Catastrophic out-of-pocket payments for households of people with severe mental disorder: a comparative study in rural Ethiopia

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Abstract

Background

There are limited data on healthcare spending by households containing a person with severe mental disorder (SMD) in low- and middle-income countries (LMIC). This study aimed to estimate the incidence and intensity of catastrophic out-of-pocket (OOP) payments and coping strategies implemented by households with and without a person with SMD in a rural district of Ethiopia.

Methods

A comparative cross-sectional community household survey was carried out from January to November 2015 as part of the Emerald programme (emerging mental health systems in low- and middle-income countries). A sample of 290 households including a person with SMD and 289 comparison households without a person with SMD participated in the study. An adapted and abbreviated version of the World Health Organization SAGE (Study on global Ageing and adult health) survey instrument was used. Households were considered to have incurred catastrophic health expenditure if their annual OOP health expenditures exceeded 40% of their annual non-food expenditure. Multiple logistic regression was used to explore factors associated with catastrophic expenditure and types of coping strategies employed.

Results

The incidence of catastrophic OOP payments in the preceding 12 months was 32.2% for households of a person with SMD and 18.2% for comparison households (p = 0.006). In households containing a person with SMD, there was a significant increase in the odds of hardship financial coping strategies (p < 0.001): reducing medical visits, cutting down food consumption, and withdrawing children from school. Households of a person with SMD were also less satisfied with their financial status and perceived their household income to be insufficient to meet their livelihood needs (p < 0.001).

Conclusions

Catastrophic OOP health expenditures in households of a person with SMD are high and associated with hardship financial coping strategies which may lead to poorer health outcomes, entrenchment of poverty and intergenerational disadvantage. Policy interventions aimed at financial risk pooling mechanisms are crucial to reduce the intensity and impact of OOP payments among vulnerable households living with SMD and support the goal of universal health coverage.

Electronic supplementary material

The online version of this article (10.1186/s13033-019-0294-7) contains supplementary material, which is available to authorized users.

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Most cited references 48

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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?

Diane McIntyre, Michael Thiede, Göran Dahlgren … (2006)

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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Challenges and Opportunities for Implementing Integrated Mental Health Care: A District Level Situation Analysis from Five Low- and Middle-Income Countries

Charlotte Hanlon, Nagendra P. Luitel, Tasneem Kathree … (2014)

Background Little is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and between countries. In this paper we compare the baseline context, challenges and opportunities in districts in five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) participating in the PRogramme for Improving Mental health carE (PRIME). The purpose was to inform development and implementation of a comprehensive district plan to integrate mental health into primary care. Methods A situation analysis tool was developed for the study, drawing on existing tools and expert consensus. Cross-sectional information obtained was largely in the public domain in all five districts. Results The PRIME study districts face substantial contextual and health system challenges many of which are common across sites. Reliable information on existing treatment coverage for mental disorders was unavailable. Particularly in the low-income countries, many health service organisational requirements for mental health care were absent, including specialist mental health professionals to support the service and reliable supplies of medication. Across all sites, community mental health literacy was low and there were no models of multi-sectoral working or collaborations with traditional or religious healers. Nonetheless health system opportunities were apparent. In each district there was potential to apply existing models of care for tuberculosis and HIV or non-communicable disorders, which have established mechanisms for detection of drop-out from care, outreach and adherence support. The extensive networks of community-based health workers and volunteers in most districts provide further opportunities to expand mental health care. Conclusions The low level of baseline health system preparedness across sites underlines that interventions at the levels of health care organisation, health facility and community will all be essential for sustainable delivery of quality mental health care integrated into primary care.

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Equity and health sector reforms: can low-income countries escape the medical poverty trap?

Thomas G. Dahlgren, M. Whitehead, T. Evans (2001)

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Author and article information

Contributors

Yohannes Hailemichael: yohannes.h.michael@gmail.com

Damen Hailemariam: damen_h@hotmail.com

Kebede Tirfessa: kebede.tirfessa@yahoo.com

Sumaiyah Docrat: s.docrat@uct.ac.za

Atalay Alem: atalay.alem@gmail.com

Girmay Medhin: gtmedhin@yahoo.com

Crick Lund: crick.lund@uct.ac.za

Dan Chisholm: chisholmd@who.int

Abebaw Fekadu: abe.wassie@kcl.ac.uk

Charlotte Hanlon: charlotte.hanlon@kcl.ac.uk

Journal

Journal ID (nlm-ta): Int J Ment Health Syst

Journal ID (iso-abbrev): Int J Ment Health Syst

Title: International Journal of Mental Health Systems

Publisher: BioMed Central (London )

ISSN (Electronic): 1752-4458

Publication date (Electronic): 1 June 2019

Publication date PMC-release: 1 June 2019

Publication date Collection: 2019

Volume: 13

Electronic Location Identifier: 39

Affiliations

[1 ]ISNI 0000 0001 1250 5688, GRID grid.7123.7, Department of Reproductive Health and Health Services Management, School of Public Health, College of Health Sciences, , Addis Ababa University, ; Addis Ababa, Ethiopia

[2 ]ISNI 0000 0001 1250 5688, GRID grid.7123.7, Department of Psychiatry, School of Medicine, College of Health Sciences, , Addis Ababa University, ; Addis Ababa, Ethiopia

[3 ]ISNI 0000 0001 2322 6764, GRID grid.13097.3c, Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, , King’s College, ; London, UK

[4 ]ISNI 0000 0004 1937 1151, GRID grid.7836.a, Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, , University of Cape Town, ; Cape Town, South Africa

[5 ]ISNI 0000 0001 1250 5688, GRID grid.7123.7, Aklilu-Lemma Institute of Pathobiology, , Addis Ababa University, ; Addis Ababa, Ethiopia

[6 ]ISNI 0000000121633745, GRID grid.3575.4, Department of Mental Health and Substance Abuse, , World Health Organization, ; Geneva, Switzerland

[7 ]ISNI 0000 0001 2322 6764, GRID grid.13097.3c, Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, , King’s College, ; London, UK

Article

Publisher ID: 294

DOI: 10.1186/s13033-019-0294-7

PMC ID: 6544918

PubMed ID: 31164919

SO-VID: 5f291c1b-c2ad-4a40-aff1-17fe0e380a95

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 10 August 2018

Date accepted : 23 May 2019

Funding

Funded by: European Union's Seventh Framework

Award ID: FP7/2007-2013

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ScienceOpen disciplines: Neurology

Keywords: catastrophic health expenditure,severe mental disorders,low- and middle-income,ethiopia,universal health coverage

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ScienceOpen disciplines: Neurology

Keywords: catastrophic health expenditure, severe mental disorders, low- and middle-income, ethiopia, universal health coverage

Catastrophic out-of-pocket payments for households of people with severe mental disorder: a comparative study in rural Ethiopia

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Most cited references 48

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

Challenges and Opportunities for Implementing Integrated Mental Health Care: A District Level Situation Analysis from Five Low- and Middle-Income Countries

Equity and health sector reforms: can low-income countries escape the medical poverty trap?

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