RETA-6515 REG IMPACT OF MATERNAL AND CHILD HEALTH PRIVATE EXPENDITURE ON POVERTY AND INEQUITY

Project Findings
Ravi P. Rannan-Eliya
Asian Development Bank Manila 6 November 2012

Disclaimer: The views expressed in this paper/presentation are the views of the author and do not necessarily reflect the views or policies of the Asian Development Bank (ADB), or its Board of Governors, or the governments they represent. ADB does not guarantee the accuracy of the data included in this paper and accepts no responsibility for any consequence of their use. Terminology used may not necessarily be consistent with ADB official terms.

Background
Coogee Beach Group
Concerns over lack of attention to challenges in reaching MDGs 4 and 5 within Asia-Pacific region Potential impact and burden of out-of-pocket expenditures on access and use of MNCH services

Parallel initiatives led by ADB and AusAID

ADB RETA-6515 AusAID/Unicef MNCH Investment Cases AusAID ADRA grant on inequities in access/OOPE in Asia

RETA-6515 Questions
What evidence is there on the impacts of MNCH OOPE on households in Asia-Pacific countries? How much do households spend on MNCH OOPE in selected Asia-Pacific DMCs? and what is its impact? What are the OOPE costs incurred by families in accessing government health services, and what are the costs and expenditures on MNCH services in Bangladesh?

RETA-6515 Components
Global/Regional
Systematic literature review of economic burden on household of MNCH OOPE

Regional
Inventory of available household survey data resources Analysis of household expenditure and utilization surveys in 6 DMCs

Bangladesh
Cost study of MOHFW healthcare facilities Patient exit survey of OOPE costs incurred at MOHFW facilities Analysis of MNCH costs and financing

Systematic review of household impact of MNCH OOPE

Methodology
Systematic review for 1990-2010, building on earlier WHO review 127 studies identified (64 from Asia-Pacific)

Review questions
1. What are the main direct/indirect costs to households from MNCH care and their relative importance? 2. What is the magnitude of MNCH care costs relative to other household health and non-health expenditures? 3. How and to what extent may MNCH care expenditures have an impoverishing effect on individuals and households respectively? 4. What coping strategies are available to women, households and how effective are they? 5. Does the financial burden associated with MNCH fall disproportionately on the poor and other vulnerable groups? 6. How well does the literature cover the experience of the region?
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Component 1

SYSTEMATIC REVIEW OF LITERATURE ON HOUSEHOLD IMPACTS OF MNCH OOPE

Systematic review of household impact of MNCH OOPE

Findings
Substantial increase globally in published work since 2006 Regional coverage appropriate given MNCH burden, but within region coverage is poor (AFG, LAO, PAK, PNG) Limited comparability of studies owing to lack of consistent definition and inclusion of costs Indirect costs rarely studied, but can be large MNCH OOPE costs can be very large in relation to household budgets (catastrophic/impoverishing(, especially where public expenditures are low Largest single cost, especially in Asia, is the purchase of medicines and supplies associated with accessing formal care OOPE costs highest for maternal care and surgery

Component 2

INVENTORY OF AVAILABLE HOUSEHOLD SURVEY RESOURCES IN 16 DMCS

Assessment of available household survey data

Findings Household surveys in 16 DMCs inventoried (N=130) and examined for suitability to assess MNCH OOPE Most surveys inadequate to estimate MNCH OOPE burdens
Failure to ask about cause of illness/reason for treatment in most surveys No standardization and poor design/classification when asked Sample sizes too small to separate out MNCH spending Non-sampling biases make estimates of the level and share of MNCH OOPE unreliable in surveys that fail to use detailed household budget module

Implications Current survey platforms grossly inadequate for addressing calls to track domestic MNCH resource flows Need for regional effort to improve comparability and bring question design up to best practices
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Component 3

ANALYSIS OF HOUSEHOLD EXPENDITURE AND UTILIZATION SURVEYS IN 6 DMCS

Country analyses of household OOPE

Country coverage
Bangladesh (HIES 2000, 2005, 2010) Cambodia (CSES 2007) Laos (LECS 2007-08) Pakistan (PSLMS 2005-06, CWIQ 2006-07) PNG (HIES 1996, HIES 2010) Timor Leste (TSLS 2001, 2007)

To be released as series of ADB policy briefs

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Country analyses of household OOPE

Analyses
Inequalities in illness Inequalities in healthcare utilization and factors discouraging care Inequalities in OOPE on all, and mothers/children where relevant Impoverishing and catastrophic impacts of OOPE

Key findings
Distinct differences between countries in impact and importance of MNCH OOPE as barrier to care Large variations in level of impoverishment due to OOPE OOPE a significant financial barrier in some countries, whilst distance and physical access more important in others Spending dominated by richest households and medicines, suggesting that modest public investments can have large impacts
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TLS: Catastrophic impacts of OOPE close to zero

Percentage (%) of households exceeding catastrophic threshold
16% 14% 10% of household budget 12% 25% of household budget 10% 8% 6% 4% 2% 0%

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TLS: Overall use of services very low

Outpatient visits to doctors/capita/year
Japan
13.0 10.5 9.3 6.7 6.4 5.9 5.7 5.2 4.9 4.3 4.2 3.9 2.9 2.1 2.0 1.8 1.7 1.5 0.9 16 14 12 10 8 6 4 2 0

Inpatient admissions/1000 capita/year

Sri Lanka Hong Kong Mongolia Australia Korea OECD New Zealand Thailand Asia-19 Viet Nam Brunei Darussalam Malaysia
120 120 113 109 107 102 89 79 75 60 38 36 29 0 50 100 150 200 250 300 163 162 145 140 137 234 228

Korea Hong Kong Singapore OECD Australia Macao Mongolia Asia-18 Sri Lanka New Zealand Malaysia Brunei Darussalam Fiji Thailand Viet Nam China Timor Leste Solomon Islands Papua New Guinea

Japan Singapore Fiji Macao Solomon Islands China Bangladesh Papua New Guinea Timor Leste

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TLS: Public outpatient care free in practice for poorest

20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% poorest 3% 2% 1% 1% 1% 0% 0% 0% middle 1% 2nd richest 2% 1% 8% 7% 15%

Percentage of public sector outpatients reporting costs by type of costs (%)

18%

2nd poorest

richest

Fees

Medicines

Travel
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TLS: But public inpatient care often not free because of stock-outs
100% 90% 80% 70% 62% 60% 50% 40% 30% 20% 10% 0% poorest 2nd poorest middle 2nd richest richest 25% 54% 44%

Percentage of public sector inpatients reporting costs by type of costs (%)

89% 89% 87%

74%

41%

21%

Treatment

Travel
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TLS: Physical access not OOPE critical

Reasons for not using healthcare when having serious illness by income level (%)
richest 42%

2nd richest

53%

middle

58%

2nd poorest

59%

poorest 0% 10% 20% 30%

77% 40% 50% 60% 70% 80% 90% 100%

Facility too far Transport too expensive Healthcare not good quality

No transport Health worker unfriendly Other

Healthcare too expensive Health workers not present

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TLS: Simulation results on impact of distance on healthcare use

Probability of obtaining healthcare when sick
70%

Probability of seeking healthcare when sick: typical rural patient (simulation estimates)

65%

60%

55% 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6

Time to nearest public healthcare facilty (hours)

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BGD: Inequalities in recognizing illness important, but improving

45
% of children reported sick in the past 30 days

40 35 30 25 20 15 10 5 0

2000 2005 2010

Poorest

Q2

Q3

Q4

Richest
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BGD: Reducing inequality in healthcare use by children

40
% of children taken for treatment

2000 2005 2010

35 30 25 20 15 10 5 0

Poorest

Q2

Q3

Q4

Richest
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BGD: Cost most important factor for poor, quality for non-poor
Treatment too expensive 100
% of children not seeking care

Distance too far

Other

90 80 70 60 50 40 30 20 10 0
2000 2005 2010 2000 2005 2010 2000 2005 2010 2000 2005 2010 2000 2005 2010

Poorest

Q2

Q3

Q4

Richest

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BGD: Poor rely on pharmacies and less on public/private medical care

100
% of individuals seeking care

90 80 70 60 50 40 30 20 10 0 Poorest Q2 Q3 Quintile
Government Modern allopathic Traditional/homepathic NGO

Q4

Richest

Rural

Urban Sector

All

Private modern allopathic Pharmacy Other

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BGD: Government treatment not cheaper than private, largely because of medicines

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Component 4

MNCH EXPENDITURES AND OOPE COSTS IN BANGLADESH

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RETA-6515 Bangladesh Component

Collaboration with MOHFW Health Economics Unit (HEU)
Activities
Nationwide government facility cost study
Nationally representative sample of 135 MOHFW facilities from tertiary teaching facilities to union subcentres Stratification designed to separate out maternal voucher facilities Designed to produce national cost reference dataset, and estimates and analysis of MNCH costs Designed to be comparable with earlier 1997 facility cost study

Exit survey of patients at MOHFW facilities

Exit interviews of MOHFW outpatients and inpatients about costs

Analysis of MNCH financing flows

Total public and private financing flows, including expenditures at pharmacies

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RETA-6515 Bangladesh Facility Cost Survey

High levels of patient throughput at all levels in MOHFW delivery system
Bed occupancy rates ~80 - >100% in main facilities Reduction in efficiency variations between facilities

Result of increased patient throughput

Declining ALOS across all facilities since 1997 (MCHs 10 > 4 days) Evidence indicates that quality was maintained, but large increase in Caesarian Section Rates

Reductions in real units of service delivery

Expansions in service delivery funded mainly through efficiency gains

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RETA-6515 Bangladesh Facility Cost Survey

Large improvements in technical efficiency 1998-2010

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RETA-6515 Bangladesh Facility Cost Survey

Changes in costs and efficiencies, UHCs 1998-2010
Indicators
Inputs Total recurrent expenditures (Taka million) Medicines expenditures (Taka million) Hospital beds Doctors Nurses Outputs Admissions/year Outpatients/year Inpatient efficiency indicators Bed-turnover rate (annual) Bed occupancy rate (%) ALOS (days) Unit costs Admissions (Taka) Outpatients (Taka) 1,938 63 1,962 79 74 75 3.9 119 90 2.8 2,347 50,228 4,043 81,431 6.28 0.27 31.7 4.3 6.3 18.23 2.0 34.8 6.2 9.5

1997

2010

Note: Estimates for 1997 from FES 1998 study, and for 2010 from FES 2011. Statistics are weighted means.

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RETA-6515 Bangladesh Patient Exit Survey

Exit survey of patients at MOHFW facility sample
2,080 inpatients, 3,080 outpatients Oversampling of MNCH patients Questions on basic demographics, costs incurred and to whom, travel costs, asset module to estimate SES

Main costs faced

Travel costs
Almost all patients, and higher for pregnant mothers

Official fees
Low, but much higher for pregnant mothers

Informal payments
Incidence much lower than anticipated (1-9%), but one third of mothers

Purchase of medicines and supplies

Largest and most frequent costs (50% of outpatients, >90% of inpatients)
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RETA-6515 Bangladesh Facility Cost Survey

Large increases in childbirth deliveries at maternal voucher facilities

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RETA-6515 Bangladesh Patient Exit Survey

Access by poor
Utilization highly pro-rich in all types of facilities and for all types of care Catastrophic expenditures significantly higher for mothers

Impact of maternal voucher DSF schemes

Utilization
Substantial increases in childbirth in DSF facilities, but greatest in universal DSF schemes Universal DSF facilities also have large increases in overall utilization No change in income inequality of use

OOPE costs
No impact on reported OOPE costs, but DSF patients receive retroactive cash payments

DSF facilities have modest increase in operating budgets

But substantial increases in operating efficiencies and unit costs at universal DSF facilities
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RETA-6515 Bangladesh MNCH Financing Flows

Table 1: Current healthcare expenditures by major financing source and type of provider, Bangladesh 2006/2007 (Taka billions)

Provider General administration Hospitals Ambulatory providers Pharmacies and other medicine retailers Other medical goods suppliers Public health programs Other providers Total

MOHFW 0.6 17.1 11.6 0.0 0.0 1.8 0.8 31.9

Other public 0.0 0.4 0.0 0.0 0.0 0.0 0.0 0.4

Households 0.0 13.7 17.9 65.5 3.0 0.0 0.0 100.1

Other private 0.1 1.1 0.9 0.6 0.0 0.4 0.7 3.7

Rest of the World 0.0 6.0 4.5 0.0 0.0 1.8 0.0 12.4

Total 0.7 38.3 34.9 66.1 3.0 4.0 1.5 148.5

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RETA-6515 Bangladesh MNCH Financing Flows Pharmacy expenditures

4,000,000 3,500,000 3,000,000 2,500,000 2,000,000 1,500,000 1,000,000 500,000 0

5-9

15-19

25-29

35-39

45-49

55-59

65-69

75-79

85-89

20-24

30-34

40-44

50-54

60-64

70-74

80-84

Acute Respiratory Infections Chronic Respiratory Disease Disease of the Digestive System III-defined conditions & other Contacts Malignant Neoplasms Musculoskeletal Disorders Oral Health Unspecified Abnormal Clinical &

10-14

Benign Neoplasms Congenital Anomalies Endocrine & Metabolic Disorders Infecticious & Parasitic Diseases Maternal Conditions Nervous System and Sense Organ Disorders Other Anaemias and Blood/Immune Disorder

Cardiovascular Disease Diabetes Mellitus Genitourinary Diseases Injuries Mental Disorders Nutritional Deficiencies Skin Diseases

90-94

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95+

1-4

RETA-6515 Bangladesh MNCH Financing Flows Pharmacy expenditures

14%

27% 59%

Children (<5 years)

Childbirth

Other maternal

Figure 1: Expenditure on MNCH care by major types of care, Bangladesh 2006/07

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RETA-6515 Bangladesh MNCH Financing Flows Pharmacy expenditures

Total MNCH

28%

Other maternal

47%

Childbirth

24%

Children (<5 years)

26%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

MOHFW Budget Informal payments at MOHFW facilities Private purchases of medicines

Official fees paid to MOHFW facilities Self-purchases of medicines for MOHFW treatment Treatment at private providers

Figure 1: Sources of financing of MNCH care and its key components, Bangladesh 2006/07

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RETA-6515 Bangladesh Findings

Public financing covers only one third of MNCH costs Inadequate funding of medicines at MOHFW facilities leads to high OOPE costs for public sector patients and discourages use by poor Evidence that DSF schemes improved access overall by reducing financial barriers, but benefits still partial Evidence that improving access to MOHFW facilities leads to increasing efficiencies

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Conclusions
Financial barriers and costs important in many DMCs facing challenges in improving MNCH outcomes
Large catastrophic impacts, especially for childbirth Costs often associated with lack of supplies/medicines at government facilities

Other barriers also important in some DMCs

Physical access an issue in TLS, LAO, PNG

Evidence that effciency gains and marginal modest investments can make a difference to acces

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