Informal payments for primary health services in Zambia: Evidence from a health facility patient exit survey

Masiye, Felix; Kaonga, Oliver; Banda, Charles

doi:10.1016/j.hpopen.2020.100020

Cited by 8 publications

(14 citation statements)

References 39 publications

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“…The billing department maintains a separate electronic record for each patient and collects payment from hospitalized patients daily. Though informal payments for healthcare are common in some parts of Africa 21 , none of our patients reported using anything other than the Rwandan currency to pay, and this is not common in the Rwandan healthcare context.…”

Section: Study Settingmentioning

confidence: 66%

“…Even modest nonmedical direct and indirect costs such as the median of ~$30 for a c-section are nontrivial for poor patients. Additional informal payments are noted in some African contexts 21 , and these would certainly increase this OOP expenditure and rates of CHE. However, given strongly enforced anti-corruption policies throughout Rwanda, it was felt by hospital leadership that such payments are rare, and hence this was not assessed in our study.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Does Community-Based Health Insurance Protect Women from Financial Catastrophe After Cesarean Section? A Prospective Study from a Rural Hospital in Rwanda

Koch

Nkurunziza

Rudolfson

et al. 2021

Preprint

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BackgroundThe implementation of community-based health insurance in (CBHI) in Rwanda has reduced out of pocket (OOP) spending for the >79% of citizens who enroll in it but the effect for surgical patients is not well described. For all but the poorest citizens who are completely subsidized, the OOP (out of pocket) payment at time of service is 10%. However, 55.5% of the population is below the international poverty line meaning that even this copay can have a significant impact on a family’s financial health. The aim of this study was to estimate the burden of OOP payments for cesarean sections in the context of CBHI and determine if having it reduces catastrophic health expenditure (CHE). MethodsThis study is nested in a larger randomized controlled trial of women undergoing cesarean section at a district hospital in Rwanda. Eligible patients were surveyed at discharge to quantify household income and routine monthly expenditures and direct and indirect spending related to the hospitalization. This was used in conjunction with hospital billing records to calculate the rate of catastrophic expenditure by insurance group. ResultsAbout 94% of the 340 women met the World Bank definition of extreme poverty. Of the 330 (97.1%) with any type of health insurance, the majority (n=310, 91.2%) have CBHI. The average OOP expenditure for a cesarean section and hospitalization was $9.36. The average cost adding transportation to the hospital was $19.29. 164 (48.2%) had to borrow money and 43 (12.7%) had to sell possessions. The hospital bill alone was a CHE for 5.3% of patients. However, when including transportation costs, 15.4% incurred a CHE and including lost wages, 22.6%. ConclusionTo ensure universal health coverage (UHC), essential surgical care must be affordable. Despite enrollment in universal health insurance, cesarean section still impoverishes households in rural Rwanda, the majority of whom already lie below the poverty line. Although CBHI protects against CHE from the cost of healthcare, when adding in the cost of transportation, lost wages and caregivers, cesarean section is still often a catastrophic financial event. Further innovation in financial risk protection is needed to provide equitable UHC.

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Section: Study Settingmentioning

confidence: 66%

Section: Discussionmentioning

confidence: 99%

Does Community-Based Health Insurance Protect Women from Financial Catastrophe After Cesarean Section? A Prospective Study from a Rural Hospital in Rwanda

Koch

Nkurunziza

Rudolfson

et al. 2021

Preprint

View full text Add to dashboard Cite

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“…For example, a systematic review found that the cost of healthcare, which is a supply-side factor, is related to using healthcare facilities for child illness, but we could not assess this variable due to a lack of suitable data. Although primary healthcare services are free at public healthcare facilities in Zambia, in a recent study conducted in three provinces, 6.2% of patients reported incurring informal payments, but the incidence was low in rural areas and among maternal and child health service users [ 27 ]. This informal cost can be a barrier to using public healthcare facilities in Zambia in general, but may have less of an influence on the association between geological proximity to a public healthcare facility and the use of the facility for child fever and diarrhea.…”

Section: Discussionmentioning

confidence: 99%

Supply-Side Barriers to the Use of Public Healthcare Facilities for Childhood Illness Care in Rural Zambia: A Cross-Sectional Study Linking Data from a Healthcare Facility Census to a Household Survey

Mochida

Nonaka

Wamulume

et al. 2021

IJERPH

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Child mortality due to malaria and diarrhea can be reduced if proper treatment is received timely at healthcare facilities, but various factors hinder this. The present study assessed the associations between the use of public healthcare facilities among febrile/diarrheal children in rural Zambia and supply-side factors (i.e., the distance from the village to the nearest facility and the availability of essential human resources and medical equipment at the facility). Data from the Demographic and Health Survey 2018 and the Health Facility Census 2017 were linked. Generalized linear mixed models were used to assess the associations, controlling for clustering and other variables. The median distances to the nearest facility were 4.5 km among 854 febrile children and 4.6 km among 813 diarrheal children. Children who were over 10 km away from the facility were significantly less likely to use it, compared to those within 5 km (fever group: odds ratio (OR) = 0.37, 95% confidence interval (CI) = 0.21–0.68; diarrhea group: OR = 0.32, 95% CI = 0.20–0.50). The availability of human resources and equipment was, however, not significantly associated with facility use. Poor geographic access could be a critical barrier to facility use among children in rural Zambia.

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“…Mostly, healthcare workers rather than the patients initiated informal payments 13,31,32,43,51 . Patients paid informally, before care, mainly to access drugs and services, many of which should have been provided for free [32][33][34]42,48,51 . Some patients also made informal payments after service delivery as gifts to express gratitude 42,50 .…”

Section: Discussionmentioning

confidence: 99%

“…Patients or their relatives made informal payments for treatment to be initiated 32,50 , to receive both minor services such as bedpans 42 , injections 51 , or vaccinations 33 ; and major services, such as surgeries 32,42 . Informal payments were also made to receive drugs that were supposed to be provided for free [32][33][34]42,44,48,51 , and to obtain medical record books and reports 48 . In Tanzania, some healthcare providers feigned stockouts of commodities and sought money from patients disguising to purchase the commodities from the private market on their behalf 42 .…”

Section: Reasons For Paying Informal Paymentsmentioning

confidence: 99%

The hidden financial burden of healthcare: a systematic literature review of informal payments in Sub-Saharan Africa

et al. 2021

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Background: Informal payments limit equitable access to healthcare. Despite being a common phenomenon, there is a need for an in-depth analysis of informal charging practices in the Sub-Saharan Africa (SSA) context. We conducted a systematic literature review to synthesize existing evidence on the prevalence, characteristics, associated factors, and impact of informal payments in SSA. Methods: We searched for literature on PubMed, African Index Medicus, Directory of Open Access Journals, and Google Scholar databases and relevant organizational websites. We included empirical studies on informal payments conducted in SSA regardless of the study design and year of publication and excluded reviews, editorials, and conference presentations. Framework analysis was conducted, and the review findings were synthesized. Results: A total of 1700 articles were retrieved, of which 23 were included in the review. Several studies ranging from large-scale nationally representative surveys to in-depth qualitative studies have shown that informal payments are prevalent in SSA regardless of the health service, facility level, and sector. Informal payments were initiated mostly by health workers compared to patients and they were largely made in cash rather than in kind. Patients made informal payments to access services, skip queues, receive higher quality of care, and express gratitude. The poor and people who were unaware of service charges, were more likely to pay informally. Supply-side factors associated with informal payments included low and irregular health worker salaries, weak accountability mechanisms, and perceptions of widespread corruption in the public sector. Informal payments limited access especially among the poor and the inability to pay was associated with delayed or forgone care and provision of lower-quality care. Conclusions: Addressing informal payments in SSA requires a multifaceted approach. Potential strategies include enhancing patient awareness of service fees, revisiting health worker incentives, strengthening accountability mechanisms, and increasing government spending on health.

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Informal payments for primary health services in Zambia: Evidence from a health facility patient exit survey

Cited by 8 publications

References 39 publications

Does Community-Based Health Insurance Protect Women from Financial Catastrophe After Cesarean Section? A Prospective Study from a Rural Hospital in Rwanda

Does Community-Based Health Insurance Protect Women from Financial Catastrophe After Cesarean Section? A Prospective Study from a Rural Hospital in Rwanda

Supply-Side Barriers to the Use of Public Healthcare Facilities for Childhood Illness Care in Rural Zambia: A Cross-Sectional Study Linking Data from a Healthcare Facility Census to a Household Survey

The hidden financial burden of healthcare: a systematic literature review of informal payments in Sub-Saharan Africa

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