Narayanan Devadasan

Editorial: Iatrogenic poverty

keywords poverty, iatrogenesis, catastrophic health care expenditure, health insurance, socialassistance, Asia, transitionPoverty and illness are intertwined. It is a well-documentedfact that poverty leads to ill-health. In every society,morbidity and mortality are higher among the poor(Wagstaff 2002). Determinants of lower health statusinclude nutrition, environment, education, lifestyle andaccess to health care. Less is known about how illness itselfcan lead to poverty in developing countries. There are twomajor pathways. The first is through the death or disabilityof a household income earner. This reduces future incomegeneration and may jeopardize household consumption.After a household has depleted its wealth it may have lesscapacity to invest in the education of their children. Thistransmits poverty to the next generation.The second is through the treatment itself, or moreexactly its cost. The chain of events is as follows: whensomeone falls ill, the household faces several different costs(opportunity cost of care giving, transportation, treat-ment), and to cope with them, it follows diverse strategies.Sometimes the costs are limited, and the household is ableto buffer them by making a short-term adjustment (such asconsuming precautionary saving, calling on assistance frominformal support networks, temporarily reducing its con-sumption of other goods). Yet, sometimes, the costs are at,or increase to, a level where these coping mechanisms arenot sufficient anymore. The household then adopts theriskier strategies of selling or mortgaging its productiveassets (Ensor & Bich San 1996; Bloom & Lucas 2000;Meessen & Criel 2003). Some households recover from thefinancial shock, but others do not (Wilkes et al. 1997). Thenext time when they have to deal with an illness, a cropfailure or another problem, they may be tipped intopoverty. Chambers (1983) has called this process a povertyratchet.Iatrogenic povertyPoor people are well aware of that cycle. Surveys havefound that they identify sickness as one of their greatestworries (Milimo et al. 2002). Economists and experts inpoverty analysis have raised the issue. The WHO, theWorld Bank and the ILO are trying to put it higher on theagenda by referring to it as catastrophic health careexpenditure. But the issue is still little recognized by thepolitical, scientific and, most of all, the medical commu-nities. Doctors are trained to assess the outcome of theirinterventions in terms of health status, it is high time toconsider them in terms of welfare.Let us have a look at the world outside the health sector.What has been the major change for humanity these lasttwo decades? The average reader of this journal mightidentify globalization. But for 1.7 billion people, the majorchange has another name: transition. The transition from aplanned economy to a market economy has concernedChina, most of South East Asia, Eastern Europe and theRepublics of the former Soviet Union. What has thistransition meant for the citizens of these countries?Economic growth in some countries, but also a reshapingof the pattern of entitlements (Sen 1981). While education,jobs, income and welfare services used to be taken forgranted, today they are determined by a combination ofmarket forces and political commitment to provide bene-fits. One can find a job and earn an income according toone’s skills and the demand in the labour market. Access toeducation and health care are no longer universal, but areinfluenced by the ability to pay.Most governments fail to fund their health sectoradequately because of limited budgets, excessive faith inmarket forces or other priorities. Consequently, manypublic health care facilities are run down or they generaterevenue by charging patients. At the same time, ruralhouseholds in many countries have a new opportunity tomortgage or sell their land and other productive assets.Marketization is indeed ubiquitous. Today, more thanever, the Cambodian or Chinese farmer is able tomatch his ability to pay for health care with his willing-ness to pay. Credit and land markets, i.e. usurious

Out-of-pocket healthcare payments on chronic conditions impoverish urban poor in Bangalore, India

BackgroundThe burden of chronic conditions is on the rise in India, necessitating long-term support from healthcare services. Healthcare, in India, is primarily financed through out-of-pocket payments by households. Considering scarce evidence available from India, our study investigates whether and how out-of-pocket payments for outpatient care affect individuals with chronic conditions.MethodsA large census covering 9299 households was conducted in Bangalore, India. Of these, 3202 households that reported presence of chronic condition were further analysed. Data was collected using a structured household-level questionnaire. Out-of-pocket payments, catastrophic healthcare expenditure, and the resultant impoverishment were measured using a standard technique.ResultsThe response rate for the census was 98.5%. Overall, 69.6% (95%CI=68.0-71.2) of households made out-of-pocket payments for outpatient care spending a median of 3.2% (95%CI=3.0-3.4) of their total income. Overall, 16% (95%CI=14.8-17.3) of households suffered financial catastrophe by spending more than 10% of household income on outpatient care. Occurrence and intensity of financial catastrophe were inequitably high among poor. Low household income, use of referral hospitals as place for consultation, and small household size were associated with a greater likelihood of incurring financial catastrophe.The out-of-pocket spending on chronic conditions doubled the number of people living below the poverty line in one month, with further deepening of their poverty. In order to cope, households borrowed money (4.2% instances), and sold or mortgaged their assets (0.4% instances).ConclusionsThis study provides evidence from India that the out-of-pocket payment for chronic conditions, even for outpatient care, pushes people into poverty. Our findings suggest that improving availability of affordable medications and diagnostics for chronic conditions, as well as strengthening the gate keeping function of the primary care services are important measures to enhance financial protection for urban poor. Our findings call for inclusion of outpatient care for chronic conditions in existing government-initiated health insurance schemes.

Promoting universal financial protection: evidence from the Rashtriya Swasthya Bima Yojana (RSBY) in Gujarat, India

BackgroundIndia’s health expenditure is met mostly by households through out-of-pocket (OOP) payments at the time of illness. To protect poor families, the Indian government launched a national health insurance scheme (RSBY). Those below the national poverty line (BPL) are eligible to join the RSBY. The premium is heavily subsidised by the government. The enrolled members receive a card and can avail of free hospitalisation care up to a maximum of US

Advancing the application of systems thinking in health: a realist evaluation of a capacity building programme for district managers in Tumkur, India

600 per family per year. The hospitals are reimbursed by the insurance companies. The objective of our study was to analyse the extent to which RSBY contributes to universal health coverage by protecting families from making OOP payments.MethodsA two-stage stratified sampling technique was used to identify eligible BPL families in Patan district of Gujarat, India. Initially, all 517 villages were listed and 78 were selected randomly. From each of these villages, 40 BPL households were randomly selected and a structured questionnaire was administered. Interviews and discussions were also conducted among key stakeholders.ResultsOur sample contained 2,920 households who had enrolled in the RSBY; most were from the poorer sections of society. The average hospital admission rate for the period 2010–2011 was 40/1,000 enrolled. Women, elderly and those belonging to the lowest caste had a higher hospitalisation rate. Forty four per cent of patients who had enrolled in RSBY and had used the RSBY card still faced OOP payments at the time of hospitalisation. The median OOP payment for the above patients was US

No longer diseases of the wealthy: prevalence and health-seeking for self-reported chronic conditions among urban poor in Southern India

80 (interquartile range,

Community Health Insurance in Developing Countries

16–

How does capacity building of health managers work? A realist evaluation study protocol

200) and was similar in both government and private hospitals. Patients incurred OOP payments mainly because they were asked to purchase medicines and diagnostics, though the same were included in the benefit package.ConclusionsWhile the RSBY has managed to include the poor under its umbrella, it has provided only partial financial coverage. Nearly 60% of insured and admitted patients made OOP payments. We plea for better monitoring of the scheme and speculate that it is possible to enhance effective financial coverage of the RSBY if the nodal agency at state level would strengthen its stewardship and oversight functions.

Constraints faced by urban poor in managing diabetes care: patients’ perspectives from South India

BackgroundHealth systems interventions, such as capacity-building of health workers, are implemented across districts in order to improve performance of healthcare organisations. However, such interventions often work in some settings and not in others. Local health systems could be visualised as complex adaptive systems that respond variously to inputs of capacity building interventions, depending on their local conditions and several individual, institutional, and environmental factors. We aim at demonstrating how the realist evaluation approach advances complex systems thinking in healthcare evaluation by applying the approach to understand organisational change within local health systems in the Tumkur district of southern India.MethodsWe collected data on several input, process, and outcome measures of performance of the talukas (administrative sub-units of the district) and explore the interplay between the individual, institutional, and contextual factors in contributing to the outcomes using qualitative data (interview transcripts and observation notes) and quantitative measures of commitment, self-efficacy, and supervision style.ResultsThe talukas of Tumkur district responded differently to the intervention. Their responses can be explained by the interactions between several individual, institutional, and environmental factors. In a taluka with committed staff and a positive intention to make changes, the intervention worked through aligning with existing opportunities from the decentralisation process to improve performance. However, commitment towards the organisation was neither crucial nor sufficient. Committed staff in two other talukas were unable to actualise their intentions to improve organisational performance. In yet another taluka, the leadership was able to compensate for the lack of commitment.ConclusionsCapacity building of local health systems could work through aligning or countering existing relationships between internal (individual and organisational) and external (policy and socio-political environment) attributes of the organisation. At the design and implementation stage, intervention planners need to identify opportunities for such triggering alignments. Local health systems may differ in their internal configuration and hence capacity building programmes need to accommodate possibilities for change through different pathways. By a process of formulating and testing hypotheses, making critical comparisons, discovering empirical patterns, and monitoring their scope and extent, a realist evaluation enables a comprehensive assessment of system-wide change in health systems.

Primary Health Care in the 21st century: primary care providers and people’s empowerment

BackgroundThe burden of chronic conditions is high in low- and middle-income countries and poses a significant challenge to already weak healthcare delivery systems in these countries. Studies investigating chronic conditions among the urban poor remain few and focused on specific chronic conditions rather than providing overall profile of chronic conditions in a given community, which is critical for planning and managing services within local health systems. We aimed to assess the prevalence and health- seeking behaviour for self-reported chronic conditions in a poor neighbourhood of a metropolitan city in India.MethodsWe conducted a house-to-house survey covering 9299 households (44514 individuals) using a structured questionnaire. We relied on self-report by respondents to assess presence of any chronic conditions, including diabetes and hypertension. Multivariable logistic regression was used to analyse the prevalence and health-seeking behaviour for self-reported chronic conditions in general as well as for diabetes and hypertension in particular. The predictor variables included age, sex, income, religion, household poverty status, presence of comorbid chronic conditions, and tiers in the local health care system.ResultsOverall, the prevalence of self-reported chronic conditions was 13.8% (95% CI = 13.4, 14.2) among adults, with hypertension (10%) and diabetes (6.4%) being the most commonly reported conditions. Older people and women were more likely to report chronic conditions. We found reversal of socioeconomic gradient with people living below the poverty line at significantly greater odds of reporting chronic conditions than people living above the poverty line (OR = 3, 95% CI = 1.5, 5.8). Private healthcare providers managed over 80% of patients. A majority of patients were managed at the clinic/health centre level (42.9%), followed by the referral hospital (38.9%) and the super-specialty hospital (18.2%) level. An increase in income was positively associated with the use of private facilities. However, elderly people, people below the poverty line, and those seeking care from hospitals were more likely to use government services.ConclusionsOur findings provide further evidence of the urgent need to improve care for chronic conditions for urban poor, with a preferential focus on improving service delivery in government health facilities.

Social protection in health: the need for a transformative dimension

Community Health Insurance (CHI) is a health insurance arrangement serving a social purpose, operating at the local level of the health system and thriving on community solidarity. This article describes the origins, formats, and evolution of CHI in Africa, Asia, and Latin America. It discusses the strengths, weaknesses, and opportunities of CHI from different perspectives: its contribution to equitable health-care access, to health sector financing, to provider responsiveness and quality of care, and to wider developmental objectives. Particular attention is drawn to factual issues such as management and support needs, scaling-up, the use of subsidies, and persistent knowledge gaps.