Out-of-pocket expenditures for primary health care in Tajikistan: a time-trend analysis

Abstract

BackgroundAligned with the international call for universal coverage of affordable and quality health care, the government of Tajikistan is undertaking reforms of its health system aiming amongst others at reducing the out-of-pocket expenditures (OPE) of patients seeking care. Household surveys were conducted in 2005, 2007, 2008 and 2011 to explore the scale and determinants of OPE of users in four district of Tajikistan, where health care is legally free of charge at the primary level.MethodsUsing the data from four cross-sectional household surveys conducted between 2005 and 2011, time trends in OPE for consultation fees, drugs and transport costs of adult users of family medicine services were analysed. To investigate differences along the economic status, an asset index was constructed using principal component analysis.ResultsAdjusted for inflation, OPE for primary care have substantially increased in the period 2005 to 2011. While the proportion of patients reporting the payment of informal consultation fees to providers and their amount were constant over time, the proportion of patients reporting expenditures for drugs has increased, and the median amounts have doubled from 5.3 US$ to 10.7 US$. Thus, the expenditures on medicine represent the biggest financial burden for patients accessing a primary care facility. Regression models showed that in 2011 patients from the most remote district with spread-out villages reported significant higher expenditures on medicine. Besides the steady increase in the median amount for OPE, the proportion of patients reporting making an informal payment to their care provider showed great variations across district of residence (between 20% and 73%) and economic status (between 33% among the ‘worst-off’ group and 68% among the ‘better-off’ group).ConclusionsIn a context of limited governmental funds allocated to health and financing reforms aiming to improve financial access to primary care, the present paper indicates that in Tajikistan OPE – especially in relation to expenditures for drugs – have increased over time, and vary substantially across geographical areas and economic status. The fact that better-off households report disbursing more and in higher proportions hints towards a discrimination along the capacity to pay from providers. Increased public investments in the health sector, incentives for family doctors to provide PHC services free of charge and a strengthened drug control and supply system are necessary strategies to improve access of patients to services.

Trends in Out of Pocket Payments and Catastrophic Health Expenditure in the Kyrgyz Republic Post the “Den Sooluk” Health Reform, 2012 - 2018

“…This is most signi cant when patients self-treat since cost rose by about US $7 between 2012 and 2018. Exponential rising cost of healthcare has also been reported in Tajikistan (26) and Kazakhstan (27).…”

“…Evidence from other Central Asia countries suggest that informal payments as a share of total out-of-pocket payments continue to rise. In Tajikistan, informal payments can be as high as 20-73 percent of healthcare spending between 2005 and 2011(26).…”

Exploring the changes of physicians' behaviour toward informal payment based on Health Transformation Plan in Iran: A qualitative study

“…27 It seems that the establishment of a competitive market among physicians, regardless of other corrective events, has the potential for economic equilibrium in the financial market and financial pro- Most of this demand was justified by insufficient and unsuitable physicians' expenses, unreasonable earning and unreal tariffs. 28,29 Such justifications may raise the pressure on people because they may not be rightly compensated by the government, which might, in turn, diminish any economic order in society. If people are to be held accountable for the low allocation of credits, what should the low-income group do?…”

Determinants of Out-of-Pocket Expenditure for Health Care: A Systematic Review

“…Similarly, patients from two semi-urban districts made informal payments to their family doctors in higher proportions and in higher amounts. The findings raise questions on the allocation of resources across regions in Tajikistan and issues of access and quality of the health care in certain districts (Schwarz et al, 2013).…”

“…The richer group pay higher prices for medicine may result from an access to better quality drugs or substituting from generic medicines to a more expensive drug. Similarly, patients ranked higher economically pay their family doctors in higher proportions, which reflect that wealthier patients pay their provider better and thus receive better care (Schwarz et al, 2013).…”