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RETA-6515 REGIMPACT OF MATERNAL AND CHILD HEALTHPRIVATE EXPENDITURE ON POVERTY AND

INEQUITYProject Findings

Ravi P. Rannan-Eliya

Asian Development BankManila

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 dataincluded in this paper and accepts no responsibility for any consequence of their use. Terminology

used may not necessarily be consistent with ADB official terms.


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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

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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 accessinggovernment health services, and what are the costs and

expenditures on MNCH services in Bangladesh?

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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

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Systematic review of household impact ofMNCH OOPE

Methodology

Systematic review for 1990-2010, building on earlier WHO review

127 studies identified (64 from Asia-Pacific)

Review questions1. 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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SYSTEMATIC REVIEW OF LITERATURE ONHOUSEHOLD IMPACTS OF MNCH OOPE

Component 1

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Systematic review of household impact ofMNCH 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 medicinesand supplies associated with accessing formal care

OOPE costs highest for maternal care and surgery

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INVENTORY OF AVAILABLE HOUSEHOLDSURVEY RESOURCES IN 16 DMCS

Component 2

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Assessment of available household surveydata

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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ANALYSIS OF HOUSEHOLD EXPENDITUREAND UTILIZATION SURVEYS IN 6 DMCS

Component 3

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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 tozero

12

0%

2%

4%

6%

8%

10%

12%

14%

16%

Pe

rcentage(%)ofho

useholdsexceedin

g

catastrophicthreshold

10% of household budget

25% of household budget


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TLS: Overall use of services very low

0.9

1.5

1.7

1.8

2.0

2.1

2.9

3.9

4.2

4.3

4.9

5.2

5.7

5.9

6.4

6.7

9.3

10.5

13.0

0246810121416

Papua New Guinea

Solomon Islands

Timor Leste

China

Viet Nam

Thailand

Fiji

Brunei Darussalam

Malaysia

New Zealand

Sri Lanka

Asia-18

Mongolia

Macao

Australia

OECD

Singapore

Hong Kong

Korea

Japan

Outpatient visits to doctors/capita/year

29

36

38

60

75

79

89

102

107

109

113

120

120

137

140

145

162

163

228

234

0 50 100 150 200 250 300

Timor Leste

Papua New Guinea

Bangladesh

China

Solomon Islands

Macao

Fiji

Singapore

Japan

Malaysia

Brunei Darussalam

Viet Nam

Asia-19

Thailand

New Zealand

OECD

Korea

Australia

Mongolia

Hong Kong

Sri Lanka

Inpatient admissions/1000 capita/year

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TLS: Public outpatient care free in practicefor poorest

1%0%

1%1%

1%

0%

3%

7%

15%

18%

1%0%

2% 2%

8%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

poorest 2nd poorest middle 2nd richest richest

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

Fees Medicines Travel

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TLS: But public inpatient care often not freebecause of stock-outs

54%

25%

44%

21%

41%

62%

89% 89%

74%

87%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

poorest 2nd poorest middle 2nd richest richest

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

Treatment Travel

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TLS: Physical access not OOPE critical

77%

59%

58%

53%

42%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

poorest

2nd poorest

middle

2nd richest

richest

Reasons for not using healthcare when having serious illness byincome level (%)

Facility too far No transport Healthcare too expensive

Transport too expensive Health worker unfriendly Health workers not present

Healthcare not good quality Other

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TLS: Simulation results on impact ofdistance on healthcare use

55%

60%

65%

70%

0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6Probabilityofobtaininghealthcarewhensick

Time to nearest public healthcare facilty (hours)

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

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BGD: Inequalities in recognizing illnessimportant, but improving

0

5

10

15

20

25

30

35

40

Poorest Q2 Q3 Q4 Richest

%

ofc

hildrenreportedsickinthepast

30days

2000

2005

2010

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BGD: Reducing inequality in healthcare useby children

19

0

5

10

15

20

25

30

35

40


%

ofc

hildrentakenfor

treatment

2000

2005

2010


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BGD: Cost most important factor for poor,quality for non-poor

20

0

10

20

30

40

50

60

70

80

90

100

2000

2005

2010

2000

2005

2010

2000

2005

2010

2000

2005

2010

2000

2005

2010


%

ofchildrennots

eekingcare

Treatment too expensive Distance too far Other


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

21

0

10

20

30

4050

60

70

80

90

100

Poorest Q2 Q3 Q4 Richest Rural Urban All

Quintile Sector

%

ofindividuals

seekingcare

Government Modern allopathic Private modern allopathic

Traditional/homepathic Pharmacy

NGO Other


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BGD: Government treatment not cheaperthan private, largely because of medicines

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MNCH EXPENDITURES AND OOPE COSTSIN BANGLADESH

Component 4

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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 SurveyLarge improvements in technical efficiency 1998-2010

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RETA-6515 Bangladesh Facility Cost SurveyChanges in costs and efficiencies, UHCs 1998-2010

Indicators 1997 2010

Inputs

Total recurrent expenditures (Taka million) 6.28 18.23

Medicines expenditures (Taka million) 0.27 2.0

Hospital beds 31.7 34.8

Doctors 4.3 6.2

Nurses 6.3 9.5

Outputs

Admissions/year 2,347 4,043

Outpatients/year 50,228 81,431

Inpatient efficiency indicators

Bed-turnover rate (annual) 74 119

Bed occupancy rate (%) 75 90ALOS (days) 3.9 2.8

Unit costs

Admissions (Taka) 1,938 1,962

Outpatients (Taka) 63 79

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 SurveyLarge 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 FinancingFlows Pharmacy expenditures

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

0

1-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90-94

95+

Acute Respiratory Infections Benign Neoplasms Cardiovascular Disease

Chronic Respiratory Disease Congenital Anomalies Diabetes Mellitus

Disease of the Digestive System Endocrine & Metabolic Disorders Genitourinary Diseases

III-defined conditions & other Contacts Infecticious & Parasitic Diseases Injuries

Malignant Neoplasms Maternal Conditions Mental Disorders

Musculoskeletal Disorders Nervous System and Sense Organ Disorders Nutritional Deficiencies

Oral Health Other Anaemias and Blood/Immune Disorder Skin Diseases

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33

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

59%

27%

14%

Children (


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34

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

26%

24%

47%

28%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Children (


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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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