BackgroundThe goal of universal health coverage is challenging for chronically under-resourced health systems. Although household out-of-pocket payments are the most important source of health financing in low-income countries, relatively little is known about the drivers of primary health care expenditure and the predictability of the burden associated with high fee-for-service payments. This study describes out-of-pocket health expenditure and investigates demand- and supply-side drivers of excessive costs in the Democratic Republic of Congo (DRC), a central African country in the midst of a process of reforming its health financing system towards universal health coverage.MethodsA population-based household survey was conducted in four provinces of the DRC in 2014. Data included type, level and utilization of health care services, accessibility to care, patient satisfaction and disaggregated health care expenditure. Multivariate logistic regressions of excessive expenditure for outpatient care using alternative thresholds were performed to explore the incidence and predictors of atypically high expenditure incurred by individuals.ResultsOver 17% (17.5%) of individuals living in sample households reported an illness or injury without being hospitalized. Of 3341 individuals reporting an event in the four-week period prior to the survey, 65.6% sought outpatient care with an average of one visit (SD = 0.0). The overall mean expenditure per visit was US$ 6.7 (SD = 10.4) with 29.4% incurring excessive expenditure. The main predictors of a financial risk burden included utilizing public services offering the complementary benefit package, dissatisfaction with care received, being a member of a large household, expenditure composition, severity of illness, residence and wealth (p < .05). The insured status influenced the expenditure level, with no association with catastrophe. Those who did not seek care when needed reported financial constraints as the major reason for postponing or foregoing care. Wealth-related inequities were found in service and population coverage and in out-of-pocket payment for outpatient care.ConclusionBurdensome expenditure for primary care and its key drivers are of utmost importance. Forthcoming health financing reform agendas must incorporate a strategy for getting data used in the design of financial risk protection. Realizing equitable and efficient access to outpatient care is a vital ingredient for sustainable health systems.

Spillover effects on the welfare of family members may refer to caregiver health effects, informal care time costs, or both. This review focuses on methods that have been used to measure and value informal care time and makes suggestions for their appropriate use in cost-of-illness and cost-effectiveness analyses. It highlights the importance of methods to value informal care time that are independent of caregiver health effects in order to minimize double counting of spillover effects. Although the concept of including caregiver time costs in economic evaluations is not new, relatively few societal perspective cost-effectiveness analyses have included informal care, with the exception of dementia. This is due in part to challenges in measuring and valuing time costs. Analysts can collect information on time spent in informal care or can assess its impact in displacing other time use, notably time in paid employment. A key challenge is to ensure appropriate comparison groups that do not require informal care to be able to correctly estimate attributable informal care time or foregone market work. To value informal care time, analysts can use estimates of hourly earnings in either opportunity cost or replacement cost approaches. Researchers have used widely varying estimates of hourly earnings. Alternatively, stated-preference methods (i.e. contingent valuation, conjoint analysis) can be used to value the effect of informal care on utility, but this can entail double counting with health effects. Lack of consensus and standardization of methods makes it difficult to compare estimates of informal care costs. Electronic supplementary material The online version of this article (10.1007/s40273-019-00782-9) contains supplementary material, which is available to authorized users.

Wealth-related disparities in the use of reproductive health services remain a substantial problem in many low- and middle-income countries. Very few studies have attempted to explain such inequalities through decomposition of the contributions made by various individual- and household-level factors. This study aims to: (1) assess the degree of wealth-related inequality and inequity in the use of institutional delivery services in selected low- and middle-income countries, and (2) to explain wealth-related inequity through decomposition by the contributions made by various components, including health insurance coverage. Data come from Demographic and Health Surveys in three countries: Ghana, Rwanda, and the Philippines. Concentration indices are used to calculate inequality and horizontal inequity in service utilization. Multivariate methods are used to decompose inequity. Findings indicate a moderate to high degree of inequity in institutional delivery service use in all study countries. The study provides some evidence of the contribution of health insurance to increased wealth-related inequity in the use of institutional delivery services, although having health insurance was also associated with increased utilization of services. Results suggest that increased health insurance coverage does not automatically translate to lower wealth-related inequity in service utilization. Inequities in service utilization exist if there are still inequities in the health insurance status. The study advocates for expanding health insurance coverage, particularly among the poor to reduce inequity in insurance coverage and increase service utilization.

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