Self-reported illness and household strategies for coping with health-care payments in Bangladesh

Bull World Health Organ 2013;91:449–458 | doi: http://dx.doi.org/10.2471/BLT.12.115428 Research 449 Self-reported illness and household strategies for coping with health-care payments in Bangladesh Md Mizanur Rahman,a Stuart Gilmour,a Eiko Saito,a Papia Sultanab & Kenji Shibuyaa Introduction The so-called “double burden” of noncommunicable and infectious diseases is a major challenge for the fragile health systems in many low- and middle-income countries.1–4 In these countries, poverty and illness are closely linked: poverty leads to ill health and ill health perpetuates poverty.1,2,5 Noncom- municable and infectious diseases cause financial hardship both directly, via out-of-pocket spending on treatment, and indirectly, by limiting participation in income-generating ac- tivities.6–9 In low- and middle-income countries where public funding for health services is inadequate and mechanisms for “risk-pooling”, such as “demand-side” financing and formal health insurance, are limited or unavailable, out-of-pocket payments and illness-related loss of income can lead to asset depletion, debt and reductions in essential consumption that, together, can result in financial catastrophe.6–10 Although much progress has been made in measuring the impact of out-of-pocket payments for health care on house- hold welfare, knowledge gaps remain. We know relatively little about the strategies that households adopt to cope – or, at least, try to cope – with the financial costs of illness, and we have few data to show how such coping strategies affect the future welfare of the households that implement them.10 In the few relevant studies that have been conducted, the cop- ing strategies that are followed have been found to differ with the type of disease involved,6,7,11–13 with the sector (private or public) providing the outpatient facilities used, if any,9,14 with the need for inpatient care,14–16 and with the economic status of the patients or their households.9,10,14,17 In Bangladesh, a country with high burdens of both noncommunicable and infectious diseases, out-of-pocket payments remain the most important source of funding for health care. Health insurance in Bangladesh is limited to a few small-scale schemes sponsored by nongovernmental organizations.18 The results of only three studies on out-of- pocket payments in Bangladesh have been published. These investigations were focused on household strategies for coping with the health-care expenses associated with pneumonia,11 tuberculosis12 and obstetric care.19 No attempt has been made to investigate the strategies followed by households in Ban- gladesh to cope with all payments associated with illness. The aims of the present study were to determine the self-reported prevalence of any illness among households in a city in Ban- gladesh and to identify the associated risk factors for illness and for the “distress” financing of any related health care (e.g. paying for the health care by borrowing, selling, reducing food expenditure, removing children from school or performing additional paid work). Methods Study area Rajshahi city, which lies in Rajshahi district, in north-western Bangladesh, is the third largest city in the country and is con- sidered broadly representative of the country’s urban areas. At the time of the present study, Rajshahi city had a population of about 400 000. About 71% of the males and 62% of the females in Rajshahi district are literate.20 This study was conducted in an urban setting in the absence of risk-pooling mechanisms such as “demand-side” financing (i.e. financing that transfers resources to poor households solely to facilitate the house- holds’ access to health services) or formal health insurance. Although programmes to finance some aspects of health care, including programmes of demand-side financing, exist in rural Objective To investigate self-reported illness and household strategies for coping with payments for health care in a city in Bangladesh. Methods A cluster-sampled probability survey of 1593 households in the city of Rajshahi, Bangladesh, was conducted in 2011. Multilevel logistic regression – with adjustment for any clustering within households – was used to examine the risk of self-reported illness in the previous 30 days. A multilevel Poisson regression model, with adjustment for clustering within households and individuals, was used to explore factors potentially associated with the risk of health-care-related “distress” financing (e.g. paying for health care by borrowing, selling, reducing food expenditure, removing children from school or performing additional paid work). Findings According to the interviewees, about 45% of the surveyed individuals had suffered at least one episode of illness in the previous 30 days. The most frequently reported illnesses among children younger than 5 years and adults were common tropical infections and noncommunicable diseases, respectively. The risks of self-reported illness in the previous 30 days were relatively high for adults older than 44 years, women and members of households in the poorest quintile. Distress financing, which had been implemented to cover health-care payments associated with 13% of the reported episodes, was significantly associated with heart and liver disease, asthma, typhoid, inpatient care, the use of public outpatient facilities, and poverty at the household level. Conclusion Despite the subsidization of public health services in Bangladesh, high prevalences of distress financing – and illness – were detected in the surveyed, urban households. a Department of Global Health Policy, Medical Building No 3, Hongo Campus, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan. b Department of Statistics, University of Rajshahi, Rajshahi, Bangladesh. Correspondence to Md Mizanur Rahman (e-mail: mizanur_rub@yahoo.com). (Submitted: 19 November 2012 – Revised version received: 7 March 2013 – Accepted: 8 March 2013 – Published online: 18 April 2013 ) Bull World Health Organ 2013;91:449–458 | doi: http://dx.doi.org/10.2471/BLT.12.115428450 Research Illness and household payments for health care Md Mizanur Rahman et al. areas of Bangladesh, these programmes do not currently cover urban areas,21 even though urban households tend to suffer more illness and use more health facilities than rural households.1 Study design and sample size Between August and November 2011, information was collected from house- holds in Rajshahi city. The households were selected using three-stage cluster- sampling. The primary sampling unit was the mahallah – the lowest adminis- trative unit of a Bangladeshi city. Forty mahallahs were selected, from the 159 forming Rajshahi city, using a method that made the probability of selection proportional to the population of the mahallah. Systematic random sampling was then used to select 40 buildings in each selected mahallah and, subse- quently, to select one household from each selected building. Data collection Overall, 27 interviewers – all social science, demography or statistics gradu- ates with experience in survey methods – and five supervisors were recruited to administer the pretested, validated, structured questionnaire used to col- lect data (Appendix A, available at: http://www.ghp.m.u-tokyo.ac.jp/wp- content/uploads/2013/03/Appendix- A-BulletinWHO-MR-20130328.pdf ). Before the survey, the interviewers and supervisors each received 10 days’ training and 2 days of practical sessions on the content of the questionnaire, on techniques for eliciting more informa- tion and on strategies for obtaining complete and reliable data. Data were collected in face-to-face interviews with an adult member of each selected household (usually a woman or the male head of the household). Only adults who provided informed consent were interviewed. Data on sociodemographic status, household expenditure and ill- ness experienced in the previous 30 days were collected. All illnesses were coded according to a disease list that had been developed in previous studies2,7,10,22,23 and finalized after pilot testing in 100 households (Appendix A). Data were collected on the time of onset and, if possible, duration of illness, diagnosis, treatment response, treatment cost and coping strategies. These data were collected separately for each episode of illness and related care-seeking (n = 4461), for each individual who had been ill (n = 3300) and for each surveyed household (n = 1593). Interviewees were asked about the primary sources of the finances that their households had used to pay for any health care received for each reported episode of illness. These sources were categorized as: routine in- come; pre-existing savings; loans (from relatives, friends, neighbours, banks or moneylenders); money released by the sale of land or other assets; additional paid work; ex-gratia payments from family members; savings achieved by reducing expenditure on food; and/or savings achieved by removal of children from school. Unless the money used to pay for health care came from the house- hold’s routine income or pre-existing savings, it was considered to have come from “distress” financing.7,9–11,17 Variables The primary outcome variables that were investigated were the presence of illness in a member of a study household and the distress financing of health care for each reported episode of illness. At episode-of-illness level, the independent variables considered were type of illness and type of health facility used. At the patient level, the independent variables considered were age, sex and educa- tional status; at household level, they were household size (i.e. the number of people in the household) and wealth (i.e. household expenditure quintile). Statistical analysis Findings were recorded as frequencies and percentages. Univariate analyses were used to investigate the associa- tions between distress financing and the 20 most commonly reported types of illness, care-seeking behaviour and so- ciodemographic characteristics, at both the patient and the household levels. A multilevel logistic regression model was used – with a household-level random Table 1. Descriptive statistics of surveyed households and household members, Bangladesh, 2011 Characteristic No.a % (95% CI) Household Size (no. of members) 1–2 127 7.6 (6.3–9.2) 3–5 1132 69.7 (67.2–72.2) ≥ 6 334 22.7 (20.3–27.9) Expenditure Quintile 1 (lowest) 319 21.4 (17.5–25.9) Quintile 2 319 21.5 (18.3–25.1) Quintile 3 318 20.4 (18.0–23.1) Quintile 4 319 19.7 (16.9–22.8) Quintile 5 (highest) 318 17.0 (13.2–21.7) Household member (patient) Sex Male 3590 49.9 (48.7–51.1) Female 3612 50.1 (48.9–51.4) Age (years) 0–4 449 6.2 (5.7–6.9) 5–9 565 7.8 (7.1–8.6) 10–14 740 10.6 (9.7–11.5) 15–29 2128 29.8 (28.3–31.4) 30–44 1612 22.4 (21.3–23.5) 45–59 1119 15.3 (14.3–16.3) ≥ 60 589 7.9 (7.2–8.7) Educational status No education 1265 18.0 (16.2–19.9) Primary 1831 26.2 (23.7–28.9) Secondary 2002 28.3 (27.0–29.7) Higher 2104 27.5 (24.1–31.2) CI, confidence interval. Bull World Health Organ 2013;91:449–458 | doi: http://dx.doi.org/10.2471/BLT.12.115428 451 Research Illness and household payments for health careMd Mizanur Rahman et al. intercept – to adjust for the clustering effect of households when analysing the presence of illness at the individual level. A three-level Poisson regression model was used – with random inter- cepts at the individual and the house- hold levels and model selection based on backward stepwise model building – to assess disease-specific strategies for coping with health-care payments. Only predictors that gave P-values of < 0.25 in the univariate analyses were entered into this Poisson regression model. All analyses were adjusted for the probability sampling used for the survey. Data management and statistical analyses were performed using version 12.0 of the Stata/MP software package (StataCorp, LP, College Station, United States of America). Ethical considerations The study protocol, questionnaire and disease codes were approved by the Research Ethics Committee of the Uni- versity of Tokyo and the Bangladesh National Research Ethics Committee. Table 2. Self-reported illness among household members, Bangladesh, 2011 Illness No (%) of household members aged (years) No. (%) of episodes diagnosed by cliniciana< 5 (n = 449) 5–20 (n = 2059) 20–59 (n = 4 105) ≥ 60 (n = 589) Any age (n = 7202) Cold/fever 188 (41.5) 450 (21.6) 610 (14.7) 80 (14.1) 1328 (18.4) 342 (24.9) Hypertension – – 393 (9.0) 156 (26.5) 549 (7.2) 509 (92.5) Gastritis/peptic ulcer 2 (0.4) 14 (0.7) 306 (7.4) 70 (11.9) 392 (5.4) 241(61.0) Rheumatic arthritis 2 (0.6) 16 (0.8) 254 (6.1) 98 (16.8) 370 (5.1) 290 (77.3) Diabetes – – 214 (4.9) 79 (13.0) 293 (3.8) 291 (99.5) Heart disease – 3 (0.2) 124 (3.0) 87 (13.4) 214 (2.8) 210 (98.2) Migraine/headache – 28 (1.5) 150 (3.5) 12 (2.1) 190 (2.6) 135 (70.4) Asthma 4 (0.8) 26 (1.2) 87 (2.0) 37 (6.1) 154 (2.0) 139 (90.9) Diarrhoea/gastroenteritis 25 (5.6) 27 (1.2) 78 (2.0) 10 (1.5) 140 (2.0) 66 (47.9) Allergy 2 (0.4) 19 (0.9) 67 (1.6) 8 (1.4) 96 (1.3) 72 (75.5) Injury – 11 (0.5)) 56 (1.5) 10 (1.7) 77 (1.1) 55 (68.2) Skin disease 3 (0.7) 20 (1.0) 45 (1.1) 6 (1.1) 74 (1.1) 54 (74.7) Cataract 1 (0.1) 7 (0.3) 33 (0.8) 30 (5.0) 71 (1.0) 65 (90.6) Dental 1 (0.1) 6 (0.2) 36 (1.0) 4 (0.6) 47 (0.6) 33 (67.1) Nephrolithiasis – 3 (0.2) 25 (0.6) 5 (1.0) 33 (0.5) 33 (100.0) Haemorrhoids 1 (0.3) – 28 (0.7) 10 (1.6) 39 (0.5) 29 (73.5) Urinary tract infection – 5 (0.3) 18 (0.5) 9 (1.8) 32 (0.5) 28 (85.8) Liver disease 2 (0.6 12 (0.4) 25 (0.6) 2 (0.4) 41 (0.5) 35 (86.5) Otitis media 3 (0.7) 3 (0.2) 16 (0.4) 2 (0.4) 24 (0.4) 19 (82.4) Tumourb 1 (0.3) 1 (0.1) 23 (0.6) – 25 (0.4) 19 (79.9) Typhoid 2 (0.6) 10 (0.6) 11 (0.3) 2 (0.3) 25 (0.4) 23 (91.5) Mental disease – 6 (0.3) 18 (0.5) 2 (0.5) 26 (0.4) 23 (88.3) Physical weakness 1 (0.1) 2 (0.04) 18 (0.4) 4 (0.4) 25 (0.3) 17 (67.3) Pneumonia 9 (2.1) 1 (0.03) 2 (0.1) – 12 (0.2) 12 (100.0) Paralysis – 1 (0.03) 5 (0.2) 10 (1.7) 16 (0.2) 14 (88.5) Cancerb – – 6 (0.2) 2 (0.4) 8 (0.1) 8 (100.0) Food poisoning – 1 (0.1) 4 (0.1) – 5 (0.1) 3 (60.0) Chicken pox – 3 (0.1) 1 (0.03) – 4 (0.1) 2 (66.7) Insomnia – – 7 (0.2) 6 (0.8) 13 (0.1) 9 (70.1) Uterine prolapse – – 5 (0.1) – 5 (0.1) 5 (100.0) Nasal polyps – 4 (0.2) 3 (0.1) 1 (0.0) 8 (0.1) 7 (94.9) Cholelithiasis/cholecystitis – – 6 (0.2) 1 (0.2) 7 (0.1) 7 (100.0) Tuberculosis – – 4 (0.1) – 4 (0.1) 3 (75.0) Inguinal hernia – 1 (0.1) 5 (0.1) 3 (0.5) 9 (0.1) 9 (100.0) Dengue – 1(0.03) 1 (0.03) 1 (0.2) 3 (0.0) 3 (100.0) Otherc 6 (1.4) 19 (0.8) 57 (1.4) 18 (3.3) 102 (1.4) 84 (82.5) Total 241 (53.3) 656 (31.6) 1958 (46.8) 436 (73.7) 3300 (44.9) 2894 (64.1) a Clinicians all had medical degrees. b The conditions in this table are given as reported. This explains the existence of a category for “tumours” and another for “cancers”. c Appendicitis, benign prostatic hyperplasia, epilepsy, hypercholesterolemia, anaemia, abdominal, foot or hand pain, swelling/oedema, filariasis, hearing or renal problems, osteoporosis, thyroid goitre, vitamin deficiency and helminth infections. Bull World Health Organ 2013;91:449–458 | doi: http://dx.doi.org/10.2471/BLT.12.115428452 Research Illness and household payments for health care Md Mizanur Rahman et al. Results Background characteristics and prevalence of morbidity Since the members of seven selected households refused to participate in the study, the data analysis was based on the responses of the members of 1593 households. Table 1 presents the key characteristics of these 1593 households and their members. The households had a mean of 4.6 members (95% confidence interval: 4.5–4.7). The age-specific frequencies of the 20 most frequently reported types of illness, over the 30 days preceding the interview, are presented in Table 2. About 44.9% of the members of the study households had reportedly suf- fered at least one episode of illness. Most (> 90%) of those who had report- edly suffered typhoid, pneumonia, hypertension, diabetes, heart disease or asthma had had their illness di- agnosed by a doctor with a medical degree. The most frequently reported illnesses among children younger than 5 years were infectious diseases such as cold/fever, diarrhoea/gastroenteritis and pneumonia, whereas the elderly members of the study households (i.e. those aged at least 60 years) were more likely to have had noncommunicable diseases such as hypertension, rheu- matoid arthritis, heart disease, diabe- tes, gastritis/peptic ulcer or asthma. Infectious diseases predominated in those younger than 15 years but were less common than noncommunicable diseases among household members aged 30 years or older (Appendix A). Certain illnesses, especially some com- mon tropical infectious diseases, were considerably more frequent among the poorest household quintile than among the richest (Appendix A). In contrast, heart disease and some chronic life- long conditions, such as hypertension and diabetes, were reported more fre- quently among members of households in the richest quintile than among those of households in the poorest quintile. Determinants of reporting illness The results of the multilevel analysis of the influence of individual- and household-level characteristics on the reporting of any illness are presented in Table 3. A likelihood-ratio test, in which multilevel modelling was com- pared with a model without random effects, gave a statistically significant result (χ2 = 1202.54; P < 0.001). This indicates that multilevel modelling was necessary to analyse the frequencies of reported illness. As expected, after early childhood, the age of the individual was found to be significantly associ- ated with reported illness, the higher frequencies of reported illness being observed in the older age groups. The odds of reported illness were, however, broadly similar across the five quintiles of household expenditure and four levels of educational attainment that were considered. Illness and distress financing According to the interviewees, most (4127) of the 4461 reported episodes of illness led to increases in household expenditure. As shown in Table 4, heart and liver disease, asthma and tumours were significantly associated with dis- tress financing, as were certain forms of care-seeking behaviour, certain levels of educational attainment, and certain levels of household wealth. Nearly half of all the episodes of illness that had led to inpatient care – but only 8% of those that had been treated by traditional healers – had resulted in distress financing. About 33% of inpatient treatments but only 6% of outpatient treatments and about 0.8% of the treatments by traditional healers had been entirely funded by household loans (Fig. 1). Determinants of distress financing Table 5 presents the results of the multi- ple regression modelling of the relative risks of distress financing among those households that reported expenditure for the treatment of illness. The results of a likelihood ratio test, in which the multilevel modelling was compared with a model without random effects, indicated that the multilevel modelling was appropriate (χ2 = 659.75; P < 0.001). Again, heart and liver diseases, asthma and typhoid were significantly associ- ated with distress financing. The type of health care sought, if any, was also significantly related to the risk of dis- Table 3. Odds of self-reported illness during the 30-day recall period, by household or household member characteristics, Bangladesh, 2011 Characteristic OR (95% CI) (n = 7 202) Household Size (no. of members) 0.85 (0.82–0.87) Expenditure Quintile 1 (lowest) 0.94 (0.77–1.16) Quintile 2 1.00 (0.80–1.26) Quintile 3 1.08 (0.87–1.33) Quintile 4 1.22 (1.03–1.45) Quintile 5 (highest) 1.00 Household member (patient) Age (years) 0–4 1.00 5–9 0.37 (0.26–0.53) 10–14 0.33 (0.22–0.48) 15–29 0.36 (0.24–0.53) 30–44 0.73 (0.50–1.06) 45–59 1.78 (1.24–2.57) ≥ 60 2.73 (1.77–4.22) Sex Female 1.00 Male 0.73 (0.65–0.82) Educational status No education 1.00 Primary 1.07 (0.85–1.35) Secondary 0.84 (0.65–1.08) Higher 0.75 (0.57–0.98) CI, confidence interval; OR, odds ratio. Bull World Health Organ 2013;91:449–458 | doi: http://dx.doi.org/10.2471/BLT.12.115428 453 Research Illness and household payments for health careMd Mizanur Rahman et al. tress financing; those using inpatient care were much more likely to experi- ence distress financing than those who were self-medicated or who had sought no treatment. Outpatient care was also significantly associated with distress financing but treatment by traditional healers was not. Among the households that reported expenditure on health care in the 30 days before the inter- view, those in the poorest quintile had a sevenfold higher risk of (reported) distress financing than those in the richest quintile. Discussion As far as we are aware, this is the first study to analyse illness and strategies for financing the related health care at three different levels (i.e. episode of ill- ness, individual and household). Most previous studies on strategies to cope with health-care costs have focused on the household level;9,10,17 few related investigations have focused on the in- dividual level7,24 and almost none at the episode-of-illness level.14 In the present study, as expected, the frequency of re- ported illness generally increased with age, but there was a transition from a predominance of infectious illness to one of noncommunicable diseases as age increased. Heart disease, asthma, liver disease, typhoid, inpatient care and pre-existing household poverty were positively associated with “distress” strategies for coping with the costs of health care. About 94% of the surveyed house- holds reported that they had been af- fected by illness in the 30 days before the interview. The frequency of illness among all of the members of the house- holds surveyed over the same period (45%) was similar to that reported in Viet Nam25 but higher than the value (35%) observed in a previous study in Bangladesh.22 However, the latter study investigated only illness in adults (older than 20 years) and only illness that had occurred in the 15 days before the in- terview. In addition, disease profiles and socioeconomic situation often change rapidly in developing countries. This makes the valid interpretation of differ- ences in the results of non-concurrent studies difficult, even if the studies are in the same country. In the present study, several in- fectious diseases that are common in tropical settings, such as cold/fever, diarrhoea/gastroenteritis, pneumonia and asthma, were the leading health problems reported among young chil- dren living in a city in Bangladesh. Similar observations have been made in other developing countries.2,9 The 10 illnesses that were most frequently reported in adult members of the house- holds surveyed in the present study were mostly noncommunicable diseases such as hypertension, gastritis/peptic ulcer, rheumatoid arthritis, diabetes, heart disease, migraine/headache and asthma. In the present study, hypertension and diabetes, which were reported to have Table 4. Households implementing distress financing, by household or household member characteristics, Bangladesh, 2011 Characteristic Percentage (95% CI) of households implementing distress financinga Illness Hypertension 12.2 (8.0–18.1) Gastritis/peptic ulcer 11.9 (7.6–18.1) Rheumatoid arthritisb 16.8 (11.6–23.8) Diabetesb 12.4 (6.7–21.9) Heart diseaseb 24.4 (17.4–33.1) Migraine/headache 14.6 (9.3–22.1) Asthmab 21.9 (14.3–32.1) Diarrhoea/gastroenteritis 12.5 (7.4–20.6) Allergyb 5.8 (1.9–16.4) Injury 10.1 (4.4–21.7) Skin disease 17.7 (8.8–32.4) Cataract 17.1 (8.4–31.6) Dental 11.9 (5.2–25.0) Haemorrhoids 12.2 (4.4–29.6) Liver disease (including hepatitis B and C)b 26.1 (14.3–42.9) Urinary tract infection 18.1 (8.1–35.7) Nephrolithiasis 21.0 (8.7–42.4) Mental illness 15.1 (4.2–42.0) Tumourb 27.5 (13.7–47.5) Typhoidb 25.7 (10.7–50.0) Care-seeking behaviourb Inpatient 48.4 (35.9–61.0) Outpatient At public facility only 17.3 (12.2–24.1) At private facility only 15.1 (10.1–21.9) At both public and private facilities 30.5 (17.1–48.2) Traditional healer 8.1 (4.7–13.7) Self-medication/no treatment sought 10.0 (7.0–14.1) Educational status of household memberb No education 17.3 (12.9–22.9) Primary 15.5 (11.5–20.6) Secondary 12.2 (8.1–18.1) Higher 8.4 (5.5–12.8) Household expenditureb Quintile 1 (lowest) 24.0 (18.4–30.8) Quintile 2 15.1 (10.7–20.8) Quintile 3 9.8 (5.5–16.9) Quintile 4 10.9 (6.9–16.6) Quintile 5 (highest) 6.9 (3.7–12.6) CI, confidence interval. a The analysis was restricted to the 3300 household members who, in the 30 days before the data were collected, reportedly suffered illness that led to household expenditure. b These characteristics, which each gave a P-value of < 0.25 in the univariate analysis, were included in the multilevel Poisson regression model. Bull World Health Organ 2013;91:449–458 | doi: http://dx.doi.org/10.2471/BLT.12.115428454 Research Illness and household payments for health care Md Mizanur Rahman et al. occurred in 11% and 6% of adults in the 30 days preceding interview, appeared to have similar prevalences among adults as previously reported in Bangladesh26–28 and several other developing coun- tries.2,9 It seems clear that Bangladesh, like other low- or middle-income coun- tries,1,2,9 faces heavy burdens of both communicable and noncommunicable disease. In concordance with the results of other studies around the world,1,2,5,22,25 the reported frequency of illness tended to increase with age, at least once early childhood had passed. In the present study, as in studies in Afghanistan9 and Cambodia,2 no significant association was found between the frequency of illness and educational level. The simi- larity in the conditions recorded in the present study across the five quintiles of household wealth was less expected, since poverty often appears to help to perpetuate illness.1,2,5 Although the members of the house- holds that we surveyed were able to obtain care for most of their episodes of illness, 13% of them were forced to adopt “distress” financing to cope with the costs of the care. In Bangladesh, where an esti- mated 65% of health-care expenditure is financed from out-of-pocket payments, illness is a major cause of economic hard- ship and poverty.29 Our results indicate that severe infectious diseases, such as typhoid, are particularly likely to lead to distress financing, presumably because the associated out-of-pocket expenses are relatively high. It appears that some chronic and/or noncommunicable condi- tions, such as heart or liver disease and asthma, can sometimes lead to distress financing in Bangladesh, as in other low- or middle-income countries.6–8 It has been estimated that, within the Asia Pa- cific region, Bangladesh faces the great- est challenge from noncommunicable diseases, followed by India, Pakistan and then China.30 It has also been estimated that, in the 10 years between 2006 and 2015, Bangladesh, China and India will lose almost 140 million, 14 billion and 17 billion United States dollars, respec- tively, in national income as a result of the costs of treating heart disease, stroke and diabetes and of the productivity lost as a result of these three conditions.30 In Bangladesh and many other develop- ing countries, only the implementation of risk-pooling mechanisms, such as demand-side financing and/or formal health-insurance schemes, can protect the poorest households from financial hardship as a result of illness. Out-of- pocket expenses dropped markedly following the introduction of health-in- surance schemes in China, Ghana, India, Rwanda and Viet Nam.3,31 However, the introduction of health insurance may not be sufficient to avoid catastrophic health spending and distress financing, especially if the primary health care that is available is not of good quality.31 Even in areas with good primary health care, special programmes that target illnesses with relatively high treatment costs, such as typhoid, pneumonia, liver disease, heart disease and cancer, may also be required. As predicted – partly from the re- sults of previous studies9,14,17 – the risk that a household will need to implement distress financing to cope with the costs of health care was found to increase as the wealth of the household decreased. The high costs of inpatient care ap- peared to pose particular difficulties for many of the study households and a loan was often needed. In contrast, care from a traditional healer was relatively inexpensive and rarely required distress financing. One particularly disappointing observation made in the present study was that the costs of care from public health facilities in Bangladesh were high enough to require distress financing by many households, even though such facilities are heavily subsidized by the government.32 This result indicates that health-care subsidization programmes in Bangladesh may not be working properly, especially among disadvantaged groups. One problem may be the inadequacy of the drugs and services available in public health facilities, which may be driving patients or their caregivers to purchase drugs and ancillary health services in the private market. Study limitations This study has several limitations. First, we only investigated urban households in a single metropolitan area of Bangla- desh. Hence, the findings of the study should not be considered representative of the whole of Bangladesh. However, the results may be applicable to other urban areas of Bangladesh and may therefore reflect reality – in terms of illness, health care and health financing – for a large proportion of the Bangla- Fig. 1. Strategies used by households to cope with payments for health care from various sources, Bangladesh, 2011 Pe rc en ta ge o f i lln es s e pi so de s 100 90 80 70 60 50 40 30 20 10 0 Coping strategy Inpatient Outpatient at public facility only Outpatient at both public and private facilities Outpatient at private facility only Self-medication/no treatment sought Traditional healer Use of routine income Use of pre- existing savings Borrowing Reduction of spending on food Taking on additional paid work Acceptance of ex-gratia payment from family member Selling of assets Removal of children from school Note: Multiple strategies were often implemented to finance the care of single episodes of illness. Bull World Health Organ 2013;91:449–458 | doi: http://dx.doi.org/10.2471/BLT.12.115428 455 Research Illness and household payments for health careMd Mizanur Rahman et al. deshi population. Second, the episodes of illness that we investigated were self-reported and so the types and fre- quencies of illness that we present here may not be a true picture. However, more than 90% of the episodes of major illness that we considered had been diagnosed by clinicians with medical degrees. Reassuringly, the self-reported frequencies of diabetes and hyperten- sion that we recorded among members of the study households were very simi- lar to those recorded in another recent study in Bangladesh.28 Finally, we made no attempt to estimate the indirect costs of illness, such as income lost because the patient could not work while ill or seeking care. Questions about the indi- rect costs of health care were dropped from the questionnaire used in the final survey because, in a pilot study, many interviewees were unable to provide any information on such costs or only provided very inaccurate information about them. Conclusions In Bangladesh, the costs associated with major infectious and noncommunicable diseases appear to weigh most heavily on those least able to afford them. This puts the families concerned at great risk of financial hardship and impoverish- ment. The national government and international aid organizations need to give far greater attention to the effects of infectious and chronic noncommu- nicable diseases on household finances. Progress towards achieving national and international health goals will only be accelerated by three changes: i) Increasing government spending on health, and committing to health insurance for the whole population. Such insurance might initially be provided for salaried workers, in both the public and private sectors, while voluntary membership of an insurance scheme might be promot- ed among the workers’ dependents, farmers and the self-employed, in a strategy similar to those currently followed in Viet Nam and other developing countries.3,33 ii) Improving the quality of primary health care for infectious diseases and the routine management of noncommunicable diseases, to avoid unpredictable medical expenses and also reduce the sever- ity of illness. In its national health policy, the Bangladeshi govern- ment should give top priority to major noncommunicable diseases while consistently working on the “unfinished agenda” – of controlling infectious diseases in general and, particularly, diarrhoea, typhoid and pneumonia. iii) Ensuring standard costs and subsidies across all public health facilities, by tightening the regula- tion of both official and unofficial payments. Table 5. Multilevel Poisson regression model of risk of distress financing, Bangladesh, 2011 Characteristic RR (95% CI)a Illness Have rheumatoid arthritis? Yes 1.19 (0.95–1.49) No 1.00 Have heart disease? Yes 1.22 (1.05–1.42) No 1.00 Have asthma? Yes 1.73 (1.35–2.22) No 1.00 Have liver disease? Yes 1.63 (1.06–2.51) No 1.00 Have typhoid? Yes 1.92 (1.08–3.43) No 1.00 Have tumour? Yes 2.02 (0.92–4.42) No 1.00 Care-seeking behaviour Inpatient facility 8.64 (4.67–15.98) Outpatient facility Public only 1.80 (1.42–2.28) Private only 2.01 (1.40–2.88) Both public and private 2.14 (1.48–3.09) Traditional healer 0.89 (0.63–1.25) Self-medication/no treatment sought 1.00 Age (years) 0–4 1.00 5–9 0.96 (0.58–1.59) 10–14 0.83 (0.51–1.36) 15–29 1.15 (0.66–1.98) 30–44 1.19 (0.78–1.82) 45–59 1.45 (0.95–2.23) ≥ 60 1.29 (0.84–1.98) Household expenditure Quintile 1 (lowest) 7.97 (3.59–17.66) Quintile 2 3.94 (1.85–8.39) Quintile 3 1.97 (0.81–4.77) Quintile 4 1.94 (0.89–4.26) Quintile 5 (highest) 1.00 CI, confidence interval; RR, relative risk. a The analysis was restricted to the 3300 household members who, in the 30 days before the data were collected, reportedly suffered illness that led to household expenditure. Bull World Health Organ 2013;91:449–458 | doi: http://dx.doi.org/10.2471/BLT.12.115428456 Research Illness and household payments for health care Md Mizanur Rahman et al. In implementing such systems, policy-makers should consider the dis- ease-specific conditions in Bangladesh and especially the relative roles of major infectious diseases and noncommunica- ble diseases in driving health-care costs. Incorporation and improvement of our knowledge of the patterns of disease and risks of distress financing will be criti- cal in the development of policies and guidelines to decrease population-level health disparities, excessive expendi- tures and patient suffering. ■ Acknowledgements The authors thank the staff of the Department of Population Science and Human Resource Development, University of Rajshahi and the research project’s trainers, coordinators and su- pervisors, for their assistance, and the interviewees, for their cooperation and participation. Funding: This study was supported in part by a grant for scientific research (24030401) from the Japanese Ministry of Health, Labor and Welfare, an overseas research grant from the University of Tokyo, and grants from the Asian De- velopment Bank. The funders had no role in the study design, data collection, data analysis, interpretation or write up. Competing interests: None declared. صخلم شيدلاغنب في ةيحصلا ةياعرلا تاعوفدم عم شياعتلل سرلأا تايجيتاترساو ًايتاذ اهنع غلبلما تلالاتعلاا سرلأا تايجيتاترساو ًايتاذ اهنع غلبلما تلالاتعلاا يرتح ضرغلا .شيدلاغنب ندم ىدحإ في ةيحصلا ةياعرلا تاعوفدم عم شياعتلل ددعل ةعممج تانيعل ةيلماتحا ةيئاصقتسا ةسارد ءارجإ مت ةقيرطلا متو .2011 ماع في شيدلاغنب في يهاشجار ةنيدم في ةسرأ 1593 ليدعتلا عم – تايوتسلما ددعتم يتسيجوللا دادترلاا مادختسا غلبلما تلالاتعلاا ةروطخ ةساردل –سرلأا نمض عيمتج يلأ دادترا جذومن مادختسا متو .ةقباسلا ًاموي ينثلاثلا في ًايتاذ اهنع سرلأا نمض عيمجتلل ليدعتلا عم ،تايوتسلما ددعتم نوساوب ليوتم رطاخمب اهطابترا لمت ُحي يتلا لماوعلا فاشكتسلا ،دارفلأاو ةياعرلا لباقم عفد لثم( ةيحصلا ةياعرلاب ةلصلا تاذ “ةقئاضلا” ماعطلا لىع قافنلإا ضفخ وأ عيبلا وأ ضاترقلاا قيرط نع ةيحصلا .)رجلأا عوفدم فياضإ لمع ءادأ وأ ةسردلما نم لافطلأا جارخإ وأ % 45 لياوح ىناع ،مهتلباقم مت نيذلا صاخشلأل ًاقفو جئاتنلا ةدحاو للاتعا ةبون نم ًايئاصقتسا مهتسارد مت نيذلا دارفلأا نم غلبلما تلالاتعلاا تناكو .ةقباسلا ًاموي ينثلاثلا للاخ لقلأا لىع ينغلابلاو تاونس 5 نم لقلأا لافطلأا ينب ًاراركت رثكلأا اهنع ،ةيراسلا يرغ ضار�ملأاو ةعئاشلا ةيرادلما قطانلما ىودع يه للاخ ًايتاذ اهنع غلبلما تلالاتعلاا رطامخ تناكو .لياوتلا لىع ديزت نيذلا ينغلابلل ةبسنلاب ًايبسن ةعفترم ةقباسلا ًاموي ينثلاثلا حئاشرلا في ةيشيعلما سرلأا دارفأو ءاسنلاو ةنس 44 نع مهرماعأ ةيطغتل هذيفنت مت يذلا ،ةقئاضلا ليوتم ناكو .ًارقف دشلأا ةيسملخا غلبلما بئاونلا نم % 13 ةبسنب ةطبترلما ةيحصلا ةياعرلا تاعوفدم ديوفيتلاو وبرلاو دبكلاو بلقلا ضارمأب يربك لكشب ًاطبترم ،اهنع ينيجرالخا ضىرلما قفارم مادختساو ينيلخادلا ضىرلما ةياعرو .ةسرلأا ىوتسم لىع رقفلاو ةيمومعلا في ةيمومعلا ةحصلا تامدلخ ليالما معدلا نم مغرلا لىع جاتنتسلاا – ةقئاضلا ليوتم راشتنا تلادعم عافترا فاشتكا مت ،شيدلاغنب .ًايئاصقتسا اهتسارد مت يتلا ةيضرلحا سرلأا في – تلالاتعلااو 摘要 孟加拉国应对卫生保健支出的自我报告的疾病和家庭策略 目的 探讨孟加拉国城市应对卫生保健支出的自我报告 的疾病和家庭战略。 方法 2011 年在孟加拉国拉杰沙希市的 1593 户家庭 中执行群集抽样概率调查。使用多水平逻辑回归（调 整家庭范围内的任何群集）来研究在过去 30 天内自 我报告疾病的风险。使用多水平的泊松回归模型（调 整家庭和个人范围内的群集），探索与卫生保健相关 的“砸锅卖铁”筹钱的风险（例如，通过借钱、变卖、 减少食品支出、让孩子退学或者参加额外的有偿工作 等方式支付卫生保健费用）潜在关联的因素。 结果 在受访者中，约 45% 的受访个人在过去 30 天 中至少得过一次病。未满 5 岁的儿童和成人最常报告 的疾病分别是常见的热带感染和非传染性疾病。年龄 超过 44 岁的成人、女性和最贫穷地区家庭的成员在 过去 30 天的自我报告疾病的风险相对较高。报告疾 病有 13% 靠砸锅卖铁筹钱来填补，这种情况与心脏 和肝脏疾病、哮喘、伤寒、住院医疗、公共门诊设施 的使用以及家庭水平的贫困显著相关。 结论 尽管孟加拉国提供公共卫生服务补助，在受调查 的城镇居民家庭中仍发现有很多人得不起病、看不起 病。 Bull World Health Organ 2013;91:449–458 | doi: http://dx.doi.org/10.2471/BLT.12.115428 457 Research Illness and household payments for health careMd Mizanur Rahman et al. Résumé Maladies auto-déclarées et stratégies des ménages pour faire face aux paiements des soins de santé au Bangladesh Objectif Étudier les maladies auto-déclarées et les stratégies des ménages pour faire face aux paiements des soins de santé dans une ville du Bangladesh. Méthodes Une étude de probabilité menée sur un échantillon de 1593 ménages de la ville de Rajshahi, au Bangladesh, a été réalisée en 2011. Une régression logistique multi-niveaux, avec ajustement pour tous les regroupements au sein des ménages, a été réalisée pour examiner le risque de maladie auto-déclarée dans les 30 jours précédant l’enquête. Un modèle multi-niveaux de régression de Poisson, avec ajustement pour tous les regroupements au sein des ménages et pour les individus, a été utilisé pour examiner les facteurs potentiellement associés au financement «à risque» des soins de santé (par exemple, payer les soins de santé en empruntant, en vendant ses biens, en réduisant ses dépenses de nourriture, en retirant ses enfants de l’école ou en acceptant un travail rémunéré supplémentaire). Résultats D’après les personnes interrogées, environ 45% des individus avaient été affectés par une maladie dans les 30 jours qui précédaient. Les maladies les plus fréquemment signalées chez les enfants de moins de 5 ans et les adultes étaient respectivement des infections tropicales courantes et des maladies non transmissibles. Les risques de maladies auto-déclarées dans les 30 jours précédents étaient relativement élevés pour les personnes âgées de plus de 44 ans, les femmes et les membres des ménages du quintile le plus pauvre. Le financement «à risque», mis en place pour couvrir les paiements des soins de santé, et associé à 13% des cas déclarés, était significativement lié aux maladies du cœur et du foie, à l’asthme, à la fièvre typhoïde, aux soins hospitaliers, à l’utilisation des services de soins ambulatoires publics et au niveau de pauvreté des ménages. Conclusion Malgré les subventions accordées par les services de santé publique au Bangladesh, les prévalences élevées de financement «à risque» - et la maladie - ont été détectées chez les ménages urbains interrogés. Резюме Сообщения населением о заболевании и стратегии домохозяйств, связанные с расходами на услуги здравоохранения в Бангладеш Цель Исследовать частоту самостоятельных сообщений населением о заболевании и стратегии домохозяйств, помогающие им справиться с расходами на медицинскую помощь в одном из городов Бангладеш. Методы В 2011 г. было проведено кластерное вероятностное обследование 1593 домашних хозяйств в г. Раджшахи, Бангладеш. Для изучения уровня сообщений населением о своих заболеваниях, имевших место в течение предыдущих 30 дней, был использован метод многоуровневой логистической регрессии, с поправкой на все кластеризации среди домохозяйств. Для изучения факторов, потенциально связанных с рисковым финансированием медицинских расходов (например, оплата медицинских услуг за счет заемных средств, продажи имущества, сокращения расходов на питание, прекращения посещения детьми школы или выполнения дополнительных платных работ) использовалась многоуровневая регрессионная модель Пуассона с поправкой на кластеризацию среди домохозяйств и отдельных жителей. Результаты По словам опрошенных граждан, около 45% из них имели как минимум один случай заболевания за предыдущие 30 дней. Наиболее часто сообщалось о болезни среди детей в возрасте до 5 лет, а среди взрослых были распространены тропические инфекции и неинфекционные заболевания. Риск самообнаружения болезни за предыдущие 30 дней был относительно высок для взрослых старше 44 лет, женщин и членов домохозяйств в беднейшем квинтиле населения. Рисковое финансирование, которое применялось для покрытия медицинских расходов в 13% зарегистрированных эпизодов, было в значительной степени связано с заболеваниями сердца и печени, астмой, тифом, получением помощи в стационаре, использованием государственных амбулаторных услуг и бытовой бедностью. Вывод Несмотря на субсидирование здравоохранения, в Бангладеш в обследованных городских домохозяйствах был обнаружен высокий уровень заболеваний и высокая распространенность рискового финансирования. Resumen Las enfermedades declaradas por los propios pacientes y estrategias de los hogares para hacer frente a los pagos sanitarios en Bangladesh Objetivo Investigar las enfermedades declaradas por los propios pacientes y las estrategias de los hogares para hacer frente a los pagos sanitarios en una ciudad de Bangladesh. Métodos En el año 2011 se llevó a cabo un estudio de probabilidades sobre muestras en grupos de 1593 hogares. Se empleó una regresión logística multinivel con un ajuste para cualquier agrupación dentro de los hogares para evaluar el riesgo de enfermedad declarada por el propio paciente en los 30 días previos. Para examinar los factores que podrían estar asociados con el riesgo de sufrir dificultades económicas relacionadas con la salud (por ejemplo, pagar la atención sanitaria con préstamos, ventas, reducción del gasto en alimentos, retirar a los niños de la escuela o realizar trabajos remunerados adicionales) se utilizó un modelo de regresión de Poisson multinivel con un ajuste para los agrupamientos dentro de los hogares e individuos. Resultados De acuerdo con los entrevistados, aproximadamente el 45% de los individuos encuestados había sufrido al menos un episodio de enfermedad en los 30 días previos. Las enfermedades declaradas más frecuentemente entre niños menores de cinco años y adultos fueron, respectivamente, infecciones tropicales comunes y enfermedades no contagiosas. El riesgo de enfermedad declarada por el propio paciente en los 30 días previos fue relativamente elevado en los adultos mayores de 44 años, las mujeres y los miembros de los hogares del quintil más pobre. Las dificultades económicas derivadas de cubrir los pagos sanitarios asociados con el 13% de los episodios declarados estuvieron relacionadas de forma significativa con enfermedades cardíacas y hepáticas, asma, fiebre tifoidea, atención hospitalaria, el uso de los Bull World Health Organ 2013;91:449–458 | doi: http://dx.doi.org/10.2471/BLT.12.115428458 Research Illness and household payments for health care Md Mizanur Rahman et al. centros ambulatorios públicos y la pobreza del hogar. 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