Murphy Adrianna, Palafox Benjamin, Chifamba Jephat, Kruger Iolanthé M, Ncube Brian J, Ncube Tatenda L, Rangarajan Sumathy, Swart Elizabeth Catherina, Tsolkile Lungiswa, Walli-Attaei Marjan, West Nicola J, Yeates Karen E, Yusuf Salim, McKee Martin, Hanson Kara
Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom.
Department of Biomedical Sciences, University of Zimbabwe, Harare, Zimbabwe.
PLOS Glob Public Health. 2023 Apr 4;3(4):e0001739. doi: 10.1371/journal.pgph.0001739. eCollection 2023.
In most low- and middle-income countries (LMICs), household out-of-pocket (OOP) health spending constitutes a major source of healthcare financing. Household surveys are commonly used to monitor OOP health spending, but are prone to recall bias and unable to capture seasonal variation, and may underestimate expenditure-particularly among households with long-term chronic health conditions. Household expenditure diaries have been developed as an alternative to overcome the limitations of surveys, and pictorial diaries have been proposed where literacy levels may render traditional diary approaches inappropriate. This study compares estimates for general household and chronic healthcare expenditure in South Africa, Tanzania and Zimbabwe derived using survey and pictorial diary approaches. We selected a random sub-sample of 900 households across urban and rural communities participating in the Prospective Urban and Rural Epidemiology study. For a range of general and health-specific categories, OOP expenditure estimates use cross-sectional survey data collected via standardised questionnaire, and data from these same households collected via two-week pictorial diaries repeated four times over 2016-2019. In all countries, average monthly per capita expenditure on food, non-food/non-health items, health, and consequently, total household expenditure reported by pictorial diaries was consistently higher than that reported by surveys (each p<0.001). Differences were greatest for health expenditure. The share of total household expenditure allocated to health also differed by method, accounting for 2% in each country when using survey data, and from 8-20% when using diary data. Our findings suggest that the choice of data collection method may have significant implications for estimating OOP health spending and the burden it places on households. Despite several practical challenges to their implementation, pictorial diaries offer a method to assess potential bias in surveys or triangulate data from multiple sources. We offer some practical guidance when considering the use of pictorial diaries for estimating household expenditure.
在大多数低收入和中等收入国家（LMICs），家庭自付医疗费用是医疗保健融资的主要来源。家庭调查通常用于监测家庭自付医疗费用，但容易出现回忆偏差，无法捕捉季节性变化，并且可能低估支出，尤其是在患有长期慢性健康状况的家庭中。家庭支出日记已被开发出来作为克服调查局限性的替代方法，并且在识字水平可能使传统日记方法不适用的情况下，有人提出了图片日记。本研究比较了使用调查和图片日记方法得出的南非、坦桑尼亚和津巴布韦一般家庭和慢性医疗保健支出的估计值。我们从参与城乡前瞻性流行病学研究的城乡社区中随机抽取了900户家庭作为子样本。对于一系列一般和特定健康类别，自付费用估计使用通过标准化问卷收集的横断面调查数据，以及通过在2016 - 2019年期间重复四次的为期两周的图片日记从这些相同家庭收集的数据。在所有国家，图片日记报告的食品、非食品/非健康物品、医疗保健的月人均平均支出以及因此的家庭总支出一直高于调查所报告的支出（每个p<0.001）。医疗保健支出的差异最大。分配给医疗保健的家庭总支出份额也因方法而异，使用调查数据时在每个国家占2%，使用日记数据时占8 - 20%。我们的研究结果表明，数据收集方法的选择可能对估计家庭自付医疗费用及其给家庭带来的负担具有重大影响。尽管实施图片日记存在一些实际挑战，但图片日记提供了一种评估调查中潜在偏差或对来自多个来源的数据进行三角测量的方法。在考虑使用图片日记来估计家庭支出时，我们提供了一些实用指南。
