Correlates of Out-of-Pocket and Catastrophic Health Expenditures in Tanzania: Results from a National Household Survey.

Inequality in health services access and utilization are influenced by out-of-pocket health expenditures in many low and middle-income countries (LMICs). Various antecedents such as social factors, poor health and economic factors are proposed to direct the choice of health care service use and incurring out-of-pocket payments. We investigated the association of these factors with out-of-pocket health expenditures among the adult and older population in the United Republic of Tanzania. We also investigated the prevalence and associated determinants contributing to household catastrophic health expenditures. We accessed the data of a multistage stratified random sample of 7279 adult participants, aged between 18 and 59 years, as well as 1018 participants aged above 60 years, from the first round of the Tanzania National Panel survey. We employed multiple generalized linear and logistic regression models to evaluate the correlates of out-of-pocket as well as catastrophic health expenditures, accounting for the complex sample design effects. Increasing age, female gender, obesity and functional disability increased the adults' out-of-pocket health expenditures significantly, while functional disability and visits to traditional healers increased the out-of-pocket health expenditures in older participants. Adult participants, who lacked formal education or worked as manual laborers earned significantly less (p < 0.001) and spent less on health (p < 0.001), despite having higher levels of disability. Large household size, household head's occupation as a manual laborer, household member with chronic illness, domestic violence against women and traditional healer's visits were significantly associated with high catastrophic health expenditures. We observed that the prevalence of inequalities in socioeconomic factors played a significant role in determining the nature of both out-of-pocket and catastrophic health expenditures. We propose that investment in social welfare programs and strengthening the social security mechanisms could reduce the financial burden in United Republic of Tanzania

Health, Social, and Economic Variables Associated with Depression among Older People in Low and Middle Income Countries: WHO Study on Global AGEing and Adult Health

Objective Although depression among older people is an important public health problem worldwide, systematic studies evaluating its prevalence and determinants in low and middle income countries (LMICs) are sparse. The biopsychosocial model of depression and prevailing socioeconomic hardships for older people in LMICs have provided the impetus to determine the prevalence of geriatric depression; to study its associations with health, social, and economic variables; and to investigate socioeconomic inequalities in depression prevalence in LMICs. Methods The authors accessed the World Health Organization Study on Global AGEing and Adult Health Wave 1 data that studied nationally representative samples from six large LMICs (N = 14,877). A computerized algorithm derived depression diagnoses. The authors assessed hypothesized associations using survey multivariate logistic regression models for each LMIC and pooled their risk estimates by meta-analyses and investigated related socioeconomic inequalities using concentration indices. Results Cross-national prevalence of geriatric depression was 4.7% (95% CI: 1.9%–11.9%). Female gender, illiteracy, poverty, indebtedness, past informal-sector occupation, bereavement, angina, and stroke had significant positive associations, whereas pension support and health insurance showed significant negative associations with geriatric depression. Pro-poor inequality of geriatric depression were documented in five LMICs. Conclusions Socioeconomic factors and related inequalities may predispose, precipitate, or perpetuate depression amongolder people in LMICs. Relative absence of health safety net places socioeconomically disadvantaged older people in LMICs at risk. The need for population-based public health interventions and policies to prevent and to manage geriatric depression effectively in LMICs cannot be overemphasized

Cost and burden of informal caregiving of dependent older people in a rural Indian community

BACKGROUND: Lack of state supported care services begets the informal caregiving by family members as the mainstay of care provided to the dependent older people in many Low and Middle Income Countries (LMICs), including India. Little is known about the time spent on caregiving, its cost and the burden experienced by these informal caregivers. We aimed to estimate the costs of informal caregiving and to evaluate the nature as well as correlates of caregivers’ burden in a rural Indian community. METHODS: We assessed 1000 people aged above 65 years, among whom 85 were dependent. We assessed their socioeconomic profiles, disability, health status and health expenditures. Their caregivers’ socio-demographic profiles, mental health, and the time spent on caregiving were assessed using standard instruments. Caregiver’s burden was evaluated using Zarit Burden Scale. We valued the annual informal caregiving costs using proxy good method. We employed appropriate non-parametric multivariate statistics to evaluate the correlates of caregivers’ burden. RESULTS: Average time spent on informal caregiving was 38.6 (95% CI 35.3-41.9) hours/week. Estimated annual cost of informal caregiving using proxy good method was 119,210 US$ in this rural community. Mean total score of Zarit burden scale, measuring caregivers’ burden, was 17.9 (95% CI 15.6-20.2). Prevalence of depression among the caregivers was 10.6% (95% CI 4.1-17.1%). Cerebrovascular disease, Parkinson’s disease, higher disability, insomnia and incontinence of the dependent older people as well as the time spent on helping Activities of Daily Living and on supervision increased caregiver's burden significantly. CONCLUSIONS: Cost and burden of informal caregiving are high in this rural Indian community. Many correlates of burden, experienced by caregivers, are modifiable. We discuss potential strategies to reduce this burden in LMICs. Need for support to informal caregivers and for management of dependent older people with chronic disabling diseases by multidisciplinary community teams are highlighted