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Access to health care, social protection, and household costs of illness proposal. Cost of illness working group INDEPTH AGM 2009, Pune. Rationale. Illness is a major risk people’s livelihoods Policies that reduce the costs of illness to households,
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Access to health care, social protection, and household costs of illness proposal Cost of illness working group INDEPTH AGM 2009, Pune
Rationale • Illness is a major risk people’s livelihoods • Policies that • reduce the costs of illness to households, • to improve social protection from those costs, and • to improve access to care… >> are key reducing the vulnerability of poor households, and to achieving the millennium development goals
Gaps in international knowledge Growing body of research, but • Often focus on a particular disease, not the full burden of all illnesses that a household has to cope in a particular time period; • Little information on transport costs, or on lost income • Little known about costs for different types of households in different settings • Few studies look at whether households are impoverished or not • Studies evaluate the coverage of social protection mechanisms but few examine whether they actually protect households.
Objectives of study • Measure household cost burdens of illness (loss of income and costs of seeking care) • Describe and explain household interactions with health system that generate those costs; • Determine extent to which existing health care financing or social protection mechanisms protect poor households from impoverishment due those costs >> sites in different country settings, with varying health care financing and social protection mechanisms…. • Contribute to national and international policy debates, providing policy recommendations as how to better protect poor households
Contrasting country contexts of sites • Low & middle income; Africa & Asia • Vietnam & Ghana – health insurance that covers more than 50% of population, but… • Bangladesh – nominal fee for tax funded health care, but unofficial fees common; • India & Burkina Faso– majority pay ‘out of pocket’ • Tanzania – community health funds, but coverage is low…. (Agincourt / South Africa – already conducted study)
Conceptual framework: How the health system & health financing might lead to impoverishment Household Health system Box 4: Health care expenditure & income losses Box 1: Health care financingmechanisms (user fees, informal fees, exemptions, community or social insurance, or free care); Availability of other social protection measures such as cash transfers; Availability of services; Acceptability of care; Box 3: Health seeking behaviour & treatment strategies, (delaying or not seeking care, ‘healer shopping’, cheaper sources of care, taking partial doses ) Box 5: Financial Coping strategies (borrowing, selling assets, reducing other basic needs expenditure ) Box 6: Household Livelihood (assets, income, debt & access to basic needs) Box 2: Illness occurrence
Study design and methods: Phase 1 Cross-sectional household survey, random sample in each site, stratified by SES (n=1000 households), structured questionnaire • Level of costs as a proportion of household expenditure over one month; • Morbidity and treatment actions associated with costs; • Access to social protection mechanisms & livelihood impact;
Study design and methods: Phase 2 30 case study households in each site, followed over 12 months • Qualitative and quantitative data • Descriptive data to understand how and why household choose the actions that generate costs • Explanatory data describing household interactions with health system & processes associated with social protection • Assessment of livelihood impact over time
Strengths of methodological approach • Frequency based estimates of costs combined with rich textual data to explain causal processes • Comparison of very different country settings; • Often comparing rural and urban within the same country; • Sampling of households based on the rigorous surveillance data of the sites
Answering policy questions • Are exemptions reaching the intended beneficiaries; if not, why not? • Is free care sufficient to protect poor households, and under what circumstances? What is the impact of unofficial fees? • What aspects of poor service delivery drive up costs? • Is insurance providing the expected protection, and if not, why not? >> policy recommendations better protect poor households, in different settings, from illness related impoverishment?
Policy engagement Growing focus on best practise in translating of research to policy & practice • Sites provided evidence that national stakeholders see these issues as important; • Engage at beginning of study, & shape study to meet local needs; • Develop local communication / knowledge exchange strategies tailored to local needs; • Sharing strategies across sites;
Thank you to all the individuals and sites who have contributed towards developing this proposal….