Close
Equitable Health Systems
More than half the world's population still lacks access to essential health services such as family planning and immunisation. In many countries, health systems are failing to meet the needs of all, threatening progress towards universal health coverage and exacerbating poor health, inequality and poverty. The challenges raised by the COVID-19 worldwide pandemic and the approaching 2030 deadline for the Sustainable Development Goals underline the need for urgent action to ensure equitable health systems.
Our aim is to investigate how to ensure accessible and affordable health services and medicines. We identify and propose solutions to reduce bias in healthcare systems from medical research up to the point of care. To this end, several themes are explored by UCL researchers such as the potential contribution of the private sector, social protection, digital innovations and investment.
- Case Study: How do informal payments reinforce medical poverty and affect the health of the most vulnerable populations?
When individuals seek healthcare, related direct or indirect expenditures are usually covered through health care insurance or out-of-pocket payments. Worldwide, close to 20% of health expenditures are accounted for by out-of-pocket expenditures (The World Bank, 2019) and around 4% of the population spends more than 25% of their household income on healthcare-related expenditures (The World Bank, 2021). A particular type of out-of-pocket expenditure represents informal payments for healthcare. Such payments are frequently made to healthcare providers to circumvent formal rules of the healthcare system. Informal payments can either be requested by healthcare providers, and at times paid for by care seekers unaware of the formal rules. They can also be actively made by care seekers to get quicker and/or better healthcare. In some instances, informal payments can also be seen as a symbol of gratitude to healthcare providers (Cohen, 2012).
Private out-of-pocket healthcare expenditures, including informal payments, can drive individuals and families into poverty. Around 21% of the world population is at risk of catastrophic expenditures for surgical care (The World Bank, 2021b), while 17% are at risk of impoverishing expenditures for surgical care (The World Bank, 2021c). Coping mechanisms to manage financial stressors, such as selling possessions or the acquisition of debt, often further add to the risk of falling into poverty. Additionally, the use of informal payments can also have negative consequences for the healthcare system in terms of reduction of efficiency and may undermine trust in healthcare suppliers (Cohen, 2012).
One particularity of informal payments and its impact is that they are difficult to measure because they are usually done secretly or in private. However, surveys, focus groups and interviews are tools that can help researchers to understand this phenomenon better. Researchers from University College London (UCL) have studied the impact of informal payments in healthcare.
Healthcare spending patterns for maternal and neonatal healthcare in Mumbai slums
Prof Jolene Skordis (UCL) and colleagues conducted a cross-sectional study on healthcare spending patterns for maternity care in slums in Mumbai, India. The main aim of the study was to gain an understanding of spending patterns by income level (equity dimension) and how spending affects household poverty. Through interviews with 1200 individuals (conducted in 2005 and 2006), expenditure data were collected and analysed by socio-economic status to understand levels of catastrophic payments and coping strategies against financial stressors. The results of the study showed that a considerable number of households had spent a catastrophic level on maternity care (41%). While richer households paid for care using savings, poorer households had to use their wage income. Also, poorer households were associated with making more use of informal payments for care. The study concluded that the burden of healthcare spending lies particularly in poorer households and that the aim of increasing institutional deliveries of babies would need to be met by providing better access to care (without the need for out-of-pocket payments) and stronger regulations on informal payments.
The role of informal payments in the healthcare system in Albania
Dr. Sonila Tomini (UCL) and Prof Wim Groot (Maastricht University) explored the demand side of informal healthcare payments in Albania. Using three waves of cross-sectional survey data that included information on household characteristics and out-of-pocket healthcare expenditures, the authors assessed the relationship between household characteristics and levels of informal payments. The study results provided several important insights into informal payments. Looking at the development of informal payments during the study period, the
average expenditure for informal payments decreased. In terms of geographical differences, individuals from rural areas made larger informal payments but were less frequently engaged in making such payments, compared to individuals from urban areas. A focus on age and education level indicated that working-age individuals made larger informal payments, but a higher educational level (university degree) protected them from making such payments. Overall, having health insurance made individuals less likely of making informal payments. The study concluded that informal payment is commonplace in Albania and reforms have had little effect in decreasing them. Individuals subject to the need for informal payments are the most vulnerable in society (the elderly and lower-educated individuals) and they would benefit from improved access to health insurance.
Conclusion
The results of the two studies show that informal payments can be a threat to the financial well-being of households. The evidence indicates that the most vulnerable of society are most affected by their negative consequences. Higher-income households and working-age individuals can may easier cope with them, while lower-income households and the elderly are at higher risk of experiencing catastrophic healthcare expenditures. This is of considerable concern, particularly because of the inequitable nature of access to care. Widening the access to healthcare free at the point of use is required to prevent households from the negative consequences associated with informal payments.
References: Cohen, N. (2012). Informal payments for health care – the phenomenon and its context. Health Economics, Policy and Law, 7(3), 285-308. doi:10.1017/S1744133111000089 Skordis-Worrall, J., Pace, N., Bapat, U., Das, S., More, N. S., Joshi, W., ... & Osrin, D. (2011). Maternal and neonatal health expenditure in Mumbai slums (India): a cross sectional study. BMC public health, 11(1), 1-12. The World Bank (2019). Out-of-pocket expenditure (% of current health expenditure) | Data. [online] Available at: https://data.worldbank.org/indicator/SH.XPD.OOPC.CH.ZS [Accessed 12 Nov. 2022]. The World Bank (2021). Number of people spending more than 25% of household consumption or income on out-of-pocket health care expenditure | Data. [online] Available at: https://data.worldbank.org/indicator/SH.UHC.OOPC.25.TO [Accessed 6 Nov. 2022]. The World Bank (2021b). Risk of catastrophic expenditure for surgical care (% of people at risk) | Data. [online] Available at: https://data.worldbank.org/indicator/SH.SGR.CRSK.ZS [Accessed 6 Nov. 2022]. The World Bank (2021c). Risk of impoverishing expenditure for surgical care (% of people at risk) | Data. [online] data.worldbank.org. Available at: https://data.worldbank.org/indicator/SH.SGR.IRSK.ZS [Accessed 7 Nov. 2022]. Tomini, S. M., & Groot, W. (2013). Paying informally for public health care in Albania: scarce resources or governance failure?. Applied economics, 45(36), 5119-5130. Whitehead, M., Dahlgren, G., & Evans, T. (2001). Equity and health sector reforms: can low-income countries escape the medical poverty trap?. The Lancet, 358(9284), 833-836.