Background:
The most predominant challenge faced by health systems in many developing countries is to provide accessible and affordable healthcare for people from economically backward sections. Despite of several efforts, this challenge remains as a constant barrier to economic growth, as not only welfare of the person is affected but also the risk of impoverishment is increased due to health-related problems.(1) The report from World Bank and World Health Organization (WHO), has estimated the number of people who have no access to basic and essential health services at 400 million.(2) Also, a study by International Labour Organization (ILO) revealed that at least 40% of the total world’s population is devoid of some form of social protection.(3) Additionally, at the global level, the out of pocket health expenditures (OOPE) are in rise and the majority of the burden related to OOPE is mainly seen on those belonging to vulnerable sections of population living in low and middle-income countries (LMIC). It is estimated that almost 100 million people are pushed into extreme poverty every year because of out of pocket health expenses. This is an indication that health problems and costs associated with them are the main causes that drive people into poverty especially in developing countries where the payments for healthcare are made out of pocket.(4)
Since 1990s many developing countries have come up with solutions to improve access to health care services for their people. One of those and the most promoted solution is health insurance. The reason being, direct payment of fees by patients can be avoided and financial risk can be spread across people in the concept of health insurance. Therefore, it is considered as one of the best means to ensure health care system access and more importantly, to achieve Universal Health Coverage (UHC).(4) Since embracing UHC, all the member states of WHO had agreed that the governments have main role in achieving UHC. With that agreement, the governments of all countries started innovating and introducing newer reforms in their respective health policies.(5) Providing quality health services to everyone and everywhere became the dream of many countries and India is one of them.(6)
Since the adoption of UHC by India, there has been a series of various health insurance schemes launched across different states of the country and also at the national level. All of these schemes or policy reforms aimed at achieving UHC, mainly by providing financial risk protection to the respective citizens especially to those who are deprived by poverty.(7) But, despite the acceptance of UHC at policy level in India, around 75% of spending on health care is borne by households. The recent National Sample Survey (NSS) report says that only 12% of the urban and 13% of the rural population is covered under any forms of health protection schemes.(8) Nearly 26% of the spending for health by rural households is from either borrowings or selling of assets. Further, every year OOPE spending pushes approximately 3.5% to 6.2% of the India’s population below the poverty line.(9) As per the recent National Health Accounts (NHA) estimates, although the OOPE on health came down when compared to previous years, OOPE in India still remains one of the highest in the world at 67% with average per-capita spending of Indian National Rupee (INR) 2,394 on health. Such health care expenditures can be catastrophic and may have adverse impact on the households.(10)
Tamil Nadu Chief Ministers Comprehensive Health Insurance Scheme (TNCMCHIS)
TNCMCHIS is one of those policy level reforms aimed at providing financial protection to the people from economically weaker sections from the consequences of ill-health. The scheme was first launched in 2009 as Chief Minister Kalaignars scheme for life saving treatments. It was relaunched in 2012 as TNCMCHIS with United India Insurance Company Ltd. as the administrator. The Scheme provides quality and cashless health care to the eligible persons (annual salary of INR <72000, Srilankan refugees in the camps, migrants from other states with eligibility and orphans) through empanelled Government & Private hospitals to reduce the financial hardship to the enrolled families & move towards Universal Health Coverage (UHC) by linking with public health system. Presently this scheme covers 1.5 crore eligible families in the state with over 15 lakh beneficiaries till date with a coverage amount of INR 5 Lakhs (previously INR 1 Lakh) per family per year on floater basis. TNCMCHIS covers 1016 procedures, inclusive of 23 diagnostic procedures and 113 follow up packages.(11)
A recent study conducted among the beneficiaries of a similar scheme run by Comprehensive Health Insurance Agency of Kerala (CHIAK) revealed almost all of the study population had OOPE and more than half of them had incurred Catastrophic Health Expenditure (CHE).(12) Similar studies on other state-run schemes have also estimated OOPE among the beneficiaries. All these studies were cross-sectional in nature and specifics of the disease (Acute or Chronic) which often play an important role in determining the catastrophic effects of ill-health were payed less attention to. Also, existing studies on TNCMCHIS were limited to reporting awareness levels and experiences among the beneficiaries. Therefore, through this community based longitudinal study, we aimed to look at the economic burden of Chronic Kidney Disease (CKD) among the beneficiaries of TNCMCHIS and the impact of the scheme on it. Also, an attempt has been made to understand the areas of knowledge, with little supporting evidence, on the beneficiaries of TNCMCHIS, related to their health care expenditures and financial coping strategies.
Methodology:
This was a community based longitudinal study conducted between January 2018 to June 2019 among the beneficiaries of TNCMCHIS availing health care for CKD at a tertiary care hospital to estimate their OOPE and to explore the financial strategies undertaken by the households to cope up with OOPE. A total of 206 CKD patients who availed care during January 2018 – December 2018 were included in this study. Of which, purposive and convenience sampling method was used to consecutively recruit 163 patients on a monthly basis, who required a continuous follow-up for maintenance hemodialysis and were from Cuddalore district of Tamil Nadu residing within a distance of 30 kilometres (Km) from the hospital. House to house visit was made to all the 163 households and a pen and a book were handed over to each patient to document their post-hospitalisation OOPE related to CKD for a period of six months. The care taker at home was also given instructions on how to document OOPE on behalf of the patient and to make sure on continuous recording of the expenses. Also, to ensure the compliance of their documentation and to clarify any queries, they were contacted telephonically at least once in a month with their consent. At the end of six months, in the subsequent house visit, the cumulative expenditures were calculated and dairies were retrieved.
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Figure 1: Data collection flow-chart
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Results:
Socio-demographic details
Among all the CKD patients, more than three fourth (75.5%) were males and majority of them were in the age group of less than 60 years (83.4%). Majority of them (39.3%) had only primary level of education and many of them were either Semi-skilled (34.4%) or unskilled (31.3%) workers (Table 1). The average number of family members in each household of the patient was three. The average household monthly income was INR 10383 (SD 4299.21) and household monthly consumption expenditure was at INR 9398 (SD 3915.35).
| Table 1: Socio-demographic characteristics of CKD patients (N=163) |
Characteristic |
Category |
n (%) |
Gender |
Male |
123 (75.5) |
Female |
40 (24.5) |
Age |
<60 |
136 (83.4) |
>60 |
27 (16.6) |
Education |
Illiterate |
30 (18.4) |
Primary |
64 (39.3) |
Secondary & higher secondary |
52 (31.9) |
Graduate / postgraduate |
17 (10.4) |
Occupation |
Unemployed |
33 (20.2) |
Unskilled |
51 (31.3) |
Semiskilled |
56 (34.4) |
Skilled |
19 (11.6) |
Semi-professional |
4 (2.5) |
Professional |
0 (0) |
Out of Pocket Expenditures
The post hospitalization OOPE for the continuous follow-up and maintenance hemodialysis as part of management of CKD was calculated from the OOPE recorded by the patients/households in the notebook over a period of six months. The total median OOPE for six months was found to be INR 9540 (IQR 6990 - 13300). Also, the monthly median OOPE was found to be highest in the fourth month and remained same in the first and fifth months (Figure 2). The analysis of the split-up of total OOPE showed that, of the total expenses spent, the amount spent for care taker (INR 3400) and transportation (INR 3053) was higher when compared to expenditures on investigations, medications, food and accommodation (Figure 3).
 |
Figure 2: Trends in OOPE (INR) over a period of 6 months among the CKD patients (N=163) |
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Figure 3: OOPE (INR) split up for a period of 6 months among the CKD patients (N=163) |
Stepwise Linear regression model was used to see the predictors of total OOPE based on monthly OOPE i.e. the model was applied to see the effect of monthly OOPE on the total OOPE. The statistically significant model explained 87% (R2=0.87), p<0.001 effect of the monthly OOPE over the Total OOPE. Except second month, OOPE of all the other months were turned out to be significant predictors of total OOPE. Therefore, the change in OOPE in the first, third, fourth, fifth and sixth months would alter the total OOPE. It was also observed that first month (0.62) and third month (0.54) strongly contributed to the total OOPE than the other months (Table 2). Simple linear regression was done with Total OOPE as dependent variable and independent variables such as OOPE due to Investigations, Medication charges, Food charges, Transport, accommodation and caregiver charges. It showed significant results (R2 = 0.987). Medical charges had more influence (0.56) over OOPE (b0=9944.14, t = 2.18) (Table 3).
| Table 2: Regression analysis of monthly OOPE with total OOPE (INR) among the CKD patients (N=163) |
Model |
Un-standardized Coefficients |
Standardized
coefficients |
t- test |
p-value |
95% CI |
Correlations |
b |
SE |
Upper
Limit |
Lower
Limit |
r |
R2 |
Constant |
1903.96 |
290.46 |
|
6.55 |
<0.001 |
1330.24 |
2477.69 |
0.93 |
0.87 |
OOPE at 3rd month |
1.18 |
0.06 |
0.54 |
18.65 |
<0.001 |
1.05 |
1.30 |
OOPE at 5th month |
0.80 |
0.06 |
0.37 |
12.11 |
<0.001 |
0.67 |
0.93 |
OOPE at 1st month |
1.13 |
0.05 |
0.62 |
20.41 |
<0.001 |
1.02 |
1.24 |
OOPE at 4th month |
0.87 |
0.05 |
0.43 |
14.81 |
<0.001 |
0.76 |
0.99 |
OOPE at 6th month |
0.92 |
0.07 |
0.378 |
12.27 |
<0.001 |
0.77 |
1.07 |
| Table 3: Primary cost drivers of OOPE (INR) among the CKD patients (N=163) |
| Model |
Un-standardized Coefficients |
Standardized
coefficients |
t- test |
p-value |
95% CI |
b |
SE |
Upper Limit |
Lower Limit |
Constant |
9944.14 |
519.69 |
|
19.13 |
<0.001 |
8917.85 |
10970.43 |
OOPE
on medicines |
0.561 |
0.256 |
0.17 |
2.18 |
<0.001 |
0.05 |
1.06 |
Catastrophic Health Expenditures (CHE)
All the CKD patients had OOPE. The effect of this OOPE on the household was assessed by seeing the prevalence of catastrophic health expenditures (CHE) among the households. CHE in this study was defined as total OOPE for management of CKD equal to or more than 40% of total household expenditure (THE). The aggregate household expenditure for a period of six months was calculated and was compared with the total OOPE on health care for CKD for a period of six months. Households in which the total OOPE for six months was equal to or more than 40% of the total household expenditure for six months were defined. It was observed that 12% of the households had catastrophic health expenditures (Figure 4).
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Figure 4: Prevalence of catastrophic health expenditures among the CKD patients (N=163) |
Discussion:
In the present study, among the beneficiaries who have availed health care for CKD under TNCMCHIS, majority of the patients were males and a highly alarming revelation is that majority of them were less than sixty years old. In a similar study conducted among Acute Coronary Syndrome patients in Thiruvunanthapuram district of Kerala, the mean age of the participants was fifty-six.(13) The results of our study are also in line with the findings of other studies which have reported the average age group of beneficiaries availing care under various health schemes to be under 60 years.(14,15) This emphasis on the age group is an important aspect to understand the change in trends of health-related conditions, which in turn would help in planning and delivering comprehensive health services to the targeted populations. Our study finding also showed that none of the beneficiaries had OOPE at the time of hospitalization. Similar studies on other state health insurance schemes also reported zero OOPE at the time of hospitalization among the beneficiaries. These similar findings across different health insurance schemes would be due to the cashless nature of those schemes i.e. zero out of pocket spending by the patient at the point of health care delivery.(12,15) All the beneficiaries had post hospitalization OOPE as part of management of CKD which included various costs for outpatient care, medicines, investigations and accommodation charges. Contrary to this, in the findings reported among urban poor in Bangalore, not all the patients had OOPE and also the amount of OOPE per month for outpatient care of chronic conditions was not similar to the OOPE per month reported in our study.(16) The variation in these findings can be due to the difference in the study population along with difference in nature and type of conditions for which they availed care.
The prevalence of catastrophic health expenditures among the households was found to be largely differing from the findings of a study conducted among the beneficiaries of a similar scheme in the state of Kerala.(12) These differences can be attributed to the total insurance coverage amount, which is almost three times more in CMCHIS when compared to the scheme run by Comprehensive Health Insurance Agency of Kerala (CHIAK).(17) This can also be further emphasised and related to the impact of such schemes in reducing the economic burden of ill-health among the beneficiaries. The vicious cycle of disease and poverty always plays an important role in determining the financial status of a household. With ever increasing rise of OOPE on health and almost constant spending on health from the supply side, the difference in the gap being formed makes the households to decide on what to do and how to spend on health care services.
Conclusion and Recommendations:
Chief Ministers Comprehensive Health Insurance, the flagship scheme from Government of Tamil Nadu was always at the forefront in providing cashless quality health care services to the beneficiaries at the time of hospitalization. The findings from our study re-emphasise this fact. The study results also provides an evidence that although the beneficiaries had OOPE, the catastrophic effects of OOPE was not present in majority of them, thus showing the role of scheme in reducing the economic burden of ill-health among the beneficiaries. However, to continue the successful run of such a flag ship scheme with the ultimate aim to achieve UHC, continuous monitoring of financial risk protection aspects of the scheme, has to be in place. Recent announcement of merging central government Ayushman Bharat Scheme with the state run CMCHIS increasing the coverage amount to INR 5 Lakhs is a welcome initiative in that direction, thus by increasing the level of financial protection to the beneficiaries. However, fastening of implementation process under this merger would be an added advantage to the beneficiaries. The current study has only scratched the surface - we need many more research studies among the beneficiaries of the scheme ranging from general descriptive studies to more specialized studies focusing on specific disease conditions with focus on measuring financial risk protection which is at the core of UHC. Exploring the feasibility of providing transportation and accommodation allowances to the beneficiaries who are in need for regular follow-ups, especially to those patients suffering from chronic conditions like CKD would be much needed. Such a provision would not only reduce their dependency on caretakers and but also would definitely reduce their economic burden.
Acknowledgements:
We wish to acknowledge the support received from Professors Dr. N Seetharaman, Dr. KA Narayan and Medical Social Worker Mr. Parthasarathy. We also would like to acknowledge all the study participants who patiently participated in the study.
Declaration of Conflicting Interests:
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding:
The authors received no financial support for the research, authorship and/or publication of this article.
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