Catastrophic Health Expenditure and Impoverishment from NonCommunicable Diseases: A comparison of Private and Public Health Facilities in Ekiti State, Southwest Nigeria

Catastrophic health expenditure and impoverishment are the outcomes of poor financing mechanisms. Little is known about the prevalence and predictors of these outcomes among non-communicable disease patients in private and public health facilities. METHODS: A health facility-based comparative cross-sectional study was conducted among 360 patients with non-communicable diseases (180 per group) selected through multistage sampling. Data were collected with a semi-structured, interviewer administered questionnaire and analyzed with IBM SPSS for Windows, Version 22.0. Two prevalences of catastrophic health expenditure were calculated utilizing both the World Bank (CHE1) and the WHO (CHE2) methodological thresholds. RESULTS: The prevalence of CHE1 (Private:42.2%, Public:21.7%, p<0.001) and CHE2 (Private:46.8%, Public:28.0%, p<0.001) were higher in private health facilities. However, there was no significant difference between the proportion of impoverishment (Private: 24.3%, Public:30.9%, p=0.170). The identified predictors were occupation, number of complications and clinic visits for catastrophic health expenditure and socioeconomic status for impoverishment in private health facilities. Level of education, occupation, socioeconomic status, number of complications and alcohol predicted catastrophic health expenditure while the level of education, socioeconomic status andthe number of admissions predicted impoverishment in public health facilities. CONCLUSION: Catastrophic health expenditure and impoverishment were high among the patients, with the former more prevalent in private health facilities. Therefore, we recommend expanding the coverage and scope of national health insurance among these patients to provide them with financial risk protection. Identified predictors should be taken into account by the government and other stakeholders when designing policies to limit catastrophic health expenditure and impoverishment among them

Out-of-pocket and catastrophic expenses in households of patients with schizophrenia lacking social security / Gastos de bolsillo y catastróficos en hogares de pacientes con esquizofrenia sin seguridad social

Abstract: Objective: To estimate the magnitude of out-of-pocket (OOP) and catastrophic health expenses as well as impoverishment experienced by households of schizophrenia patients lacking social security coverage. Materials and methods: We conducted a cross-sectional study of 96 individuals treated outpatient consultation between February and December 2018, in a psychiatric hospital. Results: All households sustained OOP health expenses; the median was 510 USD (95%CI: 456-628). The OOP expenses represented 28 and 4% of the capacity to pay of poor and rich households, respectively. The 16% of households incurred catastrophic expenses and 6.6% have impoverishment for health reasons. Conclusions: Our results illustrate that pocket expenses and catastrophic expenses in patients with schizophrenia are higher than those reported for the general population. Therefore, it is necessary to rethink the financial protection policies aimed at patients with schizophrenia and their households.

Resumen: Objetivo: Estimar la magnitud del gasto de bolsillo y catastrófico en salud, así como el empobrecimiento experimentado por hogares de pacientes con esquizofrenia que carecen de cobertura en seguridad social. Material y métodos: Se hizo un estudio transversal de 96 pacientes tratados en consulta externa entre febrero y diciembre de 2018, en un hospital psiquiátrico. Resultados: Todos los hogares soportaron gastos de bolsillo (GB), la mediana fue 510 USD (IC95%: 456-628). Los GB representan 28 y 4% de la capacidad de pago de los hogares pobres y ricos respectivamente. El 16% de los hogares incurrió en gastos catastróficos y 6.6% tiene empobrecimiento por motivos de salud. Conclusiones: Los resultados muestran que los gastos de bolsillo y gastos catastróficos en pacientes con esquizofrenia son mayores que los reportados para población general, por lo que es necesario repensar las políticas de protección financiera dirigidas a pacientes con esquizofrenia y sus hogares.

Inequity & burden of out-of-pocket health spending: District level evidences from India

Background & objectives: Numerous studies have highlighted the regressive and immiserating impact of out-of-pocket (OOP) health spending in India. However, most of these studies have explored this issue at the national or up to the State level, with an associated risk of overlooking intra-State diversities in the health system and health-seeking behaviour and their implication on the financial burden of healthcare. This study was aimed to address this issue by analyzing district level diversities in inequity, financial burden and impoverishing impact of OOP health spending. Methods: A household survey of 62,335 individuals from 12,134 households, covering eight districts across three States, namely Gujarat, Haryana and Rajasthan was conducted during 2014-2015. Other than general household characteristics, the survey collected information on household OOP [sum total of expenditure on doctor consultation, drugs, diagnostic tests etc. on inpatient depatment (IPD), outpatient depatment (OPD) or chronic ailments] and household monthly consumption expenditure [sum total of monthly expenditure on food, clothing, education, healthcare (OOP) and others]. Gini index of consumption expenditure, concentration index and Kakwani index (KI) of progressivity of OOP, catastrophic burden (at 20% threshold) and poverty impact (using district-level poverty thresholds) were computed, for these eight districts using the survey data. The concentration curve (of OOP expenditure) and Lorenz curve (of consumption expenditure) for the eight districts were also drawn. Results: The distribution of OOP was found to be regressive in all the districts, with significant inter-district variations in equity parameters within a State (KI ranges from ?0.062 to ?0.353). Chhota Udepur, the only tribal district within the sample was found to have the most regressive distribution (KI of ?0.353) of OOP. Furthermore, the economic burden of OOP was more pronounced among the rural sample (CB of 19.2% and IM of 8.9%) compared to the urban sample (CB of 9.4% and IM of 3.7%). Interpretation & conclusions: The results indicate that greater decentralized planning taking into account district-level health financing patterns could be an effective way to tackle inequity and financial vulnerability emerging out of OOP expenses on healthcare.

Remanejamento, empobrecimento e mudanças no cotidiano familiar na cidade de Belém-PA / Relocation, impoverishment and changes in family daily life in the city of Belém-PA

Este artigo apresenta resultados de pesquisa acerca dos efeitos da perda da moradia na vida cotidiana de famílias remanejadas pelo governo estadual e que se encontram em fase de transição entre a casa de origem e a nova casa onde foram reassentadas. Para tanto, utilizou-se pesquisa documental e de campo, com aplicação de formulário e inventário de rotina junto às famílias. Os resultados demonstram mudanças significativas na vida cotidiana, com priorização de atividades privativas da vida doméstica em detrimento das atividades de socialização comunitária. Conclui-se que a perda da casa de origem e a submissão das famílias à condição de locatárias agravou sua condição de pobreza e marginalização.

This article presents research results about the effects of the loss of housing in the daily life of families that have been relocated and are in transition phase ­ between the house of origin and the house where they will be resettled by the state government. For that, documentary and field research were used, with application of form and routine inventory with the families. The results demonstrated significant changes in daily life with prioritization of private activities of the domestic life to the detriment of community socialization activities. It is concluded that the loss of the home of origin and the submission of the families to the condition of tenants aggravated their condition of poverty and marginalization.

As indicações freudianas para a formação dos analistas e a clínica com a população de baixa renda / Freud’s guidelines for the education of analysts and the clinic for lower income population / Les indications freudiennes pour la formation des analystes et la clinique avec les pauvres

De Freud a Lacan há um consenso de que os limites e as possibilidades de intervenção da psicanálise no laço social são proporcionais à formação e à experiência dos analistas. A prática da psicanálise com brasileiros de baixa renda, pouco escolarizados e não familiarizados com o discurso psicanalítico coloca em questão esses limites. Por que Freud considerava que a população mais pobre deveria ser atendida por analistas mais experientes? A partir teoria das pulsões, ele estabeleceu as relações entre o empobrecimento do eu e o empobrecimento econômico e social. O pacto civilizado decorre do modo como o eu realiza simultaneamente a satisfação pulsional e atende às exigências da realidade. Porém, a resultante desse processo é uma divisão constitucional do eu. Esse artigo retoma essa temática freudiana com o objetivo de resgatar as diretrizes necessárias à pesquisa sobre a expansão da psicanálise aplicada

From Freud to Lacan there is consensus that the limits and possibilities of psychoanalysis’s intervention in the social ties are related to the education and the experience of the therapists. The practice of psychoanalysis with the brazilians that perceive the lowest incomes, have less education and are not familiar with the speech of psychoanalysis raises a question as to how far these limits go. Why did Freud believe that the poorer population should be treated by more experienced analysts? From the theory of drive, he has estableshed the connections between the impoverishment of the self and socio-economical impoverishment. The pact of civilization is a consequence of the manner that the self fulfills his drive and answers to the expectations of society. However, this process results in a constitutional division of it. This article revisits this freudian theme with the purpose of retrieving the guidelines for the research on the expansion of applied psychoanalysis

Entre Freud et Lacan, il y a consensus au sujet de la proportionalité entre les limites et possibilités de l’intervention de la psychanalyse dans le lien social e la formation et l’expérience des analystes. La pratique psychanalytique avec des brésiliens pauvres , peu scolarisés et non familiers du discours psychanalytique met ces limites en question. Pourquoi Freud considérait-il que la population plus pauvre devrait-être traitée par des analystes plus expérimentés ? Prenant la théorie des pulsions comme fondement, il a établi les relations entre l’appauvrissement du moi et l’appauvrissement socio-économique. Le pacte de la civilisation est le résultat de la manière dont le sujet réalise au même temps la satisfaction pulsionelle et les attentes du réel. Toutefois, le résultat de ce processus est un moi divisé dans sa constitution. Cet article reprend ce thème freudien avec le but de retrouver les directives necéssaires pour la recherche sur l’expansion de la psychanalyse appliquée

Família, pobreza e acesso a programas de transferência de renda nas regiões metropolitanas brasileiras / Familia, pobreza y acceso a programas de transferencia de renta en las regiones metropolitanas brasileñas / Family, poverty and access to income transfer programs in the metropolitan regions of Brazil

O objetivo do artigo é evidenciar nas regiões metropolitanas brasileiras os arranjos familiares mais vulneráveis ao empobrecimento e investigar o acesso destes aos programas de transferência de renda, bem como alguns efeitos desses programas sobre a renda das famílias. Os arranjos domiciliares mais vulneráveis ao empobrecimento são assim identificados por possuírem os mais baixos rendimentos familiares per capita e concentração nos decis inferiores de renda. Apresentam estruturação e composições distintas, bem como vivenciam diferentes momentos do ciclo de vida familiar, mas são os mais fragilizados diante da mudança no padrão de emprego por apresentarem composição familiar desfavorável para a inserção de seus componentes no mercado de trabalho. Nas regiões metropolitanas brasileiras, o empobrecimento dos domicílios ocorrido nos anos 90 e início dos 2000 reflete a queda dos rendimentos do trabalho decorrente da precarização do mercado sob a reestruturação produtiva e o baixo crescimento econômico até 2004. Até 2006, sob a recuperação econômica, tais rendimentos não retornaram aos níveis da metade dos anos 90. Entre as políticas de combate à pobreza emergem aquelas de transferência de renda, que, no início dos anos 2000, apresentavam abrangência incipiente. Intensificam-se no decorrer da década, possibilitando aumento do acesso dos domicílios com rendimentos mais baixos...

El objetivo del artículo es evidenciar en las regiones metropolitanas brasileñas los asentamientos familiares más vulnerables al empobrecimiento e investigar el acceso de éstos a los programas de transferencia de renta, así como algunos efectos de estos programas sobre los ingresos de las familias. Los asentamientos domiciliarios más vulnerables al empobrecimiento son así identificados por poseer los más bajos ingresos familiares per cápita y concentración en las camadas inferiores de renta. Presentan estructuración y composiciones distintas, así como experimentan diferentes momentos del ciclo de vida familiar, pero son los más frágiles ante el cambio en el padrón de empleo, por presentar una composición familiar desfavorable para la inserción de sus componentes en el mercado de trabajo. En las regiones metropolitanas brasileñas, el empobrecimiento de los hogares ocurrido en los años 90 e inicios de los 2000 refleja la caída de los ingresos del trabajo proveniente de la precarización del mercado, bajo la reestructuración productiva y el bajo crecimiento económico hasta 2004. Hasta 2006, bajo la recuperación económica, tales ingresos no volvieron a los niveles de la mitad de los años 90. Entre las políticas de lucha contra la pobreza emergen aquéllas de transferencia de renta, que, al inicio de los años 2000, presentaban un alcance incipiente. Se intensifican en el transcurso de la década, posibilitando el aumento del acceso de los hogares con ingresos más bajos...

The objective of this article is to describe the family arrangements most vulnerable to impoverishment in the metropolitan regions of Brazil and to investigate the access of very poor families to such programs, as well as some of their effects on the earnings of these families. The household arrangements most vulnerable to impoverishment are those with the lowest per capita family income and those in the lowest income deciles. They show varying family structures and compositions and go through different moments in their family life cycles, but they are the hardest hit in terms of changes in employment patterns, since their family compositions are unfavorable for their members to enter the labor market. The impoverishment of households in the Brazilian metropolitan regions during the 1990s and the first years of the 21st century reflects the fall in income from work, due to the unstable job market that resulted from the restructuring of production and the country's low economic growth until 2004. Even by 2006, with economic improvements, these earnings failed to return to the levels of the mid-1990s. Among the policies set up in the government's "fight against poverty," one resource was the income transfer program, which was quite limited in the first years of the new century. It was intensified during the decade, enabling easier access to low-income households...