Pathways to catastrophic health expenditure for acute coronary syndrome in Kerala: ‘Good health at low cost’?

BMC Public Health

Meena Daivadanam¹ 

[1] Achutha Menon Centre for Health Science Studies (AMCHSS), Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Thiruvananthapuram, 695011, India

关键词: Universal health coverage;    Non-communicable diseases;    Out-of-pocket expenditure;    Acute coronary syndrome;    Distress financing;    Catastrophic health expenditure;   

Others  :  1163669
DOI  :  10.1186/1471-2458-12-306

 received in 2011-09-12, accepted in 2012-04-26,  发布年份 2012

【 摘 要 】

Background

Universal health coverage through the removal of financial and other barriers to access, particularly for people who are poor, is a global priority. This viewpoint describes the many pathways to catastrophic health expenditure (CHE) for patients with Acute Coronary Syndrome (ACS) based on two case studies and the thematic analysis of field notes regarding 210 patients and their households from a study based in Kerala, India.

Discussion

There is evidence of the severe financial impact of non-communicable diseases (NCDs), which is in contradiction to the widely acclaimed Kerala model: Good health at low cost. However, it is important to look beyond the out-of-pocket expenditure (OOPE) and CHE to the possible pathways and identify the triggers that make families vulnerable to CHE. The identified pathways include a primary and secondary loop. The primary pathway describes the direct path by which families experience CHE. These include: 1) factors related to the pre-event period that increase the likelihood of experiencing CHE, such as being from the lower socio-economic strata (SES), past financial losses or loans that leave families with no financial shock absorber at the time of illness; 2) factors related to the acute event, diagnosis, treatment and hospitalization and expenditures incurred for the same and; 3) factors related to the post-event period such as loss of gainful employment and means of financing both the acute period and the long-term management particularly through distress financing. The secondary pathway arises from the primary and includes: 1) the impact of distress financing and; 2) the long- and short- term consequences of CHE. These factors ultimately result in a vicious cycle of debt and poverty through non-compliance and repeat acute events.

Summary

This paper outlines the direct and indirect pathways by which patients with ACS and their families are trapped in a vicious cycle of debt and poverty. It also contradicts the prevailing impression that only low-income families are susceptible to CHE, distress financing and their aftermaths and underscores the need for a deeper understanding at the micro-level, if Kerala and India as a whole are to undertake the difficult exercise of achieving universal health coverage to successfully tackle its growing NCD burden.

【 授权许可】

   
2012 Daivadanam M; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Stuckler D, Feigl AB, Basu S, McKee M: The political economy of universal health coverage. Background paper for the global symposium on health systems research. World Health Organization, Geneva; 2010.
• [2]Beaglehole R, Bonita R, Horton R, Adams C, Alleyne G, Asaria P, Baugh V, Bekedam H, Billo N, Casswell S, Cecchini M, Colagiuri R, Colagiuri S, Collins T, Ebrahim S, Engelgau M, Galea G, Gaziano T, Geneau R, Haines A, Hospedales J, Jha P, Keeling A, Leeder S, Lincoln P, McKee M, Mackay J, Magnusson R, Moodie R, Mwatsama M, Lancet NCD Action Group, et al.: Priority actions for the non-communicable disease crisis. Lancet 2011, 377:1438-1447.
• [3]Ramachandran A, Ramachandran S, Snehalatha C, Augustine C, Murugesan N, Viswanathan V, Kapur A, Williams R: Increasing expenditure on health care incurred by diabetic subjects in a developing country: A study from India. Diabetes Care 2007, 30:252-256.
• [4]Huffman MD, Rao KD, Pichon-Riviere A, Zhao D, Harikrishnan S, Ramaiya K, Ajay VS, Goenka S, Calcagno JI, Caporale JE, Niu S, Li Y, Liu J, Thankappan KR, Daivadanam M, van Esch J, Murphy A, Moran AE, Gaziano TA, Suhrcke M, Reddy KS, Leeder S, Prabhakaran D: A cross-sectional study of the microeconomic impact of cardiovascular disease hospitalization in four low- and middle-income countries. PLoS One 2011, 6:e20821.
• [5]World Health Organization: Part 2 – Chapter 2: Chronic diseases and poverty. In Preventing Chronic Diseases: a vital investment: WHO Global Report. Geneva: World Health Organization;
• [6]Reddy KS, Shah B, Varghese C, Ramadoss A: Responding to the threat of chronic diseases in India. Lancet 2005, 366:1746-1751.
• [7]World Health Organization: India. In Non-communicable diseases country profiles 2011. WHO Press, Geneva; 2011:92.
• [8]Abegunde D, Stanciole A: World Health Organization working paper: An estimation of the economic impact of chronic non-communicable diseases in selected countries. Department of Chronic Diseases and Health Promotion, World Health Organization, ; 2006. http://www.who.int/chp/working_paper_growth%20model29may.pdf webcite (last accessed: 20 December 2011)
• [9]Mahal A, Karan A, Engelgau M: Health, Nutrition and Population (HNP) Discussion paper: The Economic Implications of Non-Communicable Disease for India. The International Bank for Reconstruction and Development / The World Bank, ; 2009. http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/281627-1095698140167/EconomicImplicationsofNCDforIndia.pdf webcite (last accessed: 20 December 2011)
• [10]Saksena P, Xu K, Evans DB: World Health Organization Discussion paper no. 2: impact of out-of-pocket payments for treatment of non-communicable diseases in developing countries: a review of literature. Health Systems Financing (Department), Health Systems and Services (Cluster). WHO, Geneva; 2011. http://www.who.int/health_financing/documents/dp_e_11_02-ncd_finburden.pdf webcite (last accessed: 20 December 2011)
• [11]Van Damme W, Van Leemput L, Por I, Hardeman W, Meessen B: Out-of-pocket health expenditure and debt in poor households: evidence from Cambodia. Trop Med Int Health 2004, 9:273-280.
• [12]Daivadanam M, Thankappan KR, Sarma PS, Harikrishnan S: Catastrophic health expenditure and coping strategies associated with acute coronary syndrome in Kerala, India. Indian J Med Resin press
• [13]Attride-Stirling J: Thematic networks: an analytic tool for qualitative research. Qual Res 2001, 1:385-405.
• [14]Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJL: Household catastrophic health expenditure: a multicountry analysis. Lancet 2003, 362:111-117.
• [15]Flores G, Krishnakumar J, O’Donnell O, van Doorslaer E: Coping with health-care costs: implications for the measurement of catastrophic expenditures and poverty. Health Econ 2008, 17:1393-1412.
• [16]Adhikari SR, Maskay NM, Sharma BP: Paying for hospital-based care of Kala-azar in Nepal: assessing catastrophic, impoverishment and economic consequences. Health Policy Plan 2009, 24:129-139.
• [17]World Health Organization: Working Paper 1.8: Research priorities: primary health care approach for prevention and control of non-communicable diseases. Prioritized Research Agenda for Prevention and Control of Non-communicable Diseaseshttp://whqlibdoc.who.int/publications/2011/9789241564205_CD_eng.pdf webcite (last accessed: 16 August 2011)
• [18]Whitehead M, Dahlgren G, Evans T: Equity and health sector reforms: can low-income countries escape the medical poverty trap? Lancet 2001, 358:833-836.
• [19]Gottret P, Gupta V, Sparkes S, Tandon A, Moran V, Berman P: Protecting pro-poor health services during financial crises: Lessons from experience. In Innovations in Health System Finance in Developing and Transitional Economies (Series: Advances in Health Economics and Health Services Research, Volume 21). Edited by Chernichovsky D, Hanson K. Emerald Group Publishing Limited, ; 2009:23-53.
• [20]Gupta R: Coronary heart disease epidemic in India: Risk factors and approaches for prevention. In Proceedings of the Summer Conference of Cardiology Society of India, Kerala Chapter. , ; 2007:44-54.
• [21]Kumar AK, Chen LC, Choudhury M, Ganju S, Mahajan V, Sinha A, Sen A: India: Towards Universal Health Coverage 6: Financing health care for all: challenges and opportunities. Lancet 2011, 377:668-679.
• [22]Thankappan KR, Shah B, Mathur P, Sarma PS, Srinivas G, Mini GK, Daivadanam M, Soman B, Vasan RS: Risk factor profile for chronic non-communicable diseases: results of a community-based study in Kerala, India. Indian J Med Res 2010, 131:53-63.
• [23]Sugathan TN, Soman CR, Sankaranarayanan K: Behavioral risk factors for non-communicable diseases among adults in Kerala, India. Indian J Med Res 2008, 127:555-563.
• [24]Thankappan KR, Valiathan MS: Health at low cost – the Kerala model. Lancet 1998, 351:1274-1275.
• [25]Kutty VR: Historical analysis of the development of healthcare facilities in Kerala state, India. Health Policy Plan 2000, 15:103-109.
• [26]Roy K, Howard DH: Equity in out-of-pocket payments for hospital care: evidence from India. Health Policy 2007, 80:297-307.
• [27]Lewis M: Informal payments and the financing of health care in developing and transition countries. Health Aff (Millwood) 2007, 26:984-997.
• [28]Rao KD, Peters DH, Bandeen-Roche K: Towards patient-centered health services in India—a scale to measure patient perceptions of quality. Int J Qual Health Care 2006, 18:414-421.
• [29]Nongkynrih B, Patro BK, Pandav CS: Current status of communicable and non-communicable diseases in India. J Assoc Physicians India 2004, 52:118-123.
• [30]Miranda JJ, Kinra S, Casas JP, Davey Smith G, Ebrahim S: Non-communicable diseases in low- and middle-income countries: context, determinants and health policy. Trop Med Int Health 2008, 13:1225-1234.
• [31]Daar AS, Singer PA, Persad DL, Pramming SK, Matthews DR, Beaglehole R, Bernstein A, Borysiewicz LK, Colagiuri S, Ganguly N, Glass RI, Finegood DT, Koplan J, Nabel EG, Sarna G, Sarrafzadegan N, Smith R, Yach D, Bell J: Grand challenges in chronic non-communicable diseases. Nature 2007, 450:494-496.
• [32]Xu K, Evans DB, Carrin G, Aguilar-Rivera AM, Musgrove P, Evans T: Protecting households from catastrophic health spending. Health Aff (Millwood) 2007, 26:972-983.
• [33]Maslow AH: A theory of human motivation. Psychol Rev 1943, 50:370-396.
• [34]Government of Kerala: Budget in brief: 2011–12. Trivandrum, India. 2011. http://www.finance.kerala.gov.in/index.php?option=com_docman&task=cat_view&gid=159&Itemid=34 webcite (last accessed: 30 Dec 2011)
• [35]Ramani KV, Mavalankar D: Health system in India: opportunities and challenges for improvements. J Health Organ Manag 2006, 20:560-572.
• [36]Dilip TR: Utilization of inpatient care from private hospitals: trends emerging from Kerala, India. Health Policy Plan 2010, 25:437-446.
• [37]Reddy KS, Vikram Patel V, Jha P, Paul VK, Kumar AKS, Dandona L: Towards achievement of universal health care in India by 2020: a call to action. Lancet 2011, 377:760-768.
• [38]Tata Institute of Social Sciences: Maternal Protection: A National Assessment: The Kerala Case. 2011. http://sakhikerala.org/downloads/maternity%20 protection%20study%20-booklet.pdf webcite (last accessed: 16 August 2011)
• [39]Tapay N, Colombo F: Ch. 6: Private Health Insurance in OECD Countries: The Benefits and Costs for Individuals and Health Systems. In The OECD Health Project: Towards high-performing health systems: policy studies. OECD, France; 2004:265-318. http://www.economia.unige.it/04/diem/economia/socio/Ocse-highperformance%20system-2004.pdf#page=258 webcite (last accessed: 30 Dec 2011)
• [40]Tangcharoensathien V, Patcharanarumol W, Ir P, Aljunid SM: Health-financing reforms in southeast Asia: challenges in achieving universal coverage. Lancet 2011, 377:863-873.
• [41]World Health Organization: Health System: Expenditures in health (2004). In World Health Statistics 2007. World Health Organization, Geneva; 2007:64-73.
• [42]Limwattanonon S, Tangcharoensathien V, Prakongsai P: Catastrophic and poverty impacts of health payments: results from national household surveys in Thailand. Bull World Health Organ 2007, 85:600-606.