leading to overestimations through respondents including expenditure in the period preceding the recall period. However, such problems should not deter researchers form studying this phenomenon. If using the same method, estimates of catastrophic spending and impoverishment can be compared between different groups – as for the elderly households – and over time; e.g. studying the protective capacity of health insurance. It should be used more, not less. The VHLSS rounds offer the Vietnamese a possibility to regularly study this. The HCFP were found to be partly protective but important problems remain to be solved, e.g. the fact that people are reluctant to use their health insurance because of e.g. quality problems and possible discrimination of the insured. The findings of a low WTP for health insurance may be another reflection of this.

Background: Non-communicable diseases (NCDs) are the leading causes of morbidity and mortality among adults in Vietnam. Little is known about the magnitude of socioeconomic inequalities in NCDs and other NCD-related factors in urban areas, in particular among the poor living in slum areas. Understanding these disparities are essential in contributing to the knowledge, needed to reduce inequalities and close the related health gaps burdening the disadvantaged populations in urban areas.  Objective: To examine the burden and health system responsiveness to NCDs in Hanoi, Vietnam and investigate the role of socioeconomic inequalities in their prevalence, subsequent healthcare utilization and related impoverishment due to health expenditures.  Methods: A cross-sectional study was conducted among 3,736 individuals aged 15 years and over who lived in 1211 randomly selected households in 2013 in urban Hanoi, Vietnam. The study collected information on household’s characteristics, household expenditures, and household member information. A qualitative approach was implemented to explore the responsiveness of commune health stations to the increasing burden of NCDs in urban Hanoi. In-depth interview approach was conducted among health staff involved in NCD tasks at four commune health stations in urban Hanoi. Furthermore, NCD managers at relevance district, provincial and national levels were interviewed.  Results: The prevalence of self-reported NCDs was significantly higher among individuals in non-slum areas (11.6%) than those in slum areas (7.9%). However, the prevalence of self-reported NCDs concentrated among the poor in both slum and non-slum areas. In slum areas, the poor needed more health care services, but the rich consumed more health care services. Among households with at least one household member reporting diagnosis of NCDs, the proportion of household facing catastrophic health expenditure and impoverishment were the greater in slum areas than in non-slum areas. Poor households in slum areas were more likely to face catastrophic health expenditure and impoverishment. The poor in non-slum areas were also more likely to face impoverishment if their household members experienced NCDs. Health system responses to NCDs at commune health stations in urban Hanoi were weak, characterized by the lack of health information, inadequate human resources, poor financing, inadequate quality and quantity of services, lack of essential medicines. The commune health stations were not prepared to respond to the rising prevalence of NCDs in urban Hanoi.  Conclusion: This thesis shows the existence of socioeconomic inequalities in the prevalence of self-reported NCDs in both non-slum and slum areas in urban Hanoi. NCDs associated with the inequalities in health care utilization, catastrophic health expenditure and impoverishment, particular in slum areas. Appropriate interventions should focus more on specific population groups to reduce the socioeconomic inequalities in the NCD prevalence and health care utilization related to NCDs to prevent catastrophic health expenditure and impoverishment among the households of NCD patients.  The functions of commune health stations in the urban setting should be strengthened through the development of NCDs service packages covered by the health insurance.

Dans le contexte d’une population vieillissante, nous avons étudié l’impact de la présence de personnes âgées sur les dépenses catastrophiques de santé (DCS), ainsi que leur impact sur trois effets reliés (le fait d’éviter des traitements, la perte de revenu, et l’utilisation de sources de financement alternatives). Nous avons utilisé les données d’une enquête du National Sample Survey Organization (Inde) en 2004, portant sur les dépenses reliées à la santé. Nous avons choisi un état développé (Kerala) et un état en voie de développement (Bihar) pour faire une comparaison des effets de la présence de personnes âgées sur les ménages. Nous avons trouvé qu’il y avait plus de DCS au Kerala et que ceci était probablement lié à la présence accrue de personnes âgées au Kerala ce qui mène à plus de maladies chroniques. Nous avons supposé que l’utilisation de services de santé privés serait lié à une augmentation de DCS, mais l’effet a varié en fonction de l’état, du présence d’une personne âgée, et du type de service utilisé (ambulatoire ou hospitalisation). Nous avons aussi trouvé que les femmes âgées au Bihar utilisait les services de santé moins qu’elle ne devrait, que les ménages ayant plus de 4 personnes ont possiblement un effet protecteur pour les personnes âgées, et que certains castes et group religieux ont dû emprunter plus souvent que d’autres groupes pour payer les frais de santé. La présence de personnes âgées, les maladies chroniques, et l’utilisation de services de santé privées sont tous liés aux DCS, mais, d’après nos résultats, d’autres groupes retardent les conséquences économiques en empruntant ou évitant les traitements. Nous espérons que ces résultats seront utilisés pour approfondir les connaissances sur l’effet de personnes âgées sur les dépenses de santé ou qu’ils seront utilisés dans des discussions de politiques de santé. / In the context of an ageing population in India, we have examined the impact of the elderly on catastrophic health expenditure (CHE) and three related access impacts (avoidance of treatment, loss of income, and alternate sources of funding). We used data from the National Sample Survey Organization (India) survey on healthcare in 2004. We chose one developed state (Kerala) and one developing state (Bihar) to compare and contrast the impact of ageing on households. Our results showed that CHE was higher in Kerala and that this was likely due to more elderly that in turn have more chronic disease. We expected the use of private treatment to lead to higher levels of CHE, and while it did for some households, the impact of private treatment on CHE, varied by state, presence of elderly, and type of health service (inpatient or outpatient). We also found that elderly females in Bihar were at a disadvantage with regards to health services utilizations, that larger household size might have a protective effect on elderly households, and that some scheduled caste and Muslim households have to borrow more often than other groups in order to fund their treatment. While the elderly, chronic disease and private treatment are linked to CHE, our results suggest that other groups may simply be delaying the consequences of paying for healthcare, by avoiding treatment or borrowing money. We hope that these results be used to explore the impact of the elderly in more detail in future research, or that it contribute to health policy discussions.

Dans le contexte d’une population vieillissante, nous avons étudié l’impact de la présence de personnes âgées sur les dépenses catastrophiques de santé (DCS), ainsi que leur impact sur trois effets reliés (le fait d’éviter des traitements, la perte de revenu, et l’utilisation de sources de financement alternatives). Nous avons utilisé les données d’une enquête du National Sample Survey Organization (Inde) en 2004, portant sur les dépenses reliées à la santé. Nous avons choisi un état développé (Kerala) et un état en voie de développement (Bihar) pour faire une comparaison des effets de la présence de personnes âgées sur les ménages. Nous avons trouvé qu’il y avait plus de DCS au Kerala et que ceci était probablement lié à la présence accrue de personnes âgées au Kerala ce qui mène à plus de maladies chroniques. Nous avons supposé que l’utilisation de services de santé privés serait lié à une augmentation de DCS, mais l’effet a varié en fonction de l’état, du présence d’une personne âgée, et du type de service utilisé (ambulatoire ou hospitalisation). Nous avons aussi trouvé que les femmes âgées au Bihar utilisait les services de santé moins qu’elle ne devrait, que les ménages ayant plus de 4 personnes ont possiblement un effet protecteur pour les personnes âgées, et que certains castes et group religieux ont dû emprunter plus souvent que d’autres groupes pour payer les frais de santé. La présence de personnes âgées, les maladies chroniques, et l’utilisation de services de santé privées sont tous liés aux DCS, mais, d’après nos résultats, d’autres groupes retardent les conséquences économiques en empruntant ou évitant les traitements. Nous espérons que ces résultats seront utilisés pour approfondir les connaissances sur l’effet de personnes âgées sur les dépenses de santé ou qu’ils seront utilisés dans des discussions de politiques de santé. / In the context of an ageing population in India, we have examined the impact of the elderly on catastrophic health expenditure (CHE) and three related access impacts (avoidance of treatment, loss of income, and alternate sources of funding). We used data from the National Sample Survey Organization (India) survey on healthcare in 2004. We chose one developed state (Kerala) and one developing state (Bihar) to compare and contrast the impact of ageing on households. Our results showed that CHE was higher in Kerala and that this was likely due to more elderly that in turn have more chronic disease. We expected the use of private treatment to lead to higher levels of CHE, and while it did for some households, the impact of private treatment on CHE, varied by state, presence of elderly, and type of health service (inpatient or outpatient). We also found that elderly females in Bihar were at a disadvantage with regards to health services utilizations, that larger household size might have a protective effect on elderly households, and that some scheduled caste and Muslim households have to borrow more often than other groups in order to fund their treatment. While the elderly, chronic disease and private treatment are linked to CHE, our results suggest that other groups may simply be delaying the consequences of paying for healthcare, by avoiding treatment or borrowing money. We hope that these results be used to explore the impact of the elderly in more detail in future research, or that it contribute to health policy discussions.

This diploma thesis deals with the Czech healthcare system. Healthcare is generally reffered to as system but not always healthcare problems are solved systematically. Therefore systems theory, theory of complex adaptive systems and other notions, that are often used in healthcare, were described in this thesis. The objective of this thesis was analysis of impacts of patient's financial participation (20 %, 25 % and 30 %) on health care to their financial situation in the complex adaptive healthcare system. In this thesis four indicators were used -- poverty line, household subsistence spending, impoverished households, catastrophic health expenditure. The World Health Organization defined this indicators for World Health Survey in different countries. The indicators were applied to a sample of Czech households and some impacts of increased participation were calculated. It results from this calculation that the increased participation of households has virtually only small impacts to their financial situation. By the indicators of poverty just few households would be on the poverty line. Nevertheless, this results aren't generalized to the whole Czech population. With this indicators we should further work and develop them in order that they could serve as tool to evaluation of state's intervetion into healthcare system.

Health economists, national decision-makers and global health specialists have been interested in calculating the cost of a disease for many years. Only more recently they started to generate more comprehensive frameworks and tools to estimate the full range of healthcare related costs of illness in a user’s perspective in resource-poor settings. There is now an ongoing trend to guide health policy, and identify the most effective ways to achieve universal health coverage. The user fee exemptions health financing schemes, which grounded the tuberculosis control strategy, have been designed to improve access to essential care for ill individuals with a low capacity to pay. After decades of functioning and substantial progress in tuberculosis detection rate and treatment success, this thesis analyses the extent of the coverage (financial and social protection) of two disease control programs in West Africa. Learning from the concept of the medical poverty trap (Whitehead, Dahlgren, et Evans 2001) and available framework related to the economic consequences of illness (McIntyre et al. 2006), a conceptual framework and a data collection tool have been developed to incorporate the direct, indirect and intangible costs and consequences of illness incurred by chronic patients. In several ways, we have sought to provide baseline for comprehensive analysis and standardized methodology to allow comparison across settings, and to contribute to the development of evidence-based knowledge.<p><p>To begin, filling a knowledge gap (Russell 2004), we have performed microeconomic research on the households’ costs-and-consequences-of-tuberculosis in Burkina Faso and Benin. The two case studies have been conducted both in rural and urban resource-poor settings between 2007 and 2009. This thesis provides new empirical findings on the remaining financial, social and ‘healthcare delivery related organizational’ barriers to access diagnosis and treatment services that are delivered free-of-charge to the population. The direct costs associated with illness incurred by the tuberculosis pulmonary smear-positive patients have constituted a severe economic burden for these households living in permanent budget constraints. Most of these people have spent catastrophic health expenditure to cure tuberculosis and, at the same time, have faced income loss caused by the care-seeking. To cope with the substantial direct and indirect costs of tuberculosis, the patients have shipped their families in impoverishing strategies to mobilize funds for health such as depleting savings, being indebted and even selling livestock and property. Damaging asset portfolios of the disease-affected households on the long run, the coping strategies result in a public health threat. In resource-poor settings, the lack of financial protection for health may impose inability to meet basic needs such as the rights to education, housing, food, social capital and access to primary healthcare. Special feature of our work lies in the breakdown of the information gathered. We have been able to demonstrate significant differences in the volume and nature of the amounts spent across the successive stages of the care-seeking pathway. Notably, pre-diagnosis spending has been proved critical both in the rural and urban contexts. Moreover, disaggregated cost data across income quintiles have highlighted inequities in relation to the direct costs and to the risk of incurring catastrophic health expenditure because of tuberculosis. As part of the case studies, the tuberculosis control strategies have failed to protect the most vulnerable care users from delayed diagnosis and treatment, from important spending even during treatment – including significant medical costs, and from hidden costs that might have been exacerbated by poor health systems. To such devastating situations, the tuberculosis patients have had to endure other difficulties; we mean intangible costs such as pain and suffering including stigmatization and social exclusion as a result of being ill or attending tuberculosis care facilities. The analysis of all the social and economic consequences for tuberculosis-affected households over the entire care-seeking pathway has been identified as an essential element of future cost-of-illness evaluations, as well as the need to conduct benefit incidence assessment to measure equity.<p><p>This work has allowed identifying a series of policy weaknesses related to the three dimensions of the universal health coverage for tuberculosis (healthcare services, population and financial protection coverage). The findings have highlighted a gap between the standard costs foreseen by the national programs and the costs in real life. This has suggested that the current strategies lack of patient-centered care, context-oriented approaches and systemic vision resulting in a quality issue in healthcare delivery system (e.g. hidden healthcare related costs). Besides, various adverse effects on households have been raised as potential consequences of illness; such as illness poverty trap, social stigma, possible exclusion from services and participation, and overburdened individuals. These effects have disclosed the lack of social protection at the country level and call for the inclusion of tuberculosis patients in national social schemes. A last policy gap refers to the lack of financial protection and remaining inequities with regards to catastrophic health expenditure still occurring under use fee exemptions strategies. Thereby, one year before 2015 – the deadline set for the Millennium Development Goals – it is a matter of priority for Benin and Burkina Faso and many other countries to tackle adverse effects of the remaining social, economic and health policy and system related barriers to tuberculosis control. These factors have led us to emphasize the need for countries to develop sustainable knowledge. <p><p>National decision-makers urgently need to document the failures and bottlenecks. Drawing on the findings, we have considered different ways to strengthen local capacity and generate bottom-up decision-making. To get there, we have shaped a decision framework intended to produce local evidence on the root causes of the lack of policy responsiveness, synthesize available evidence, develop data-driven policies, and translate them into actions.<p><p>Beyond this, we have demonstrated that controlling tuberculosis was much more complex than providing free services. The socio-economic context in which people affected by this disease live cannot be dissociated from health policy. The implications of microeconomic research on the households’ costs and responses to tuberculosis may have a larger scope than informing implementation and adaptation of national disease-specific strategies. They can be of great interest to support the definition of guiding principles for further research on social protection schemes, and to produce evidence-based targets and indicators for the reduction and the monitoring of economic burden of illness. In this thesis, we have build on prevailing debates in the field and formulated different assumptions and proposals to inform the WHO Global Strategy and Targets for Tuberculosis Prevention, Care and Control After 2015. For us, to reflect poor populations’ needs and experiences, global stakeholders should endorse bottom-up and systemic policy-making approaches towards sustainable people-centered health systems.<p><p>The findings of the thesis and the various global and national challenges that have emerged from case studies are crucial as the problems we have seen for tuberculosis in West Africa are not limited to this illness, and far outweigh the geographical context of developing countries.<p><p><p>Keywords: Catastrophic health expenditure, Coping strategies, Cost-of-illness studies, Direct, indirect and intangible costs, Evidence-based Public health, Financial and Social protection for health, Health Economics, Health Policy and Systems, Informed Decision-making, Knowledge translation, People-centered policy-making, Systemic approach, Universal Health Coverage<p> / Doctorat en Sciences de la santé publique / info:eu-repo/semantics/nonPublished