Affording what's free and paying for choice: comparing the cost of public and private hospitalizations in urban Kerala

OBJECTIVE: To assess the cost of public and private hospitalizations in urban Kerala and discuss policy implications of social disparities in the economic burden of hospital care. METHODS: The NSSO survey on health care (1995-1996) for urban Kerala was analysed with regards to expenditure incurred by hospital episodes. Multilevel linear models were built to assess factors associated with levels of health expenditure. FINDINGS: Hospital care involves paying admission fees in 68% of cases of hospitalizations (98% in private and 20% in public sector) in urban Kerala. Poor households and those headed by casual workers show significantly lower levels of health expenditure and a higher proportion of health-related loss of income than other social groups. Although there is significant expenditure in both sectors for these groups, hospitalization on free public wards is associated with lower expenditure than other options. Factors linked with higher expenditure are: duration of stay; hospitalizations on paying public wards and in the private sector; hospitalizations for above poverty line households and hospitalizations for chronic illnesses. Expenditure for services bought from outside the hospital is important in the public sector. CONCLUSION: Hospitalization incurs significant expenditure in urban Kerala. Greater availability of free medical services in the public sector and financial protection against the cost of hospitalization are warranted.     

County-Level Poverty Is Equally Associated With Unmet Health Care Needs in Rural and Urban Settings

Context: Regional poverty is associated with reduced access to health care. Whether this relationship is equally strong in both rural and urban settings or is affected by the contextual and individual-level characteristics that distinguish these areas, is unclear. Purpose: Compare the association between regional poverty with self-reported unmet need, a marker of health care access, by rural/urban setting. Methods: Multilevel, cross-sectional analysis of a state-representative sample of 39,953 adults stratified by rural/urban status, linked at the county level to data describing contextual characteristics. Weighted random intercept models examined the independent association of regional poverty with unmet needs, controlling for a range of contextual and individual-level characteristics. Findings: The unadjusted association between regional poverty levels and unmet needs was similar in both rural (OR = 1.06 [95% CI, 1.04-1.08]) and urban (OR = 1.03 [1.02-1.05]) settings. Adjusting for other contextual characteristics increased the size of the association in both rural (OR = 1.11 [1.04-1.19]) and urban (OR = 1.11 [1.05-1.18]) settings. Further adjustment for individual characteristics had little additional effect in rural (OR = 1.10 [1.00-1.20]) or urban (OR = 1.11 [1.01-1.22]) settings. Conclusions: To better meet the health care needs of all Americans, health care systems in areas with high regional poverty should acknowledge the relationship between poverty and unmet health care needs. Investments, or other interventions, that reduce regional poverty may be useful strategies for improving health through better access to health care.     

The poor pay more: Health-related inequality in Thailand

This paper examines the equality of utilization for equal need and equity of out-of-pocket expenditure for health services in a large urban area in Thailand. Data from a household health interview survey were used to explore patterns of perceived morbidity, utilization of various treatment sources, and out-of-pocket payment. Financial access to health care, as reflected in medical benefit/insurance cover, appeared to influence reported illness and hospitalization rates. Gross lack of access to health care amongst lower socio-economic groups was not the main problem in this densely populated urban area because people could choose and use alternative health services according to their ability and willingness to pay. The corollary, however, was an inequitable pattern of out-of-pocket health expenditure by income quintile and per capita. The underprivileged were more likely to pay out of their own pocket for their health problems, and to pay out of proportion to their household income when compared with more privileged groups. Furthermore, the underprivileged were least likely to be covered by government health benefit schemes, in contrast in particular to civil servants, who paid less out of pocket and did not contribute to their medical benefit fund. The private health sector (private clinics and private hospitals) was the major provider of health care to urban dwellers for both outpatient and inpatient services. Policy options for the short and long term to improve the equity of payment systems for health care are discussed.     

Frailty Predicts Increased Health Care Utilization Among Community-Dwelling Older Adults: A Longitudinal Study in China

ObjectivesFrailty, a multidimensional syndrome characterized by vulnerability to stressors, is an emerging public health priority with high prevalence in older adults. Frailty has been identified to predictive negative health outcomes, yet quantified evidence regarding its effect on health care systems is scarce. This study examines how frailty affects health care utilization, and explores whether these associations varied by gender.DesignCohort study with a 2-year follow-up.Settingand Participants: Data were derived from 2 waves (2011 and 2013) of the China Health and Retirement Longitudinal Study, and 3119 community-dwelling participants aged ≥60 years were analyzed.MethodsFrailty was assessed by a validated frailty phenotype scale, and measures for health care utilization were self-reported. Panel data approach of mixed-effects regression models was used to examine the associations.ResultsLongitudinal results demonstrated that compared with robustness, prefrailty and frailty were both significantly associated with increased likelihood of outpatient visit, inpatient visit, and inpatient length of stay, even after adjusting for multimorbidity in multivariate analyses (all P < .05). Every 1-component increase in frailty was also found to significantly increase the risk for health care utilization [any outpatient visit: adjusted odds ratio (OR) 1.30, 95% confidence interval (CI) 1.14–1.48; number of outpatient visits: adjusted incident rate ratio (IRR) 1.34, 95% CI 1.18–1.53; any inpatient visit: adjusted OR 1.44, 95% CI 1.22–1.71; number of inpatient visits: adjusted IRR 1.40, 95% CI 1.20–1.62; inpatient length of stay: adjusted IRR 1.50, 95% CI 1.18–1.92]. The preceding associations were similarly observed irrespective of gender.Conclusions and ImplicationsFrailty is a significant predictor for increased health care utilization among community-dwelling older adults. These findings have important implications for routine clinical practice and public health investment. Early screening and intervention for potentially modifiable frailty could translate into considerable savings for households and health care systems.     

Redistribution or horizontal equity in Hong Kong's mixed public-private health system: a policy conundrum

We examine the distributional characteristics of Hong Kong's mixed public-private health system to identify the net redistribution achieved through public spending on health care, compare the income-related inequality and inequity of public and private care and measure horizontal inequity in health-care delivery overall. Payments for public care are highly concentrated on the better-off whereas benefits are pro-poor. As a consequence, public health care effects significant net redistribution from the rich to the poor. Public care is skewed towards the poor in part not only because of allocation according to need but also because the rich opt out of the public sector and consume most of the private care. Overall, there is horizontal inequity favouring the rich in general outpatient care and (very marginally) inpatient care. Pro-rich bias in the distribution of private care outweighs the pro-poor bias of public care. A lesser role for private finance may improve horizontal equity of utilisation but would also reduce the degree of net redistribution through the public sector.     

Primary health care in practice: is it effective?

Primary health care is accepted as the model for delivering basic health care to low income populations in developing countries. Using El Salvador as a case study, the paper draws on three data sets and a qualitative survey to assess health care access and utilization across public and private sector options (including NGOs). Multivariate analysis is used to estimate the quantitative determinants of health seeking behavior. Physical and financial access is generally good. Households do not value the community health workers, and prefer high cost private care, even the poorest families, because of the lower waiting times and higher probability of successful treatment. Similarly, higher level public facilities--health centers and hospitals--are preferred because they are less costly in terms of time as they offer "one stop shopping" and do not require multiple visits, and treatment success is higher than among health posts, health units or community health workers. These results combined with the small size of El Salvador suggest that alternative strategies to community health workers may be a more cost effective approach. While prevention is desirable, community health workers do not have the skills or services that the communities value, which makes them less effective in promoting prevention. Alternative modes of reaching the community could reduce costs and raise the effectiveness of public health spending.     

Is Neighborhood Access to Health Care Provision Associated with Individual-Level Utilization and Satisfaction?

Objective. To explore whether travel time access to the nearest general practitioner (GP) surgery (which is equivalent to U.S. primary care physician [PCP] office) and pharmacy predicts individual‐level health service utilization and satisfaction. Data Sources. GP and pharmacy addresses were obtained from the New Zealand Ministry of Health in 2003 and merged with a geographic boundaries data set. Travel times derived from these data were appended to the 2002/03 New Zealand Health Survey (N=12,529). Study Design. Multilevel logistic regression was used to model the relationship between travel time access and five health service outcomes: GP consultation, blood pressure test, cholesterol test, visit to pharmacy, and satisfaction with latest GP consultation. Data Collection/Extraction. Travel times between each census meshblock centroid and the nearest GP and pharmacy were calculated using Geographical Information System. Principal Findings. When travel times were long, blood pressure tests were less likely in urban areas (odds ratio [OR] 0.75 [0.59–0.97]), GP consultations were less likely in rural centers (OR 0.42 [0.22–0.78]) and pharmacy visits were less likely in highly rural areas (OR 0.36 [0.13–0.99]). There was some evidence of lower utilization in rural areas. Conclusions. Locational access to GP surgeries and pharmacies appears to sometimes be associated with health service use but not satisfaction.     

Does the Universal Health Insurance Program Affect Urban‐Rural Differences in Health Service Utilization Among the Elderly? Evidence From a Longitudinal Study in Taiwan

Purpose: To assess the impact of the introduction of Taiwan's National Health Insurance (NHI) on urban‐rural inequality in health service utilization among the elderly. Methods: A longitudinal data set of 1,504 individuals aged 65 and older was constructed from the Survey of Health and Living Status of the Elderly. A difference‐in‐differences model was employed and estimated by the random‐effect probit method. Finding: The introduction of universal NHI in Taiwan heterogeneously affected outpatient and inpatient health service utilization among the elderly in urban and rural areas. The introduction of NHI reduced the disparity of outpatient (inpatient) utilization between the previously uninsured and insured older urban residents by 12.9 (22.0) percentage points. However, there was no significant reduction in the utilization disparity between the previously uninsured and insured elderly among rural residents. Conclusions: Our study on Taiwan's experience should provide a valuable lesson to countries that are in an initial stage of proposing a universal health insurance system. Although NHI is designed to ensure the equitable right to access health care, it may result in differential impacts on health service utilization among the elderly across areas. The rural elderly tend to confront more challenges in accessing health care associated with spatial distance, transportation, social isolation, poverty, and a lack of health care providers, especially medical specialists.     

Responsiveness of the urban primary health care delivery system in Bangladesh: A comparative analysis

This study analyses the responsiveness of outpatient care to assess the quality of urban primary health care among all 5 types of health care providers in Bangladesh, namely, the Urban Primary Health Care Services Delivery Project, the NGO Health Services Delivery Project (NHSDP), NGOs, private hospitals, and the Ministry of Health and Family Welfare (MOHFW). Other than some public‐private comparisons, there is an absolute knowledge gap regarding responsiveness in urban health systems, particularly in the context of Bangladesh, and this gap motivates this study. The study used primary data collected from 810 randomly selected outpatients. The survey used a structured questionnaire on all 7 domains of responsiveness of outpatient care suggested by the World Health Organization. The estimated mean responsiveness score reveals that overall, approximately 33% of the patients rated the responsiveness of the system as poor. In reported responsiveness, the NHSDP was ranked at the top and the MOHFW at the bottom. The latter is quite expected. Overall, prompt attention and autonomy were the worst‐performing domains, and choice of provider, dignity, and clear communication were the better‐performing ones. The results suggest the need to improve the degree of responsiveness of all domains, especially those that are more concerned with access to health care, namely, prompt attention, dignity, clear communication, and confidentiality. The Ministry of Health and Family Welfare facilities should give additional consideration to promote prompt attention, autonomy, and quality of basic amenities. Private facilities should also provide additional stress on improving prompt attention and autonomy. The nontherapeutic quality of health care needs to be emphasized in the medical education system. Further research based on household surveys could be worthwhile to measure responsiveness more comprehensively.     

Marginal benefit incidence of public health spending: evidence from Indonesian sub-national data

We examine the marginal effects of decentralized public health spending by incorporating estimates of behavioural responses to changes in health spending in benefit incidence analysis. The analysis is based on a panel dataset of 207 Indonesian districts over the period from 2001 to 2004. We show that district public health spending is largely driven by central government transfers, with an elasticity of around 0.9. We find a positive effect of public health spending on utilization of outpatient care in the public sector for the poorest two quartiles. We find no evidence that public expenditures crowd out utilization of private services or household health spending. Our analysis suggests that increased public health spending improves targeting to the poor, as behavioural changes in public health care utilization are pro-poor. Nonetheless, most of the benefits of the additional spending accrued to existing users of services, as initial utilization shares outweigh the behavioural responses.     

Influence of Place of Residence in Access to Specialized Cancer Care for African Americans

Context: Disparities in cancer care for rural residents and for African Americans have been documented, but the interaction of these factors is not well understood.
Purpose: The authors examined the simultaneous influence of race and place of residence on access to and utilization of specialized cancer care in the United States.
Methods: Access to specialized cancer care was measured using: (1) travel time to National Cancer Institute (NCI) Cancer Centers, academic medical centers, and any oncologist for the entire continental US population, and (2) per capita availability of oncologists for the entire United States. Utilization was measured as attendance at NCI Cancer Centers, specialized hospitals, and other hospitals in the Surveillance, Epidemiology, and End Results (SEER) program Medicare population from 1998-2004.
Findings: In urban settings, travel times were shorter for African Americans compared with Caucasians for all three cancer care settings, but they were longer for rural African Americans traveling to NCI Cancer Centers. Per capita oncologist availability was not significantly different by race or place of residence. Urban African American patients were almost 70% more likely to attend an NCI Cancer Center than urban Caucasian patients (OR = 1.66; 95% CI 1.51-1.83), whereas rural African American patients were 58% less likely to attend an NCI Cancer Center than rural Caucasian patients (OR = 0.42; 95% CI 0.26-0.66).
Conclusions: Urban African Americans have similar or better access to specialized cancer care than urban Caucasians, but rural African Americans have relatively poor access and lower utilization compared with all other groups.     

The effects of mandatory health insurance on equity in access to outpatient care in Indonesia

This paper examines the effects of mandatory health insurance on access and equity in access to public and private outpatient care in Indonesia. Data from the second round of the 1997 Indonesian Family Life Survey were used. We adopted the concentration index as a measure of equity, and this was calculated from actual data and from predicted probability of outpatient-care use saved from a multinomial logit regression. The study found that a mandatory insurance scheme for civil servants (Askes) had a strongly positive impact on access to public outpatient care, while a mandatory insurance scheme for private employees (Jamsostek) had a positive impact on access to both public and private outpatient care. The greatest effects of Jamsostek were observed amongst poor beneficiaries. A substantial increase in access will be gained by expanding insurance to the whole population. However, neither Askes nor Jamsostek had a positive impact on equity. Policy implications are discussed.     

The Impact of Accessibility on the Use of Specialist Health Care in Norway

The aim of this study is to explore to what extent the policy goal of allocating health care according to medical need is fulfilled in Norway. Hence, we are interested in studying the impact of a person's health relative to the impact of access to specialist care. We distinguish between services provided by public hospitals and services provided by private specialists financed by the National Insurance Scheme. While a person's self-assessed health plays a major role in the utilization of hospitals, we find no significant effect of this variable on the utilization of private specialists. The accessibility indices for specialist care have significant effects on the utilization of private specialists, but not on hospital visits and inpatient stays. The challenge to policy makers is to consider measures that bring the utilization of publicly funded private specialists in accordance with national health policy.     

The effect of wealth status on care seeking and health expenditures in Afghanistan

This paper analyses the effect of wealth status on care-seekingpatterns and health expenditures in Afghanistan, based on anational household survey conducted within public health facilitycatchment areas. We found high rates of reported care-seeking,with more than 90% of those ill seeking care. Sick individualsfrom all wealth quintiles had high rates of care-seeking, althoughthose in the wealthiest quintile were more likely to seek carethan those from the poorest (odds ratio 2.2; 95% CI 1.6, 3.0).The nearest clinic providing the government's Basic Packageof Health Services (BPHS) was the most commonly sought firstprovider (53% overall), especially for relatively poor households(62% in poorest vs. 42% in least poor quintile, P < 0.0001).Sick individuals from wealthier quintiles used hospitals andfor-profit private providers more than those in poorer quintiles.Multivariate analysis showed that wealth quintile was the strongestpredictor of seeking care, and of going first to private providers.More than 90% of those seeking care paid money out-of-pocket.Mean (median) expenditures among those paying for care in theprevious month were 873 Afghanis (200 Afghanis), equivalentto US$17.5 (US$4). Expenditures were lowest at BPHS clinicsand highest at private providers. Financing care through borrowingmoney or selling assets/land (‘any distress’ financing)was reported in nearly 30% of cases and was almost twice ashigh among households in the poorest versus the least poor quintile(P < 0.0001). Financing care through selling assets/land(‘severe distress’ financing) was less common (10%overall) and did not differ by wealth status. These findingsindicate that BPHS facilities are being used by the poor wholive close to them, but further research is needed to assessutilization among populations in more remote areas. The highout-of-pocket health expenditures, particularly for privatesector services, highlight the need to develop financial protectionmechanisms in Afghanistan.     

Have out‐of‐pocket health care payments risen under free health care policy? The case of Sri Lanka

Compared to its neighbors, Sri Lanka performs well in terms of health. Health care is provided for free in the public sector, yet households' out‐of‐pocket health expenditures are steadily increasing. We explore whether this increase can be explained by supply shortages and insufficient public health care financing or whether it is rather the result of an income‐induced demand for supplementary and higher quality services from the private sector. We focus on total health care expenditures and health care expenditures for specific services such as expenses on private outpatient treatments and expenses on laboratory and other diagnostic services. Overall, we find little indication that limited supply of public health care per se pushes patients into the private sector. Yet income is identified as one key driver of rising health care expenditures, ie, as households get richer, they spend an increasing amount on private services suggesting a dissatisfaction with the quality offered by the public sector. Hence, quality improvements in the public sector seem to be necessary to ensure sustainability of the public health care sector. If the rich and the middle class increasingly opt out of public health care, the willingness to pay taxes to finance the free health care policy will certainly shrink.     

Private Care and Public Health: Do Vaccination and Prenatal Care Rates Differ between Users of Private versus Public Sector Care in India?

Objective. To determine whether patients who use private sector providers for curative services have lower vaccination rates and are less likely to receive prenatal care.
Data Sources/Study Setting. This study uses data from the 52d round of the National Sample Survey, a nationally representative socioeconomic and health survey of 120,942 rural and urban Indian households conducted in 1995–1996.
Study Design. Using logistic regression, we estimate the relationship between receipt of preventive care at any time (vaccinations for children, prenatal care for pregnant women) and use of public or private care for outpatient curative services, controlling for demographics, household socioeconomic status, and state of residence.
Data Collection/Extraction Methods. We analyzed samples of children ages 0 to 4 and pregnant women who used medical care within a 15-day window prior to the survey.
Principal Findings. With the exception of measles vaccination, predicted probabilities of the receipt of vaccinations and prenatal care do not differ based on the type of provider at which children and women sought curative care. Children and pregnant women in households who use private care are almost twice as likely to receive preventive care from private sources, but the majority still obtains preventive care from public providers.
Conclusions. We do not find support for the hypothesis that children and pregnant women who use private care are less likely to receive public health services. Results are consistent with the notion that Indian households are able to successfully navigate the coexisting public and private systems, and obtain services selectively from each. However, because the study employed an observational, cross-sectional study design, findings should be interpreted cautiously.     

Socioeconomic inequalities of outpatient and inpatient service utilization in China: personal and regional perspectives

Background

China’s health system has shown remarkable progress in health provision and health outcomes in recent decades, however inequality in health care utilization persists and poses a serious social problem. While government pro-poor health policies addressed affordability as the major obstacle to equality in health care access, this policy direction deserves further examination. Our study examines the issue of health care inequalities in China, analyzing both regional and individual socioeconomic factors associated with the inequality, and provides evidence to improve governmental health policies.

Methods

The China Health and Nutrition Survey (CHNS) 1991–2011 data were used to analyze the inequality of health care utilization. The random effects logistic regression technique was used to model health care utilization as the dependent variable, and income and regional location as the independent variables, controlling for individuals’ age, gender, marital status, education, health insurance, body mass index (BMI), and period variations. The dynamic trend of 1991–2011 regional disparities was estimated using an interaction term between the regional group dummy and the wave dummy.

Results

The probability of using outpatient service and inpatient services during the previous 4 weeks was 8.6 and 1.1% respectively. Compared to urban residents, suburban (OR: 0.802, 95% CI: 0.720–0.893), town (OR: 0.722, 95% CI: 0.648–0.804), rich (OR: 0.728, 95% CI: 0.656–0.807) and poor village (OR: 0.778, 95% CI: 0.698–0.868) residents were less likely to use outpatient service; and rich (OR: 0.609, 95% CI: 0.472–0.785) and poor village (OR: 0.752, 95% CI: 0. 576–0.983) residents were less likely to use inpatient health care. But the differences between income groups were not significant, except the differences between top and bottom income group in outpatient service use.

Conclusion

Regional location was a more important factor than individual characteristics in determining access to health care. Besides demand-side subsidies, Chinese policy makers should pay enhanced attention to health care resource allocation to address inequity in health care access.

     

Use of Health Professionals for Delivery Following the Availability of Free Obstetric Care in Northern Ghana

Objectives To assess the factors associated with the use of health professionals for delivery following the implementation of a free obstetric care policy in the poorest regions of Ghana. Methods All 4,070 women identified in the Navrongo demographic surveillance system with pregnancy outcomes in the Kassena-Nankana district between January 1 and December 31, 2004 were eligible for the study. Three thousand four hundred and thirty three women completed interviews on socio-demographic and pregnancy related factors. Information on 259 communities including travel distance to the nearest health facility was also obtained. Multilevel logistic regression analyses were conducted. Results ninety eight percent of women received antenatal care but only 38% delivered with the assistance of health professionals. In a multilevel logistic model, physical access factors {such as availability of public transport, odds ratio (OR) = 1.50 (1.15-1.94), travel distance to the district hospital [for 20+ km, OR = 0.31 (0.23-0.43)] as well as community perception of access to the nearest health facility [for highest quintile, OR = 4.44 (2.88-6.84)]} showed statistically significant associations with use of health professionals at last delivery. Women who knew that delivery care was free of charge were 4.6 times more likely to use health professionals. Higher parity was strongly negatively associated with use of health professionals [OR = 0.37 (0.29-0.48) for parity >/=4 compared to parity 0-1]. However, community perception of quality of care was not associated with use of health professionals for delivery. Conclusion Physical access factors remain strong determinants of use of professional delivery care in rural northern Ghana.     

上海市贫困居民的卫生服务需要和利用

与上海市平均水平相比，贫困居民门诊服务的需要和利用偏低，但住院需要和利用较高。而且，贫困居民的卫生服务实际需要被低估。妇女和儿童的卫生服务利用在贫困家庭影响较大。从疾病构成看，贫困居民大重病患病率明显高于一般人群，这些大病患者应该得到关注。     

Progressive universalism? The impact of targeted coverage on health care access and expenditures in Peru

Like other countries seeking a progressive path to universalism, Peru has attempted to reduce inequalities in access to health care by granting the poor entitlement to tax‐financed basic care without charge. We identify the impact of this policy by comparing the target population's change in health care utilization with that of poor adults already covered through employment‐based insurance. There are positive effects on receipt of ambulatory care and medication that are largest among the elderly and the poorest. The probability of getting formal health care when sick is increased by almost two fifths, but the likelihood of being unable to afford treatment is reduced by more than a quarter. Consistent with the shallow coverage offered, there is no impact on use of inpatient care. Neither is there any effect on average out‐of‐pocket health care expenditure, but medical spending is reduced by up to 25% in the top quarter of the distribution. Copyright © 2017 John Wiley & Sons, Ltd.