Department of Obstetrics and Gynaecology, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Main Road, Observatory 7925, Cape Town, South Africa.
Health Economics Unit, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa.
Hum Reprod. 2017 Dec 1;32(12):2431-2436. doi: 10.1093/humrep/dex315.
How do households recover financially from direct out-of-pocket payment for government subsidized ART?
After a mean of 3.8 years, there was poor recovery from initiated financial coping strategies with the poorest households being disproportionatley affected.
Out-of-pocket payment for health services can create financial burdens for households and inequities in access to care. A previous study conducted at a public-academic institution in South Africa documented that patient co-payment for one cycle of ART resulted in catastrophic expenditure for one in five households, and more frequently among the poorest, requiring diverse financial coping strategies to offset costs.
STUDY DESIGN, SIZE, DURATION: An observational follow-up study was conducted ~4 years later to assess financial recovery among the 135 couples who had participated in this previous study. Data were collected over 12 months from 73 informants.
PARTICIPANTS/MATERIALS, SETTING, METHOD: The study was conducted at a level three referral hospital in the public-academic health sector of South Africa. At this institution ART is subsidized but requires patient co-payments. A purpose-built questionnaire capturing socio-economic information and recovery from financial coping strategies which had been activated was administered to all informants. Financial recovery was defined as the resolution of strategies initiated for the specific purpose of covering the original ART cycle. Results were analysed by strategy and household with the latter including analysis by tertiles based on socio-economic status at the time of the original expenditure. In addition to descriptive statistics, the Pearson Chi squared test was used to determine differences between socioeconomic tertiles and associations between recovery and other variables.
The participation rate in this follow-up study was 54.1% with equal representation from the three socio-economic tertiles. The average duration of follow-up was 46.1 months (±9.78 SD) and respondents' mean age was 42 years (range 31-52). The recovery rate was below 50% for four of five strategies evaluated: 23.1% of households had re-purchased a sold asset; 23.5% had normalized a previous reduction in household spending, 33.8% had regained their savings, and 48.7% were no longer bolstering income through additional work. Two-thirds of households (60.0%) had repaid all loans and debts. The poorest households showed lower rates of recovery when compared to households in the richest tertile. Complete recovery from all strategies initiated was reported by only 10 households (13.7%): 1 of 19 in the lowest tertile, 3 of 30 in the middle and by 6 of 24 households in the richest tertile (P > 0.05). No association was found between the degree of financial recovery and additional cost burdens incurred, including related to babies born; or between the degree of recovery and ongoing pursuit of ART.
LIMITATIONS, REASONS FOR CAUTION: The sample size was limited. The participation rate was just over 50%. Results were dependent on participants' narrative and recall.
The willingness of patients to pay for ART does not necessarily imply the ability to pay. As a result, the lack of comprehensive third-party funding for ART can create immediate and long-term financial hardship which is more pronounced among poorer households. While more data on the impact of out-of-pocket payment for ART are needed to illustrate the problem in other low resource settings, the results from South Africa provide useful information for similar developing countries. The current absence of more extensive data should therefore not be a barrier to the promotion of financial risk protection for infertile couples, especially the poorest, in need of ART.
STUDY FUNDING/COMPETING INTEREST(S): The study was supported by a Masters Student Grant from the Faculty of Health Sciences, University of Cape Town. The authors had no competing interests.
Not applicable.
家庭如何从政府补贴的 ART 的自费中恢复财务？
在平均 3.8 年后，从启动的财务应对策略中恢复情况不佳，最贫困的家庭受到的影响不成比例。
医疗服务自费可能会给家庭带来经济负担，并导致获得医疗服务的不平等。先前在南非一所公立学术机构进行的一项研究表明，ART 一个周期的患者自付费用导致五分之一的家庭出现灾难性支出，而最贫困的家庭更为频繁，需要采取各种财务应对策略来抵消成本。
研究设计、规模和持续时间：在之前的研究之后大约 4 年进行了一项观察性随访研究，以评估 135 对夫妇中哪些夫妇在财务上已经恢复。在 12 个月内，从 73 名受访者那里收集了数据。
参与者/材料、设置、方法：该研究在南非公立学术卫生部门的三级转诊医院进行。在该机构，ART 是补贴的，但需要患者自付费用。向所有受访者发放了一份专门设计的问卷，该问卷记录了社会经济信息和为支付最初的 ART 周期而启动的财务应对策略的恢复情况。财务恢复的定义是解决特定目的的策略得到解决，该目的是为了支付最初的 ART 周期。结果按策略和家庭进行分析，后者包括根据最初支出时的社会经济状况进行的三分位数分析。除了描述性统计数据外，还使用 Pearson Chi 平方检验来确定社会经济三分位数之间的差异以及恢复与其他变量之间的关联。
这项随访研究的参与率为 54.1%，三个社会经济三分位数的代表性相等。平均随访时间为 46.1 个月（±9.78 SD），受访者的平均年龄为 42 岁（范围 31-52）。在评估的五种策略中，有四种的恢复率低于 50%：23.1%的家庭重新购买了已出售的资产；23.5%的家庭恢复了之前减少的家庭支出；33.8%的家庭恢复了储蓄；48.7%的家庭通过额外工作来增加收入。三分之二的家庭（60.0%）已经偿还了所有贷款和债务。与最富裕的三分位数相比，最贫困的家庭的恢复率较低。只有 10 户家庭（13.7%）报告了所有策略的完全恢复：19 户中最贫困的家庭中有 1 户，30 户中中等的家庭中有 3 户，24 户中最富裕的家庭中有 6 户（P > 0.05）。研究未发现财务恢复程度与婴儿出生等相关额外费用负担之间的关联，也未发现恢复程度与正在进行的 ART 之间的关联。
局限性、谨慎的原因：样本量有限。参与率略高于 50%。结果取决于参与者的叙述和回忆。
患者愿意支付 ART 并不一定意味着有能力支付。因此，ART 缺乏全面的第三方资助可能会立即和长期造成经济困难，而贫困家庭受到的影响更为明显。虽然其他资源匮乏的国家需要更多关于自费支付 ART 的影响的数据来说明这一问题，但南非的研究结果为类似的发展中国家提供了有用的信息。目前缺乏更广泛的数据不应该成为促进有需要的 ART 的不育夫妇，特别是最贫困的夫妇的财务风险保护的障碍。
研究资金/利益冲突：该研究得到了开普敦大学健康科学学院硕士学生赠款的支持。作者没有利益冲突。
不适用。
