Best international health practice requires that all people benefit equally from health care services regardless of their socio-economic status and that healthcare payments be based on ability to pay. Although recent household surveys in Malawi show progress in a number of health indicators population averages, many inequalities in health outcomes still exist or are widening among households stratified by socioeconomic and geographical location variables. Inequalities in out-of-pocket expenditures (OOPEs) for healthcare and how they influence utilization of healthcare services are of particular interest to policy makers as they ultimately affect overall health of households. The rationale for this study is that analysis of inequities in healthcare between socioeconomic groups can help to unmask intra-group and between groups' inequities hidden in national population averages. The study's three main papers examined equity in households' out-of-pocket healthcare payments and utilization of medical care. The study adopted the widely used economic frameworks and techniques developed by O'Donnell et al (2008) for analyzing health equity using household data. These economic frameworks focus on the notion of equal treatment for equal need and that payment for healthcare should be according to ability to pay. The Malawi Integrated Household Survey 2(2005) (MIHS2) was the main dataset used in the analysis. The MIHS2 is currently the only dataset that presents inequalities in healthcare expenditures at the household level in Malawi. However, the MIHS2 report does not examine the extent to which these inequalities are inequities. It is in this context that the first study focused on assessing, first, the progressivity of OOPEs for healthcare and second, the redistributive effect of OOPEs for healthcare as a source of finance in the Malawi health system. The progressivity results indicate that OOPEs for healthcare are relatively regressive in Malawi with the poor shouldering the highest financial burden relative to their ability to pay. The study found no evidence of redistributive effect of OOPEs on income inequalities in Malawi. The second study focused on linking OOPEs to use of healthcare using the recommended two-part model (Probit and OLS). The concentration indices were decomposed into contributing factors after standardizing for health need factors, which include age, sex, self-assessed health, chronic illness and disabilities. Probability of use of healthcare and OOPEs were both found to be concentrated among the non-poor while the poor who have higher health need have less use of healthcare. The last study assessed the socioeconomic factors associated with horizontal equity in use of medical facilities and predicted use using logistic regression. General medical facilities use was found to be more concentrated among the non-poor despite the poor having a higher health need. The results showed no significant inequalities in use of public medical facilities and self-treatment between the poor and the non-poor. Overall, inequalities in healthcare utilization and out-of-pocket healthcare expenditures in Malawi are mainly influenced by socioeconomic factors, which are non-need factors than health need factors. Inequalities due to non-need factors suggest presence of inequities, which are avoidable and unjust. This study can help policy makers have a better understanding of the possible effects of OOPEs and help in explaining the factors contributing to inequities in medical care utilization in Malawi. Such information is necessary so that highest priority should be given to the health problems or challenges disproportionately affecting households with varying levels of socioeconomic privilege. / Graduation date: 2012

<b>Background</b>: In order to protect the poor from health shocks, the Government of India launched Rashtriya Swasthya Bima Yojna (RSBY) in 2008. The objectives of this study are: a) to assess the changes in the financial burden of health care on the poor population; b) to estimate the effects of RSBY in reducing the financial burden on the poor; and c) to examine the impact of RSBY on the labour supply of the poor. <b>Methods</b>: The study is based on data from the National Sample Survey Organisation (NSSO). The sample size is between 100-125 thousand households at the all-India level. The study uses pooled cross-section regression analysis to assess the changing pattern of out-of-pocket (OOP) payments on healthcare. The impact of RSBY on financial risk protection and labour force participation rate in India were estimated using the difference-in-differences (DID) method. <b>Findings</b>: My thesis consists of three papers. The findings in the first paper, changing pattern of out-of-pocket payments, reflect that the poorest 20% of households, compared to the richest 20%, realised a slower increase in out-of-pocket as a share of the household’s total expenditure (-0.5%) and catastrophic payments (-2%) during the period of 2000-2012. However, during the same period, Scheduled caste/tribe and Muslim households reported an increased burden of out-of-pocket. The second paper finds reduction in the probability of incurring ‘any inpatient expenditure’ and ‘catastrophic inpatient expenditure’ after RSBY intervention but marginal increase in the ‘per person monthly inpatient expenditure’ and insignificant change in ‘inpatient expenditure as a share of households’ total expenditure’. The effects of the scheme on the total out-of-pocket payment are negligible and non-drug expenditure reflected significant increase. The third paper finds that women’s labour supply increased (3% per annum) but the elderly labour supply declined (1.5%). Further, men switched from self-employment to casual work while women moved to wage-paid regular and casual jobs at the cost of being self-employed. <b>Discussion and conclusion</b>: The poor and other less advantaged population groups realised an increasing OOP burden mainly on account of two factors: i) outpatient care is not covered under RSBY; and ii) the benefit package under the scheme is very modest. Women’s labour supply increased and the elderly labour supply declined in favour of leisure because of possible improvements in health. However, the overall labour supply did not change. The Indian government needs to consider broadening the benefit package and including outpatient coverage under RSBY.

Oral cancer drugs are branded and expensive medications that generally do not have generics available. The restrictions of the Medicare Part D program, including the coverage gap and high cost-sharing, and the high cost of oral chemotherapy may lead to patients’ non-adherence to medication. Few studies have examined the cost and utilization of oral anti-cancer medications. This study will be the first to examine the costs associated with the use of oral anti-cancer medications and the impact of cost-sharing and type of prescription drug subsidy on medication discontinuation in the Medicare Part D elderly population. Objectives: To determine the usage and costs of oral cancer treatment in elderly Medicare Part D beneficiaries and to examine the relationship between out of pocket costs and medication discontinuation or delay. Methods: A cross-sectional study of the spending and usage of oral cancer drugs in the Medicare Part D population was conducted. A 5% random sample of 2008 Medicare beneficiaries was used. The study sample included all members of this group who: 1) were 65 years of age and older and 2) filled at least one prescription for imatinib, erlotinib, anastrozole, letrozole, or thalidomide. We examined the average costs patients paid per day, the cost that the Part D plan paid per day, and the total cost that patients paid for the entire year for each drug. The demographic characteristics and type of prescription drug subsidy of Part D beneficiaries who used oral cancer drugs were reported in frequency counts and percentages. We also determined the percentage of enrollees who entered the Part D coverage gap, the time and duration that they fell into the coverage gap, the number of beneficiaries who discontinued treatment and the association between OOP costs and medication discontinuation or delay, controlling for polypharmacy, prescription coverage and socio-demographic factors. Results: Prescription drug subsidy was categorized in four groups: 1) Dual Eligible (DE), 2) full Low Income Subsidy (LIS), 3) partial LIS, and 4) no subsidy. Mean out-of-pocket (OOP) costs per day were between $0.03 and $0.09 for DE beneficiaries, between $0.04 and $0.23 for full LIS beneficiaries, between $1.17 and $6.34 for partial LIS beneficiaries and between $2.93 and $36.84 for beneficiaries who did not receive a subsidy. On average, the beneficiaries who used oral cancer medications were between 75 and 76 years of age. Over half of oral cancer medication users were Caucasian and female. Over two-thirds of oral cancer medication users received no subsidies for their prescription coverage. About 99% of users of the more expensive drugs - imatinib, erlotinib and thalidomide - entered the coverage gap and the majority of these entered the coverage gap at the time of their first fill. In contrast, beneficiaries who filled the less expensive drugs - anastrozole and letrozole - entered the coverage gap later. Less than 7% entered the coverage gap at the time of the first fill of their prescriptions. Beneficiaries who used imatinib, erlotinib, or thalidomide spent approximately a month in the coverage gap. Over the course of a year, the majority of their time was spent in the catastrophic phase. Approximately 33-60% of total oral cancer drug users discontinued their therapies. About 50% of these discontinued during the coverage gap for anastrozole and letrozole and about 80% discontinued during the catastrophic phase for imatinib, erloinib and thalidomide. OOP costs were associated with medication discontinuation for all five oral cancer drugs. The odds of discontinuation and delay increased 101%, 170%, and 264% for each $100 increase in OOP spending for imatinib, erlotinib and thalidomide users, respectively. The odds of discontinuation and delay increased 9%-10%, and 6-8% for every $10 increase in OOP spending for anastrozole and letrozole users, respectively. Conclusions: About 33-60% of all users discontinued their therapies. Beneficiaries receiving subsidies had low OOP costs, averaging between $0.03 and $6.34 per day. Beneficiaries on the more expensive drugs and not having subsidies had high OOP costs, averaging between $15.66 and 36.84 per day. Higher OOP costs were associated with an increased likelihood of discontinuation or delay.

The focus of this study is the vicious circle of poverty and ill-health. The case is injuries but it could have been any lasting and severe disease. Poverty and health have very close links to economic development and to how health care is financed. Out-of-pocket payment seems to increase the risk of poverty while prepaid health care reduces it. The overall objective is to investigate the “injury poverty trap” and suggest possible solutions for it. A cohort of 23,807 people living in 5,801 households in Bavi district of Vietnam was followed from 1999 to 2003 to investigate income losses caused by non-fatal unintentional injuries in 2000 as well as the relationships between social position in 1999 and those injuries. For the possible solutions, a survey in 2064 household was performed to elicit people’s preferences and willingness to pay for different health care financing options. The results showed that unintentional injuries imposed a large economic burden on society, especially on the victims. By two pathways – treatment costs and income losses – unintentional injury increased the risk of being poor. The losses for non-poor and poor injured households were about 15 and 11 months of income of an average person in the non-poor and poor group, respectively. Furthermore, poverty was shown to be a probable cause of non-fatal unintentional injuries. Specifically, poverty led to home injuries among children and the elderly, and adults 15 – 49 years of age were particularly at risk in the workplace. The middle-income group was at greatest risk for traffic injuries, probably due to the unsafe use of bicycles or motorbikes. About half of the population preferred to keep an out-of-pocket system and the other half preferred health insurance. People’s willingness to pay suggested that a community-based health insurance scheme would be feasible. However, improvements in the existing health insurance systems are imperative to attract people to participate in these or any alternative health insurance schemes, since the limitations of the existing systems were generalized to health insurance as a whole. A successful solution should follow two tracks: prepayment of health care and some insurance based compensation of income losses during the illness period. If the risk of catastrophic illness is more evenly spread across the society, it would increase the general welfare even if no more resources are provided.

Background: In 2007, Saskatchewan’s Ministry of Health launched the Seniors’ Drug Plan (SDP), whereby provincial beneficiaries at or above the age of 65 receive medications at a maximum self-payment of $15. The purpose of this study was to document the impact of the SDP using provincial health-administrative databases. Methods: Aggregate medication utilization and costs were described using the prescription drug database starting two years before the implementation of the SDP and continuing for two years after. Interrupted time series analysis using segmented regression models were developed to test the impact of the SDP. Also, the probability of achieving optimal medication adherence was examined among cohorts receiving medications after SDP implementation versus similar patients receiving medications before the SDP and also a group of patients <65 years who were not eligible for the SDP at all. The impact of the SDP on the outcome of optimal adherence was estimated using logistic regression models with generalized estimating equations (GEE). Results: Monthly government spending on medications increased by 47.5% following implementation of the SDP, while total medication dispensations only increased by 5.8%. The SDP was associated with more dispensations per month among prevalent users (+5.4%, 95% CI: 1.3% to 9.5%) but not incident users who did not receive the study medication in the previous 365 days (+1.3%, 95% CI: -8.0% to 10.7%). Similarly, the SDP did not appear to impact the use of blood-glucose-lowering agents, (-0.5%, 95% CI: -6.2% to 5.2%). A small but significant increase in the odds of optimal medication adherence was observed after the SDP compared with before (OR=1.08, 95% CI 1.04 to 1.11). However, the impact was only observed in prevalent users (OR=1.08, 95% CI 1.04 to 1.12), but not incident users (OR=1.05, 95% CI 0.98 to 1.13). Also, the impact of the SDP on medication adherence was not consistent for all medication classes examined. Discussion: In summary, the SDP resulted in substantially higher government investment into drug costs without a major effect on medication utilization and adherence. However, cost reduction for seniors must have provided substantial relief independent of the impact on adherence and utilization.

BACKGROUND AND PURPOSE OF RESEARCH: Nigeria’s National Health Insurance Scheme (NHIS) was setup to secure universal access to affordable quality care. However, after 11yrs, and despite launching different programs, NHIS coverage is still less than 3% nationally, and out-of-pocket payments (OOP) remain the major health financing mechanism. The reasons for the low level of enrollment in NHIS are not well understood. Quality of care may be a factor in enrolment. This study compares technical and perceived quality of care between NHIS enrollees and the uninsured, using diabetes as a tracer condition. It also compares OOP and generic prescription patterns by health insurance enrollment status. METHODS: We conducted a cross sectional clinic-based intercept study. Subjects were adult diabetes patients recruited from 10 NHIS accredited hospitals in Abuja, Nigeria. Data collection included survey and chart review, covering technical aspects of quality – performance of eye and feet exam and HbA1c request; perception of quality, generic medication prescribing pattern and OOP. We performed logistic regression analysis to evaluate the effect of NHIS enrollment status on the technical quality of care, perceived quality of care, generic prescribing and OOP. RESULTS: Out of 455 participants, 149 (33%) were NHIS enrollees, 10 (2%) were enrolled in private health insurance and 296 (65%) had no insurance. After adjusting for correlated data and controlling for facility, BMI, chronic disease score, age, sex, and education, patients under NHIS coverage were 0.85 times less likely to have eye exam (Cl=0.4–1.8), 0.98 times less likely to have feet exam (Cl= 0.4–2.2), and 0.98 times less likely to have A1c test requested (Cl= 0.7–1.3), compared to those without insurance. These findings were not statistically significant at alpha=0.05. On the other hand, compared to the uninsured, NHIS covered patients perceived care to be worse even though they spent significantly less, 56% (Cl=45%–69%) in OOP in public hospitals. DISCUSSION/CONCLUSION: Perception of care quality under the NHIS could be a contributory factor to the reluctance of prospective enrollees. To advance towards the goal of universal health coverage, NHIS must strengthen policy to overcome identified barriers such as medication stock outs and wait times at the facility level.

The rising cost of health care in the Philippines is a concern for the Department of Defense and TRICARE beneficiaries. The purpose of this quantitative cross-sectional research study was to determine the efficacy and acceptability of a different method to deliver health care to increase access to health care and decrease out-of-pocket costs while maintaining quality of care for TOP Standard beneficiaries who receive health care under the Philippine Demonstration. Secondary data was used to determine the acceptability of an alternative reimbursement methodology to decrease cost but maintain access to quality care. The Andersen's behavioral health care model and the Donabedian quality health care model were used to interpret the study results. A data set of 180 participants was evaluated using a cross-sectional quantitative methodology. Two Spearman correlations were used to examine the relationship between financial burden and satisfaction (r = .41, p < .001) and financial burden and confidence (r = .44, p < .001). Linear and binary regressions assessed the effects of age and gender on satisfaction with health care finder functionality when requesting a waiver (F (2,26) = 1.22, p = .313, R2 = .09). A computation of one-sample t-tests to determine the impact of a closed network, beneficiary out-of-pocket cost, and quality health care in Demonstration areas found the beneficiaries were satisfied with the demonstration. An analysis of the claims data pre and post demonstration showed a difference in the patients' out-of-pocket expenses and the acceptability and preference for a closed network. Social change was demonstrated by a decrease in the cost for TRICARE standard beneficiaries in the Philippines.

Community-Based Health Insurance (CBHI) in Rwanda was promulgated as the best alternative to address the financial barriers for accessibility to health care services for the poor population and the informal sector. The purpose of this study was to investigate whether CBHI reduce Out-of-pocket health expenses for their members as compared to non-members and to what extent CBHI provide financial protection for the poorest population. This research based itself on secondary source of data primarily collected for a prospective quasi-experimental design which evaluated the impact of Performance-Based Financing. The primary study had reported on the Out-Of-Pocket expenses for health by members and non-members of CBHI; residing in a sample of 1961 households; in addition to their demographics and socio-economic characteristics. The findings indicate that insured individuals were about 2.6 times more likely to utilize health care services than respondents without health insurance. It is also worth noting that households with health insurance coverage were less likely to experience a catastrophic health expenditure than households without health insurance (aOR: 0.744; 95% CI:[0.586 - 0.945]), and that the effect of health insurance coverage was higher in people living in poor households than in people living in middle or richer households / Health Studies / M.A. (Public Health)

Rationale Epilepsy is a common, chronic, neurological condition that disproportionately affects individuals living in low- and middle- income countries, including much of sub-Saharan Africa. Epilepsy is treatable, with the majority of individuals who take anti-epileptic drugs experiencing a reduction, or elimination, of seizures. Yet the number of individuals taking and adhering to medication in Africa is low and interventions aimed at improving treatment are lacking. Aims To define the epidemiology of convulsive epilepsy in rural South Africa in terms of incidence, mortality and disability-adjusted life years; to determine outpatient, out-of-pocket costs resulting from epilepsy treatment; to establish the level of adherence to anti-epileptic drugs amongst people with epilepsy; and, to determine whether the introduction of routine visits to people with epilepsy by community health workers is a cost-effective intervention for improving adherence to anti-epileptic drugs. Methods Nested within the Agincourt Health and Demographic Surveillance System, this work utilized a cohort of individuals diagnosed with convulsive epilepsy in 2008 to determine health care utilization and out-of-pocket costs due to care sought for epilepsy. Additionally, using blood samples from the cohort, anti-epileptic drug adherence was measured and, following the cohort, mortality rates were determined. Using these collected epidemiological parameters, disability-adjusted life years due to convulsive epilepsy were determined. Finally, combining the epidemiological and cost parameters, a community health worker intervention was modeled to determine its incremental cost-effectiveness ratio. Key Findings The burden of convulsive epilepsy is lower in rural South Africa than other parts of Africa, likely due to lower levels of known risk factors. Yet the burden, especially in terms of mortality, remains high, as does the treatment gap and health care utilization. Findings from the economic evaluation found the introduction of a community health worker to be highly cost-effective and would likely lower the burden of epilepsy in rural South Africa. Implications Epilepsy contributes to the burden of disease in rural South Africa, with high levels of mortality and a substantial treatment gap. The introduction of a community-health worker is likely to be one cost-effective, community based intervention that would lower the burden of epilepsy by improving adherence to anti-epileptic drugs. Implementing this intervention, based on these findings, is a justified and important next step.

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