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      Out-of-pocket cost for medical care of injured patients presenting to emergency department of national hospital in Tanzania: a prospective cohort study

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          Abstract

          Objective

          We aimed to determine the out-of-pocket (OOP) costs for medical care of injured patients and the proportion of patients encountering catastrophic costs.

          Design

          Prospective cohort study

          Setting

          Emergency department (ED) of a tertiary-level hospital in Dar es Salaam, Tanzania.

          Participants

          Injured adult patients seen at the ED of Muhimbili National Hospital from August 2019 to March 2020.

          Methods

          During alternating 12-hour shifts, consecutive trauma patients were approached in the ED after stabilisation. A case report form was used to collect social-demographics and patient clinical profile. Total charges billed for ED and in-hospital care and OOP payments were obtained from the hospital billing system. Patients were interviewed by phone to determine the measures they took to pay their bills.

          Primary outcome measure

          The primary outcome was the proportion of patients with catastrophic health expenditure (CHE), using the WHO definition of OOP expenditures ≥40% of monthly income.

          Results

          We enrolled 355 trauma patients of whom 51 (14.4%) were insured. The median age was 32 years (IQR 25–40), 238 (83.2%) were male, 162 (56.6%) were married and 87.8% had ≥2 household dependents. The majority 224 (78.3%) had informal employment with a median monthly income of US$86. Overall, 286 (80.6%) had OOP expenses for their care. 95.1% of all patients had an Injury Severity Score <16 among whom OOP payments were US$176.98 (IQR 62.33–311.97). Chest injury and spinal injury incurred the highest OOP payments of US$282.63 (84.71–369.33) and 277.71 (191.02–874.47), respectively. Overall, 85.3% had a CHE. 203 patients (70.9%) were interviewed after discharge. In this group, 13.8% borrowed money from family, and 12.3% sold personal items of value to pay for their hospital bills.

          Conclusion

          OOP costs place a significant economic burden on individuals and families. Measures to reduce injury and financial risk are needed in Tanzania.

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          Most cited references30

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          Trends in catastrophic health expenditure in India: 1993 to 2014

          Anamika Pandey, George Ploubidis, Lynda Clarke … (2017)
          Abstract Objective To investigate trends in out-of-pocket health-care payments and catastrophic health expenditure in India by household age composition. Methods We obtained data from four national consumer expenditure surveys and three health-care utilization surveys conducted between 1993 and 2014. Households were divided into five groups by age composition. We defined catastrophic health expenditure as out-of-pocket payments equalling or exceeding 10% of household expenditure. Factors associated with catastrophic expenditure were identified by multivariable analysis. Findings Overall, the proportion of catastrophic health expenditure increased 1.47-fold between the 1993–1994 expenditure survey (12.4%) and the 2011–2012 expenditure survey (18.2%) and 2.24-fold between the 1995–1996 utilization survey (11.1%) and the 2014 utilization survey (24.9%). The proportion increased more in the poorest than the richest quintile: 3.00-fold versus 1.74-fold, respectively, across the utilization surveys. Catastrophic expenditure was commonest among households comprising only people aged 60 years or older: the adjusted odds ratio (aOR) was 3.26 (95% confidence interval, CI: 2.76–3.84) compared with households with no older people or children younger than 5 years. The risk was also increased among households with both older people and children (aOR: 2.58; 95% CI: 2.31–2.89), with a female head (aOR: 1.32; 95% CI: 1.19–1.47) and with a rural location (aOR: 1.27; 95% CI: 1.20–1.35). Conclusion The proportion of households experiencing catastrophic health expenditure in India increased over the past two decades. Such expenditure was highest among households with older people. Financial protection mechanisms are needed for population groups at risk for catastrophic health expenditure.
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            The cost of injury and trauma care in low- and middle-income countries: a review of economic evidence.

            Hadley K H Wesson, Nonkululeko Boikhutso, Abdulgafoor M. Bachani … (2014)
            Injuries are a significant cause of mortality and morbidity, of which more than 90% occur in low- and middle-income countries (LMICs). Given the extent of this burden being confronted by LMICs, there is need to place injury prevention at the forefront of public health initiatives and to understand the costs associated with injury. The aim of this article is to describe the extent to which injury-related costing studies have been conducted in LMICs.
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              Determinants of community health fund membership in Tanzania: a mixed methods analysis

              Jane Macha, August Kuwawenaruwa, Suzan Makawia … (2014)
              Background In many developing countries, initiatives are underway to strengthen voluntary community based health insurance as a means of expanding access to affordable care among the informal sector. However, increasing coverage with voluntary health insurance in low income settings can prove challenging. There are limited studies on determinants of enrolling in these schemes using mixed methods. This study aims to shed light on the characteristics of those joining a community health fund, a type of community based health insurance, in Tanzania and the reasons for their membership and subsequent drop out using mixed methods. Methods A cross sectional survey of households in four rural districts was conducted in 2008, covering a total of 1,225 (524 members of CHF and 701 non-insured) households and 7,959 individuals. In addition, 12 focus group discussions were carried out with CHF members, non-scheme members and members of health facility governing committees in two rural districts. Logistic regression was used to assess the determinants of CHF membership while thematic analysis was done to analyse qualitative data. Results The quantitative analysis revealed that the three middle income quintiles were more likely to enrol in the CHF than the poorest and the richest. CHF member households were more likely to be large, and headed by a male than uninsured households from the same areas. The qualitative data supported the finding that the poor rather than the poorest were more likely to join as were large families and of greater risk of illness, with disabilities or persons with chronic diseases. Households with elderly members or children under-five years were also more likely to enrol. Poor understanding of risk pooling deterred people from joining the scheme and was the main reason for not renewing membership. On the supply side, poor quality of public care services, the limited benefit package and a lack of provider choice were the main factors for low enrolment. Conclusions Determinants of CHF membership are diverse and improving the quality of health services and expanding the benefit package should be prioritised to expand voluntary health insurance coverage.
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                Author and article information

                Journal
                Journal ID (nlm-ta): BMJ Open
                Journal ID (iso-abbrev): BMJ Open
                Journal ID (hwp): bmjopen
                Journal ID (publisher-id): bmjopen
                Title: BMJ Open
                Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                ISSN (Electronic): 2044-6055
                Publication date Collection: 2023
                Publication date (Electronic): 31 January 2023
                Volume: 13
                Issue: 1
                Electronic Location Identifier: e063297
                Affiliations
                [1 ]departmentEmegency Medicine , Muhimbili University of Health and Allied Sciences , Dar es Salaam, Tanzania, United Republic of
                [2 ]departmentEmergency Medicine , Muhimbili National Hospital , Dar es Salaam, Tanzania, United Republic of
                [3 ]departmentEmergency Medicine , Kilimanjaro Christian Medical University College , Moshi, Kilimanjaro, Tanzania, United Republic of
                [4 ]departmentEmergency Medicine , University of California San Francisco , San Francisco, California, USA
                Author notes
                [Correspondence to ] Dr Hendry Robert Sawe; hendry_sawe@ 123456yahoo.com
                Author information
                http://orcid.org/0000-0002-0395-5385
                http://orcid.org/0000-0002-0779-8209
                http://orcid.org/0000-0002-7812-8042
                Article
                Publisher ID: bmjopen-2022-063297
                DOI: 10.1136/bmjopen-2022-063297
                PMC ID: 9890776
                PubMed ID: 36720574
                SO-VID: d32a97ce-af41-4ae0-b08d-7e642155189f
                Copyright © © Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
                License:

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/.

                History
                Date received : 28 March 2022
                Date accepted : 16 January 2023
                Categories
                Subject: Emergency Medicine
                Subject: 1506
                Subject: 1691
                Series title: Original research
                Custom metadata
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                ScienceOpen disciplines: Medicine
                Keywords: trauma management,health economics,accident & emergency medicine
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: trauma management, health economics, accident & emergency medicine

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