Ashadul Islam Director General, Health Economics Unit Ministry of Health and Family Welfare

Transcription

1 Ashadul Islam Director General, Health Economics Unit Ministry of Health and Family Welfare 1

2 Indicator Population (WDI) 132,383, ,594,962 Maternal mortality ratio (per 100,000 live births, BMMS) Infant Mortality rate (per 1,000 live births, BDHS) GDP per capita (current US$, WDI) Health expenditure per capita (current US$, BNHA) Total Health expenditure (% of GDP, BNHA) 2.6% 3.5% Out-of-pocket health expenditure (% of total health expenditure, BNHA) 57.8% 63.3% 2

3 [1] Includes NIPISH financing schemes excluding Employer-based insurance (other than enterprise schemes) Other complementary or supplementary insurance

4 Two out of three Taka spent on medicine

5 Objectives To estimate the incidence of catastrophic healthcare expenditure (CHE) and associated impoverishment in Bangladesh over a period of 10 years To identify socio-economic determinants of CHE and impoverishment Data Three consecutive Household Income and Expenditure Surveys (HIES) of year 2000, 2005 and 2010 Variables used Household consumption expenditure Household size Out-of-pocket (OOP) healthcare spending in last 30 days Durable goods, types of housing and access to basic facilities 5

6 Self-reported illness/symptoms per 1,000 population Figure 1. Self-reported illness or symptoms (per 1,000 populations) in last 30 days across asset quintiles, R:P ratio=0.75 R:P diff=-57.6 Concentration Index= R:P ratio=0.76 R:P diff=-50.5 Concentration Index= R:P ratio=0.73 R:P diff=-59.6 Concentration Index= Poorest 2nd quintile 3rd quintile 4th quintile Richest Total Self-reported illness is higher in poorer socioeconomic quintiles which may imply that poor people have higher need of healthcare. 6

7 % share utilized 100% Figure 2. Utilization of healthcare providers 80% 60% 40% 20% 0% 26% 28% 25% 25% 18% 18% 16% 15% 18% 16% 17% 19% 14% 14% 15% 14% 13% 17% % 24% 21% % 28% 24% 23% 19% 18% % 20% 22% 20% 21% % 17% 21% 27% 12% 12% % 13% 12% 17% 14% 15% 16% 15% 12% 14% 17% 29% % 23% 18% 22% 20% 22% 25% 23% 23% 17% 21% 24% 20% 22% 19% 23% % 19% 25% 24% 19% 19% 24% 20% 23% 22% 20% 20% 13% 23% 24% 18% 22% 21% 23% 26% Public Private NGO Drug sellers Traditional healers Others (like, self treatment) Poorest 2nd quintile 3rd quintile 4th quintile Richest People in poorer quintiles utilized more frequently drug sellers, NGO facilities, and traditional healers on the other hand, people in richer quintiles utilized the public and private facilities more frequently for health services % 17% 32% 13%

8 Table 2. Distribution of out-of-pocket health expenditures in last 30 days Reported any health expenditure (% of total household) 59.2% 52.5% 53.4% Out-of pocket payment in BDT (Inflation adjusted for base year 2010) 1, , ,282.1 Average OOP as a share of total expenditure 8.0% 8.3% 8.8% Average OOP as a share of capacity-to-pay 16.7% 17.4% 20.7% The average household OOP spending on healthcare for the last 30 days showed an increasing trend (adjusted for inflation rate for the base year 2010). 8

9 Monthly out-of-pocket payment (BDT) inflation adjusted 3,000 2,500 R:P ratio=4.5 R:P diff=1,529.8 Concentration Index=0.268 R:P ratio=3.2 R:P diff=1,144.6 Concentration Index=0.218 R:P ratio=3.8 R:P diff=1,863.3 Concentration Index= ,000 1,500 1, ,002 1,028 1, Poorest 2nd quintile 3rd quintile 4th quintile Richest Total Higher OOP spending is observed among the better-off quintiles While the poor have a higher rate of self-reported illness, they have a relatively lower OOP spending. This may refer to the unmet healthcare needs among the poor due to their lower capacity to pay. 9

10 Incidence of catastrophic payment using 40% CTP as threshold Figure 4. Incidence of catastrophic health expenditure 14% 12% 10% 8% 6% 4% 2% 0% R:P ratio=0.44 R:P diff=-4.3% Concentration Index= R:P ratio=0.53 R:P diff=-4.0% Concentration Index= % 6.6% R:P ratio=0.46 R:P diff=-6.5% Concentration Index= % Poorest 2nd quintile 3rd quintile 4th quintile Richest Total The incidence of catastrophic spending is higher among poor households in all years and it showed an increasing trend in the last 10 years. 10

11 % population push below cost-of basic needs poverty line (number of individual in million) Poverty headcount (%) % (5.8) % population push below international poverty 3.5% line 1) (number of individual in million) (4.4) 3.9% (5.4) 3.7% (5.2) 4.2% (6.2) 3.3% (4.9) National poverty headcount2) 49.8% 40.0% 31.5% Poverty headcount due to OOP spending is almost the same, at about 4% over the period. However, the national poverty headcount have significantly decreased (by 18.3%) over this time period 11

12 Utilization of private facility Chronic illness Lower socio-economic status Having elderly member in household Having female household head Small household size Living in rural location Low level of education 12

13 Private facility utilization Treatment of chronic illness Living in rural location Smaller household size 13

14 13000 community clinics, a number of hospitals and improved hospital services Expanded demand side financing for ANC and deliveries by skilled birth attendants Adoption of the HEALTH CARE FINANCING STRATEGY ( ) Resource Allocation Formula to target the poor areas National Social Security Strategy 2015

15 Expanding Social Protection for Health: Towards Universal Health Care Coverage Health Care Financing Strategy

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17 OOP for healthcare causes high incidence of catastrophic health expenditure, especially for poor households, pushing many people into poverty. The drivers of CHE and impoverishment highlight the need to address social determinants of health and coordination across sectors The high OOP and increasing trend of CHE demand effective financial risk protection mechanisms. Govt is trying to address through HCF Strategy and National Social Security Strategy These are very challenging as it requires reforms & changes in financial regulations and cultural shift towards social solidarity. 1 7

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19 POPULATION MILLLION (2012) SOCIAL TRANSFER Below Poverty Line 31.5% 47.8 MILLION Poor Tax-funded publicly financed health care Non-contributory health protection scheme (e.g. SSK) 83.4 MILLION 20.5 MILLION Formal; regular income 13.5% Informal sector Tax-funded publicly financed health care with user fee retention Community-based health insurance initiatives Micro health insurance Other innovative initiatives Gradual move to Social Health Protection coverage Formal sector Tax-funded publicly financed health care with user fee retention Social Health Protection scheme Complementary private coverage 19

20 Utilization of private facility (odds ratio/or=6.95; 95% CI: 6.3, 7.64) Chronic illness (OR=1.5; 95% CI: 1.33, 1.60) Lower socio-economic status (OR=0.44; 95% CI=0.37, 0.53; OR for richest with refer to poorest ) Having elderly member in household (OR=1.16; 95% CI=1.03,1.30) Having female household head (OR=0.86; 95% CI: 0.75, 0.99) Small household size (OR=0.88, 95% CI=0.79, 0.97) Living in rural location (OR=1.32, 95% CI: 1.18, 1.47) Low level of education (OR=0.57; 95% CI: 0.42, 0.77; OR for household head with higher secondary with refer to no institutional education ) 20

21 Private facility utilization (OR=6.86; 95% CI: 5.76, 8.18) Treatment of chronic illness (OR= % CI: 1.44, 2.05) Living in rural location (OR=1.29; 95% CI: 1.06, 1.57) Smaller household size (OR=0.77, 95% CI: 0.64, 0.92) 21

22 Out-of-pocket payments: refer to the payment made by households at the point they receive health services Household s capacity to pay: defined as expenditure remaining after basic subsistence needs have been met. Catastrophic expenditure: Catastrophic heath expenditure occurs when a household s total out-of-pocket health payments equal or exceed 40% of household s capacity to pay. (Ref: Xu et al. 2003) Impoverishment: A non-poor household is impoverished by health payments when it becomes poor after paying for health services, based on the poverty line. Cost-of basic needs and subsistence spending were used as poverty line for assessing the impoverishment impact. 22