Health shocks, coping strategies and foregone healthcare among agricultural households in Kenya

Risks are a central part of life for households in low-income countries and health shocks in particular are associated with poverty. Formal mechanisms protecting households against the financial consequences of shocks are largely absent, especially among poor rural households. Our aim is to identify the relative importance of health shocks and to explore factors associated with coping behaviour and foregone care. We use a cross-sectional survey among 1226 randomly selected agricultural households in Kenya. In our sample, illness and injury shocks dominate all other shocks in prevalence. Almost 2% of households incurred catastrophic health expenditure in the last year. Using a probit model we identified the main coping strategies associated with facing a health shock: (1) use savings, (2) sell assets and (3) ask for gifts or loans. One in five households forewent necessary care in the last 12 months. We conclude that health shocks pose a significant risk to households. Implementing pre-payment or saving mechanisms might help protect households against the financial consequences of ill health. Such mechanisms, however, should take into account the competing shocks that agricultural households face, making it almost impossible to reserve a share of their limited resources for the protection against health shocks only

Does health care utilization match needs in Africa? Challenging conventional needs measurement

Abstract. An equitable distribution of health care use, distributed according to people’s needs instead of ability to pay, is an important goal featuring on many health policy agendas worldwide. However, relatively little is known about the extent to which this principle is violated across socio-economic groups in Sub Saharan Africa (SSA). We examine cross-country comparative micro-data from eighteen SSA countries and find that (a) considerable inequalities in health care use exist and vary across countries, but that (b) identifying the extent to which these inequalities are unfair, i.e. do not correspond to inequalities in need, is not straightforward to ascertain with the conventional tools. These tools include rank-based measures such as the concentration index and the index of inequity. The two main concerns when using conventional tools to measure equity are (i) the reporting heterogeneity in self-reported health variables across socio-economic groups and (ii) the weak relationship between need and use. We show that the use of subjective self-reports of health leads to much lower measured degrees of socio-economic inequalities than those obtained using more objective indicators. This leads to an underestimation of the degree of inequity when using self-reported health measures. The observed weak relationship between indicators of ill-health and use of health care does not appear to provide an estimate of the adequate response to needs, which further puts a downward bias on equity measures. In all countries, apart from the more developed Mauritius, health care use is distributed according to wealth rather than to need. A better match of needs and use is realized in those countries with better governance and more physicians but, perhaps surprisingly, not those with greater urbanization. Given the importance of equity in many health policies worldwide, it is vital to develop more robust equity measures relevant to low income settings

The Impact of Financial Incentives on Early and Late Adopters among U.S. Hospitals: Observational Study

OBJECTIVE To examine how hospitals that volunteered to be under financial incentives for more than a decade as part of the Premier Hospital Quality Incentive Demonstration (early adopters) compared with similar hospitals where these incentives were implemented later under the Hospital Value-Based Purchasing program (late adopters). DESIGN Observational study. SETTING 1189 hospitals in the USA (214 early adopters and 975 matched late adopters), using Hospital Compare data from 2003 through 2013. PARTICIPANTS 1 371 364 patients aged 65 years and older, using 100% Medicare claims. MAIN OUTCOME MEASURES Clinical process scores and 30 day mortality. RESULTS Early adopters started from a slightly higher baseline of clinical process scores (92) than late adopters (90). Both groups reached a ceiling (98) a decade later. Starting from a similar baseline, just below 13%, early and late adopters did not have significantly (P=0.25) different mortality trends for conditions targeted by the program (0.05% point difference quarterly) or for conditions not targeted by the program (−0.02% point difference quarterly). CONCLUSIONS No evidence that hospitals that have been operating under pay for performance programs for more than a decade had better process scores or lower mortality than other hospitals was found. These findings suggest that even among hospitals that volunteered to participate in pay for performance programs, having additional time is not likely to turn pay for performance programs into a success in the future