Estimating Willingness-to-Pay for health insurance among rural poor in India by reference to Engel's law

Community-Based Health Insurance (CBHI) (a.k.a. micro health insurance) is a contributory health insurance among rural poor in developing countries. As CBHI schemes typically function with no subsidy income, the schemes' expenditures cannot exceed their premium income. A good estimate of Willingness-To-Pay (WTP) among the target population affiliating on a voluntary basis is therefore essential for package design. Previous estimates of WTP reported materially and significantly different WTP levels across locations (even within one state), making it necessity to base estimates on household surveys. This is time-consuming and expensive. This study seeks to identify a coherent anchor for local estimation of WTP without having to rely on household surveys in each CBHI implementation. Using data collected in 2008–2010 among rural poor households in six locations in India (total 7874 households), we found that in all locations WTP expressed as percentage of income decreases with household income. This reminds of Engel's law on food expenditures. We checked several possible anchors: overall income, discretionary income and food expenditures. We compared WTP expressed as percentage of these anchors, by calculating the Coefficient of Variation (for inter-community variation) and Concentration indices (for intra-community variation). The Coefficient of variation was 0.36, 0.43 and 0.50 for WTP as percent of food expenditures, overall income and discretionary income, respectively. In all locations the concentration index for WTP as percentage of food expenditures was the lowest. Thus, food expenditures had the most consistent relationship with WTP within each location and across the six locations. These findings indicate that like food, health insurance is considered a necessity good even by people with very low income and no prior experience with health insurance. We conclude that the level of WTP could be estimated based on each community's food expenditures, and that this information can be obtained everywhere without having to conduct household surveys.     

Household health expenditures in Nepal: implications for health care financing reform.

His Majesty's Government of Nepal has embarked on an ambitious social welfare programme of increasing the accessibility of primary education and health care services in rural communities. The implications on the financing of health care services are substantial, as the number of health posts has increased twelve-fold from 1992 to 1996, from 200 to 2597. To strengthen health care financing, government policy-makers are considering a number of financing strategies that are likely to have a substantial impact on household health care expenditures. However, more needs to be known about the role of households in the current structure of the health economy before the government designs and implements policies that affect household welfare. This paper uses the Nepal Living Standards Survey, a rich, nationally-representative sample of households from 1996, to investigate level and distribution of household out-of-pocket health expenditures. Utilization and expenditures for different types of providers are presented by urban/rural status and by socioeconomic status. In addition, the sources of health sector funds are analyzed by contrasting household out-of-pocket expenditures with expenditures by the government and donors. The results indicate that households spend about 5.5% of total household expenditures on health care and that households account for 74% of the total level of funds used to finance the health economy. In addition, rural households are found to spend more on health care than urban households, after controlling for income status. Distributing health care expenditures by type of care utilized indicates that the wealthy, as well as the poor, rely heavily on services provided by the public sector. The results of this analysis are used to discuss the feasibility of implementing alternative health care financing policies.     

Access to water in the countries of the former Soviet Union

BACKGROUND: During the Soviet period, authorities in the USSR invested heavily in collective farming and modernization of living conditions in rural areas. However, many problems remained, including poor access to many basic amenities such as water. Since then, the situation is likely to have changed; economic decline has coincided with migration and widening social inequalities, potentially increasing disparities within and between countries. AIM: To examine access to water and sanitation and its determinants in urban and rural areas of eight former Soviet countries. METHODS: A series of nationally representative surveys in Armenia, Belarus, Georgia, Moldova, Kazakhstan, Kyrgyzstan, Russia and Ukraine was undertaken in 2001, covering 18,428 individuals (aged 18+ years). RESULTS: The percentage of respondents living in rural areas varied between 27 and 59% among countries. There are wide urban-rural differences in access to amenities. Even in urban areas, only about 90% of respondents had access to cold running water in their home (60% in Kyrgyzstan). In rural areas, less than one-third had cold running water in their homes (44% in Russia, under 10% in Kyrgyzstan and Moldova). Between one-third and one-half of rural respondents in some countries (such as Belarus, Kazakhstan and Moldova) obtained their water from wells and similar sources. Access to hot running water inside the homes was an exception in rural households, reflecting the lack of modern heating methods in villages. Similarly, indoor access to toilets is common in urban areas but rare in rural areas. Access to all amenities was better in Russia compared with elsewhere in the region. Indoor access to cold water was significantly more common among rural residents living in apartments, and in settlements served by asphalt roads rather than dirt roads. People with more assets or income and living with other people were significantly more likely to have water on tap. In addition, people who had moved in more recently were more likely to have an indoor water supply. CONCLUSIONS: This was the largest single study of its kind undertaken in this region, and demonstrates that a significant number of people living in rural parts of the former Soviet Union do not have indoor access to running water and sanitation. There are significant variations among countries, with the worse situation in central Asia and the Caucasus, and the best situation in Russia. Access to water strongly correlates with socio-economic characteristics. These findings suggest a need for sustained investment in rebuilding basic infrastructure in the region, and monitoring the impact of living conditions on health.     

Household income and health care expenditures in Mexico

The purpose of this paper is to examine the determinants of household health expenditures in Mexico. Our analysis involves the estimation of household monetary health care expenditures, using the economic and demographic characteristics of the household as covariates. We pay particular attention to the impact of household income on health expenditures, estimating the elasticity of health care expenditures with respect to income for different income groups and according to health insurance status. For the empirical analysis, we use the Mexican National Survey of Income and Expenditures of 1989. Our principle findings show that monetary health expenditures by Mexican households are sensitive to changes in household income levels and that the group which is most responsive to changes in income levels in the lower-income uninsured group. This suggests that in times of economic crisis, these households reduce cash expenditures on health care by proportionately more than higher-income and insured households.     

Changing access to health services in urban China: implications for equity

The ongoing reform of public institutions and state-owned enterprises in urban China has had a profound impact on the financing, organization and provision of health services. Access to health care by the urban population has become more inequitable. One of the most pressing concerns is that those who have lost jobs have increasing difficulties accessing health care. Using the data from the national household health surveys conducted in 1993 and 1998, this paper presents empirical results of changing utilization of health care among different income groups. Over 16 000 households and 54 000 individuals in the urban areas were randomly selected to collect information on perceived need of and demand for health care and expenditures on the services. The findings show that the income gap between the highest and lowest income groups increased in real terms from 1993 to 1998. There was a significant decline in the population covered by the government insurance scheme (GIS) and the labour insurance scheme (LIS), while the proportion of the population who had to pay for services out-of-pocket increased from 28% in 1993 to 44% in 1998. There was no statistically significant change in self-reported illness in the 2 weeks prior to survey among the study population over the period. While it was found that more people who reported illness from each income group received medical treatment of some kind, there was a decline in seeking care from a health provider. Among those in the lowest income group who reported illness but did not obtain treatment of any kind, nearly 70% (as compared with 38% in 1993) claimed financial difficulty as the major reason in 1998. The use of in-patient services dropped significantly from 4.5% in 1993 to 3.0% in 1998. The decreased use of in-patient services was more serious in the lowest and lower income groups than in higher and highest income groups. The percentage of patients referred for hospital admission but not being hospitalized had a negative relationship with income level. We can conclude from the data analysis that access of the urban population, particularly the poor, to formal health services has worsened and become more inequitable since the early 1990s. Among possible reasons for this trend are the rapid rise of per capita expenditure on health services and the decline in insurance coverage.     

Rural drinking water at supply and household levels: quality and management

Access to safe drinking water has been an important national goal in Bangladesh and other developing countries. While Bangladesh has almost achieved accepted bacteriological drinking water standards for water supply, high rates of diarrheal disease morbidity indicate that pathogen transmission continues through water supply chain (and other modes). This paper investigates the association between water quality and selected management practices by users at both the supply and household levels in rural Bangladesh. Two hundred and seventy tube-well water samples and 300 water samples from household storage containers were tested for fecal coliform (FC) concentrations over three surveys (during different seasons). The tube-well water samples were tested for arsenic concentration during the first survey. Overall, the FC was low (the median value ranged from 0 to 4 cfu/100ml) in water at the supply point (tube-well water samples) but significantly higher in water samples stored in households. At the supply point, 61% of tube-well water samples met the Bangladesh and WHO standards of FC; however, only 37% of stored water samples met the standards during the first survey. When arsenic contamination was also taken into account, only 52% of the samples met both the minimum microbiological and arsenic content standards of safety. The contamination rate for water samples from covered household storage containers was significantly lower than that of uncovered containers. The rate of water contamination in storage containers was highest during the February-May period. It is shown that safe drinking water was achieved by a combination of a protected and high quality source at the initial point and maintaining quality from the initial supply (source) point through to final consumption. It is recommended that the government and other relevant actors in Bangladesh establish a comprehensive drinking water system that integrates water supply, quality, handling and related educational programs in order to ensure the safety of drinking water supplies.     

Public perception of drinking water safety in South Africa 2002¿2009: a repeated cross-sectional study

ABSTRACT: BACKGROUND: In low and middle income countries, public perceptions of drinking water safety are relevant to promotion of household water treatment and to household choices over drinking water sources. However, most studies of this topic have been cross-sectional and not considered temporal variation in drinking water safety perceptions. The objective of this study is to explore trends in perceived drinking water safety in South Africa and its association with disease outbreaks, water supply and household characteristics. METHODS: This repeated cross-sectional study draws on General Household Surveys from 2002-2009, a series of annual nationally representative surveys of South African households, which include a question about perceived drinking water safety. Trends in responses to this question were examined from 2002-2009 in relation to reported cholera cases. The relationship between perceived drinking water safety and organoleptic qualities of drinking water, supply characteristics, and socio-economic and demographic household characteristics was explored in 2002 and 2008 using hierarchical stepwise logistic regression. RESULTS: The results suggest that perceived drinking water safety has remained relatively stable over time in South Africa, once the expansion of improved supplies is controlled for. A large cholera outbreak in 2000-02 had no apparent effect on public perception of drinking water safety in 2002. Perceived drinking water safety is primarily related to water taste, odour, and clarity rather than socio-economic or demographic characteristics. CONCLUSION: This suggest that household perceptions of drinking water safety in South Africa follow similar patterns to those observed in studies in developed countries. The stability over time in public perception of drinking water safety is particularly surprising, given the large cholera outbreak that took place at the start of this period.     

Family size and economic welfare

Using data from the 1972-1973 Consumer Expenditure Survey, this article examines the effect of variations in family size on such measures of family economic well-being as levels and patterns of spending, earnings and employment, public assistance and the quantity and quality of housing. In general, although overall income rises somewhat with family size, an increase in the number of children appears to reduce the family's standard of living, especially in young families with small children. Current consumption increases as the number of children increases: families with 4 or more children in which the household head is under the age of 35 and has had more than 12 years of education tend to spend 40% more than childless couples of similar age and educational level. Despite the increased spending, per capita consumption falls for all age and education categories. Larger families devote more of their income to necessities and less to luxuries. Among young couples in which the household head has had 9 to 12 years of education, the proportion of income used to buy food rises from 15% if there are no children present to 25% if there are 4 or more. The proportion of food expenditures devoted to meals eaten out also falls steadily as the number of children rises. Although husband's earnings rise with increase in family size, there is a pronounced decline in wife's earnings, particularly in young families that have children under the age of 4. Overall, as the number of children grows, families spend a larger share of their income on current consumption, and per capita income declines. The % of families receiving welfare or food stamps tends to go up as the number of children increases, particularly among younger couples with less education. When the quantity and quality of housing are examined, the average number of rooms in the family dwelling is found to increase with family size.     

Food Security in the District of iLembe,KwaZulu-Natal: A Comparison of Coping Strategies between Urban and Rural Households

Food insecurity varies between urban and rural populations, as do their household characteristics and practices. The aim of the study was to compare the behaviours and practices households in rural and urban areas carry out during times of limited food in the district of iLembe, South Africa. Using a cross-sectional study design, household surveys were carried out to collect information on household characteristics, food, and coping strategies. In total, 376 households were randomly selected from low-income wards, 229 of which were rural, and 147 from urban areas. Water access was significantly better in the urban areas, as was diet diversity. The coping strategies carried out in rural households indicated better access or reliance on natural resources compared to their urban counterparts. Interventions or policies aimed at improving household food insecurity should take into account the location of the population, the natural resources available to them, and the needs of the community.     

基于门限效应模型的我国西部地区政府医疗卫生支出城乡差异分析*

目的：分析我国西部地区政府医疗卫生支出城乡间的具体差异,为西部地区政府在区域和城乡间医疗卫生支出的合理投入提供证据支持。方法：基于2009—2019年我国西部地区12省份的132个市区面板数据,采用固定效应模型和门限效应模型实证分析影响政府医疗卫生支出的因素。结果：人均GDP与农村居民收入是影响政府医疗卫生支出的主要因素,人均GDP 门限值分别为9.84和10.48、城镇居民收入门限值分别为9.73和10.13、农村居民收入门限值分别为8.67和9.22,而我国西部地区政府医疗卫生支出更偏向于经济发达地区的城镇居民和低收入群体中的农村居民。结论：我国西部地区政府医疗卫生支出在不同区域间和区域内城乡间存在显著差别,推动区域和城乡医疗卫生协调均衡发展需因地制宜、循序渐进的开展工作。     

Socioeconomic variables and rates of diarrhoeal disease in urban Bangladesh

Sociodemographic factors including low maternal education, low economic status, inferior quality of housing, diminished access to water and sanitation facilities, and crowding in the household are associated with increased diarrhoea in the rural setting of many developing countries. To assess the relationship of these variables with diarrhoea rates in children in an urban setting we monitored the episodes of diarrhoea of children less than 6 years of age from 1921 families living in 51 clusters throughout Dhaka city, Bangladesh, for 3 1/2 months. Comparing incidence density ratios, we found that, of the factors listed above, only low family income and living in a one-room house were statistically associated with increased diarrhoea and that none of these variables was associated with a meaningfully increased risk of diarrhoea. We conclude that the risk factors for increased episodes of diarrhoea in the urban setting appear to be different from those of the rural setting.     

Greater household expenditures on fruits and vegetables but not animal source foods are associated with decreased risk of under-five child mortality among families in rural Indonesia

The specific aims of this study were to examine the relationships between household food expenditures and under-5 child mortality among families in rural Indonesia. Data collected between 2000 and 2003 in the Indonesia Nutrition and Health Surveillance System, a population-based surveillance system conducted in 7 rural provinces, were utilized for the analysis. Food expenditures were divided into 4 major categories: plant foods (fruits and vegetables), animal foods, other nongrain foods, and grain foods (primarily rice) and expressed as quintiles of proportional food expenditure. Of 292,894 households, 32,777 (11.2%) households reported a history of under-5 child mortality. Plant food expenditures were associated with reduced odds of under-5 child mortality [odds ratio (OR), 0.70; 95% CI, 0.67-0.73; P < 0.0001) among families in the highest quintile compared with the lowest quintile, adjusting for potential confounders. Grain food expenditures were associated with increased odds of under-5 child mortality (OR, 1.25; 95% CI, 1.20-1.30; P < 0.0001) among families in the highest quintile compared with the lowest quintile, adjusting for potential confounders. Animal food expenditures were not consistently and significantly associated with under-5 child mortality across quintiles of expenditures. These findings suggest that lower under-5 child mortality is found in households that spend a greater proportion of income on plant foods and less on grain foods in rural Indonesia.     

Drinking water and sanitation: progress in 73 countries in relation to socioeconomic indicators

Objective

To assess progress in the provision of drinking water and sanitation in relation to national socioeconomic indicators.

Methods

We used household survey data for 73 countries – collected between 2000 and 2012 – to calculate linear rates of change in population access to improved drinking water (n = 67) and/or sanitation (n = 61). To enable comparison of progress between countries with different initial levels of access, the calculated rates of change were normalized to fall between –1 and 1. In regression analyses, we investigated associations between the normalized rates of change in population access and national socioeconomic indicators: gross national income per capita, government effectiveness, official development assistance, freshwater resources, education, poverty, Gini coefficient, child mortality and the human development index.

Findings

The normalized rates of change indicated that most of the investigated countries were making progress towards achieving universal access to improved drinking water and sanitation. However, only about a third showed a level of progress that was at least half the maximum achievable level. The normalized rates of change did not appear to be correlated with any of the national indicators that we investigated.

Conclusion

In many countries, the progress being made towards universal access to improved drinking water and sanitation is falling well short of the maximum achievable level. Progress does not appear to be correlated with a country’s social and economic characteristics. The between-country variations observed in such progress may be linked to variations in government policies and in the institutional commitment and capacity needed to execute such policies effectively.     

Validity of rapid estimates of household wealth and income for health surveys in rural Africa

STUDY OBJECTIVE—To test the validity of proxy measures of household wealth and income that can be readily implemented in health surveys in rural Africa.DESIGN—Data are drawn from four different integrated household surveys. The assumptions underlying the choice of wealth proxy are described, and correlations with the true value are assessed in two different settings. The expenditure proxy is developed and then tested for replicability in two independent datasets representing the same population.SETTING—Rural areas of Mali, Malawi, and Côte d''Ivoire (two national surveys).PARTICIPANTS—Random sample of rural households in each setting (n=275, 707, 910, and 856, respectively).MAIN RESULTS—In both Mali and Malawi, the wealth proxy correlated highly (r?0.74) with the more complex monetary value method. For rural areas of Côte d''Ivoire, it was possible to generate a list of just 10 expenditure items, the values of which when summed correlated highly with expenditures on all items combined (r=0.74, development dataset, r=0.72, validation dataset). Total household expenditure is an accepted alternative to household income in developing country settings.CONCLUSIONS—It is feasible to approximate both household wealth and expenditures in rural African settings without dramatically lengthening questionnaires that have a primary focus on health outcomes.     

农村人均卫生费用的影响因素研究

文章运用EViews统计分析软件对中国农村人均卫生费用的影响因素进行回归分析,研究发现新型农村合作医疗保险制度的实施没有改变农村居民家庭人均纯收入和65岁及以上老年人口占总人口比率与中国农村人均卫生费用的相关关系,但是每千人口卫生技术人员数与农村人均卫生费用由原先的负相关关系变为正相关关系。     

Drinking water, mortality, and life expectancy: an assessment of the east-west mortality gap in Europe

The role of the drinking water in public health has been recognised for many years. Recent ecological studies of mortality rates in Slovakia when compared to indicators of environmental pollution have shown surprising results--areas with greater air pollution seem to have lower total mortality rates. This paradox may be explained by a number of other factors, including urban/rural occupational conditions, socio-economic status, access to health care, and perhaps drinking water. Overall population access to safe drinking water is about the same between East and West Europe, but more careful evaluation suggest at least one important difference. About 35.7% of the people in Central and Eastern European countries do not have 100% access to safe drinking water in their rural areas, compared to only 18.7% of the rural populations in Western Europe who do not have full access to safe drinking water. This study examines access to safe drinking water, assesses overall drinking water quality, and utilises an index of drinking water quality to perform correlation with total mortality, selected chronic diseases which have been associated with drinking water contamination, and life expectancy at birth. These methods are applied to data for East-West Europe, Slovakia, and detailed urban-rural comparisons for three areas of Slovakia (Trnava, Banská Bystrica, and Kosice).     

Global costs of attaining the Millennium Development Goal for water supply and sanitation

OBJECTIVE: Target 10 of the Millennium Development Goals (MDGs) is to "halve by 2015 the proportion of people without sustainable access to safe drinking water and basic sanitation". Because of its impacts on a range of diseases, it is a health-related MDG target. This study presents cost estimates of attaining MDG target 10. METHODS: We estimate the population to be covered to attain the MDG target using data on household use of improved water and sanitation for 1990 and 2004, and taking into account population growth. We assume this estimate is achieved in equal annual increments from the base year, 2005, until 2014. Costs per capita for investment and recurrent costs are applied. Country data is aggregated to 11 WHO developing country subregions and globally. FINDINGS: Estimated spending required in developing countries on new coverage to meet the MDG target is US$ 42 billion for water and US$ 142 billion for sanitation, a combined annual equivalent of US$ 18 billion. The cost of maintaining existing services totals an additional US$ 322 billion for water supply and US $216 billion for sanitation, a combined annual equivalent of US$ 54 billion. Spending for new coverage is largely rural (64%), while for maintaining existing coverage it is largely urban (73%). Additional programme costs, incurred administratively outside the point of delivery of interventions, of between 10% and 30% are required for effective implementation. CONCLUSION: In assessing financing requirements, estimates of cost should include the operation, maintenance and replacement of existing coverage as well as new services and programme costs. Country-level costing studies are needed to guide sector financing.     

Factors influencing pulse consumption in Latin America

In Latin America, pulse consumption ranges from 1 kg/capita per year (Argentina) to 25 kg/capita per year (Nicaragua). Common beans account for 87 % of the total. The differences between countries, regions or groups of population within the same country can be explained by the following factors: (1) beans are very nutritious; (2) beans and maize are traditional foods and the habit of consuming them is deeply rooted in many people and communities; (3) the rural population eats more pulses than the urban population, due to geographical constraints that limit exchanges and favour consumption of locally produced foods; (4) income level, beans are still the poor man's meat; and (5) other factors, such as consumers' taste, the constraints on cooking beans, etc. The evolution of the consumption level in the future will depend on the urbanization of the population, access to processed foods and income level. Health issues would be an argument for maintaining or increasing the current consumption level.