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      The financial burden from non-communicable diseases in low- and middle-income countries: a literature review

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          Abstract

          Non-communicable diseases (NCDs) were previously considered to only affect high-income countries. However, they now account for a very large burden in terms of both mortality and morbidity in low- and middle-income countries (LMICs), although little is known about the impact these diseases have on households in these countries. In this paper, we present a literature review on the costs imposed by NCDs on households in LMICs. We examine both the costs of obtaining medical care and the costs associated with being unable to work, while discussing the methodological issues of particular studies. The results suggest that NCDs pose a heavy financial burden on many affected households; poor households are the most financially affected when they seek care. Medicines are usually the largest component of costs and the use of originator brand medicines leads to higher than necessary expenses. In particular, in the treatment of diabetes, insulin – when required – represents an important source of spending for patients and their families. These financial costs deter many people suffering from NCDs from seeking the care they need. The limited health insurance coverage for NCDs is reflected in the low proportions of patients claiming reimbursement and the low reimbursement rates in existing insurance schemes. The costs associated with lost income-earning opportunities are also significant for many households. Therefore, NCDs impose a substantial financial burden on many households, including the poor in low-income countries. The financial costs of obtaining care also impose insurmountable barriers to access for some people, which illustrates the urgency of improving financial risk protection in health in LMIC settings and ensuring that NCDs are taken into account in these systems. In this paper, we identify areas where further research is needed to have a better view of the costs incurred by households because of NCDs; namely, the extension of the geographical scope, the inclusion of certain diseases hitherto little studied, the introduction of a time dimension, and more comparisons with acute illnesses.

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          Most cited references 46

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          What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts?

          This paper presents the findings of a critical review of studies carried out in low- and middle-income countries (LMICs) focusing on the economic consequences for households of illness and health care use. These include household level impacts of direct costs (medical treatment and related financial costs), indirect costs (productive time losses resulting from illness) and subsequent household responses. It highlights that health care financing strategies that place considerable emphasis on out-of-pocket payments can impoverish households. There is growing evidence of households being pushed into poverty or forced into deeper poverty when faced with substantial medical expenses, particularly when combined with a loss of household income due to ill-health. Health sector reforms in LMICs since the late 1980s have particularly focused on promoting user fees for public sector health services and increasing the role of the private for-profit sector in health care provision. This has increasingly placed the burden of paying for health care on individuals experiencing poor health. This trend seems to continue even though some countries and international organisations are considering a shift away from their previous pro-user fee agenda. Research into alternative health care financing strategies and related mechanisms for coping with the direct and indirect costs of illness is urgently required to inform the development of appropriate social policies to improve access to essential health services and break the vicious cycle between illness and poverty.
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            Comparative quantification of health risks: Conceptual framework and methodological issues

            Reliable and comparable analysis of risks to health is key for preventing disease and injury. Causal attribution of morbidity and mortality to risk factors has traditionally been conducted in the context of methodological traditions of individual risk factors, often in a limited number of settings, restricting comparability. In this paper, we discuss the conceptual and methodological issues for quantifying the population health effects of individual or groups of risk factors in various levels of causality using knowledge from different scientific disciplines. The issues include: comparing the burden of disease due to the observed exposure distribution in a population with the burden from a hypothetical distribution or series of distributions, rather than a single reference level such as non-exposed; considering the multiple stages in the causal network of interactions among risk factor(s) and disease outcome to allow making inferences about some combinations of risk factors for which epidemiological studies have not been conducted, including the joint effects of multiple risk factors; calculating the health loss due to risk factor(s) as a time-indexed "stream" of disease burden due to a time-indexed "stream" of exposure, including consideration of discounting; and the sources of uncertainty.
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              Treatment-seeking behaviour, cost burdens and coping strategies among rural and urban households in Coastal Kenya: an equity analysis.

              Ill-health can inflict costs on households directly through spending on treatment and indirectly through impacting on labour productivity. The financial burden can be high and, for poor households, contributes significantly to declining welfare. We investigated socio-economic inequities in self-reported illnesses, treatment-seeking behaviour, cost burdens and coping strategies in a rural and urban setting along the Kenyan coast. We conducted a survey of 294 rural and 576 urban households, 9 FGDs and 9 in-depth interviews in each setting. Key findings were significantly higher levels of reported chronic and acute conditions in the rural setting, differences in treatment-seeking patterns by socio-economic status (SES) and by setting, and regressive cost burdens in both areas. These data suggest the need for greater governmental and non-governmental efforts towards protecting the poor from catastrophic illness cost burdens. Promising health sector options are elimination of user fees, at least in targeted hardship areas, developing more flexible charging systems, and improving quality of care in all facilities. The data also strongly support the need for a multi-sectoral approach to protecting households. Potential interventions beyond the health sector include supporting the social networks that are key to household livelihood strategies and promoting micro-finance schemes that enable small amounts of credit to be accessed with minimal interest rates.
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                Author and article information

                Journal
                Health Res Policy Syst
                Health Res Policy Syst
                Health Research Policy and Systems
                BioMed Central
                1478-4505
                2013
                16 August 2013
                : 11
                : 31
                Affiliations
                [1 ]Aix-Marseille University (Aix-Marseille School of Economics), CNRS & EHESS, Centre de la Vieille Charité, 2 Rue de la Charité, 13236 Marseille, Cedex 2, France
                [2 ]Department of Health Systems Financing, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland
                [3 ]WHO Regional Office for the Western Pacific Region, P.O. Box 2932, 1000 Manila, Philippines
                [4 ]Department of Health Systems Financing, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland
                Article
                1478-4505-11-31
                10.1186/1478-4505-11-31
                3751656
                23947294
                Copyright ©2013 Kankeu et al.; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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