Incidence of impoverishing from health spending.

BackgroundThe World Health Organisation (WHO) estimates that about 3.2 billion people which is nearly half of the world’s population are at risk of malaria. Annually about 216 million cases and 445,000 deaths of malaria occur globally. Africa accounted for 90% and 91% of the malaria cases and deaths respectively. Zambia has earmarked malaria elimination on its path to Universal Health Coverage (UHC). This paper aims to determine the incidence of Out-of-Pocket Payments (OOP) and Catastrophic Health Expenditures (CHE) and impoverishment among households with malaria patients in Zambia. The paper focusses on the incidence of OOP and impoverishment for malaria in a setting without user fees for accessing primary malaria health care services and virtually no user fees at all levels of care if referred through the referral system. The results of this study will also serve as a baseline for tracking Zambia’s path towards achieving malaria financial access on its path towards UHC among patient with malaria.MethodsThe study uses a nationally representative cross-sectional survey of households in both rural and urban areas of Zambia. The study employed probability sampling procedures. A two-stage stratified cluster sample design was used. We analyse a total of 2,005 households that had at least one member suffering from malaria with a recall period of four weeks for out-patients and six months for the in-patient respectively. A logistic regression model was estimated with a Categorical Dependent variable being CHE (CHE = = 1, or otherwise = = 0). A household is considered impoverished if it fell below the poverty line due to OOP. All data was analyzed using Stata version 2013.Results and discussionThe results show that although the country has a free malaria policy at primary care level and virtually at all levels if referred through the health system process, households are still incurring costs in accessing health care services. Incidence of CHE and impoverishment were reflected at all levels. In terms of CHE, the poorest contributed almost 30% while the wealthier quintile contributed about 10%. Similarly, impoverishment effects of OOPs are more pronounced in the poorest quintile. The OOP composed mainly of transport, followed by diagnosis and medicines and was lowest for Insecticide-treated bed nets (ITNs) payments. The high costs of transport that the households had to incur when accessing health services could be due to the long distance that the households have to face as they travel to the health facilities as most of the facilities in Zambia are still outside the 5 km radius. The drug expenditure could be explained by the drugs running out of stock. Low expenditure on ITNs could be due to the country’s strategy of mass distribution working to give the country’s universal financial protection on ITNs for malaria.Conclusion and policy implicationsThis study sought to address gaps in OOP and the associated incidence of CHE and impoverishment for malaria, distribution of OOP among Social Economic Status (SES) setting and determinants of OOP in Country that has earmarked malaria elimination in the UHC agenda. Understanding household’s costs related to malaria will enable targeting intervention to accelerate Zambia’s path towards elimination of malaria and therefore contribute to attainment of the Sustainable Development Goals of household’s financial access to UHC. Thus, the study will also serve as a baseline for tracking UHC for household financial access to malaria care that the country has embarked on.背景 世界卫生组织（World Health Organisation, WHO）估算，全球约32亿人口（接近全球总人口的一半）面临疟疾感染风险。全球每年约发生2.16亿疟疾病例，导致44.5万人死亡；其中非洲地区的疟疾病例和死亡占比分别高达90%和91%。赞比亚已将消除疟疾纳入其推进全民健康覆盖（Universal Health Coverage, UHC）的发展路径中。本研究旨在明确赞比亚疟疾患者家庭的自费支出（Out-of-Pocket Payments, OOP）、灾难性卫生支出（Catastrophic Health Expenditures, CHE）发生率及因病致贫情况。本研究聚焦于赞比亚疟疾诊疗相关自费支出与因病致贫的发生情况——当地针对基层疟疾医疗服务免收诊疗费用，且通过转诊系统就医时，各级诊疗服务几乎均无需支付费用。本研究结果还将作为基准，用于追踪赞比亚在推进全民健康覆盖进程中，疟疾患者获得医疗融资保障的进展情况。 方法 本研究针对赞比亚城乡家庭开展具有全国代表性的横断面调查，采用概率抽样方法，具体设计为两阶段分层整群抽样。本次研究共纳入2005户至少有1名成员罹患疟疾的家庭，门诊相关费用的回忆周期为4周，住院相关费用的回忆周期为6个月。本研究构建逻辑回归模型，以灾难性卫生支出为分类因变量（CHE=1代表发生灾难性卫生支出，CHE=0代表未发生）。若某家庭因自费医疗支出陷入贫困线以下，则认定该家庭因病致贫。所有数据均采用Stata 2013版本软件进行分析。 结果与讨论 研究结果显示，尽管赞比亚针对基层疟疾诊疗实施免费政策，且通过医疗系统转诊的各级诊疗服务几乎均无需付费，但受访家庭在获取医疗服务时仍需承担相关费用。灾难性卫生支出与因病致贫情况在各收入层级均有发生：在灾难性卫生支出群体中，最贫困五分位组占比近30%，而最富裕五分位组占比约10%。同样，自费支出导致的因病致贫效应在最贫困五分位组中表现得更为显著。疟疾相关自费支出主要包括交通费用，其次为诊断与药品费用，经杀虫剂处理的蚊帐（Insecticide-treated bed nets, ITNs）支出占比最低。受访家庭在就医时承担高额交通费用，可能源于当地多数医疗卫生机构未覆盖5公里服务半径，家庭需长途跋涉前往医疗机构。药品支出较高则可能与药品缺货有关。经杀虫剂处理的蚊帐支出较低，或得益于赞比亚的大规模蚊帐分发策略，该策略为全民提供疟疾防控蚊帐的融资保障。 结论与政策启示 本研究针对已将消除疟疾纳入全民健康覆盖议程的赞比亚，填补了疟疾相关自费支出、灾难性卫生支出与因病致贫的发生情况、自费支出在社会经济地位（Social Economic Status, SES）分层中的分布特征，以及自费支出影响因素相关研究的空白。明确疟疾相关的家庭医疗支出情况，有助于制定精准干预措施，加快赞比亚消除疟疾的进程，进而助力实现“全民健康覆盖背景下家庭可获得医疗融资保障”的可持续发展目标。因此，本研究也将作为基准，用于追踪赞比亚正在推进的疟疾诊疗家庭医疗融资保障的全民健康覆盖进展。