Rabbani Md Golam, Hasan Md Zahid, Mehdi Gazi Golam, Ahmed Mohammad Wahid, Amin Md Nurul, Mahmud Mohammad Shahadt Hossain, Islam Ziaul, Mahmood Shehrin Shaila
Health Economics and Financing, Health Systems and Population Studies Division, icddr,b, 68 Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh.
Health Economics Unit, Health Services Division, Ministry of Health & Family Welfare, Dhaka, Bangladesh.
BMC Health Serv Res. 2025 Aug 5;25(1):1030. doi: 10.1186/s12913-025-13168-9.
In Bangladesh, households' out-of-pocket (OOP) health expenditure accounts for 68.5% of the total health expenditure. The Government of Bangladesh has been implementing a pilot health protection scheme called Shasthyo Surokhsha Karmasuchi (SSK) to protect the below-poverty-line population from higher financial burdens in accessing inpatient care since 2016. This study aimed to estimate and compare the OOP expenditures between patients enrolled in the SSK scheme and those not enrolled and identify the factors influencing OOP expenditures for inpatient care in Bangladesh.
We conducted a quasi-experimental study using an exit patient survey in 2021. A predefined standard method was used to identify the study population and among them, 314 randomly selected patients were interviewed. Simple statistics measures were employed for data presentation. The Kruskal-Wallis test and Wilcoxon Rank Sum test, and multiple log-linear regression models were applied to assess the effect of the SSK scheme and identify influencing factors. The regression results were then converted into exponentiated coefficients to facilitate interpretation of the effects on OOP health expenditures.
The SSK patients incurred significantly lower OOP health expenditures, 3.15 times compared to non-SSK patients seeking inpatient care at SSK facilities, and 3.92 times compared to non-SSK patients at non-SSK facilities. After adjusting for covariates, SSK patients still had significantly reduced OOP health expenditures, 3.71 times lower compared to non-SSK patients at SSK facilities, and 4.36 times lower compared to non-SSK patients at non-SSK facilities. The difference in OOP payment for inpatient care across patient groups was led by direct medical OOP expenditure components. The medicine component was identified as the main driver of the OOP expenditure across patient groups. Residents of town and patients who stayed a single night at hospital experienced significantly reduced OOP expenditures for inpatient care. Among other variables, residents of towns and patients who stayed a single night at the health facility had significantly lower OOP expenditures for inpatient care.
The findings suggest that the SSK scheme reduces OOP expenses for beneficiaries and has a spill-over effect on non-beneficiaries. Ensuring service availability and accessibility is crucial for maximizing its benefits. Given its positive impact, scaling up SSK could further reduce OOP nationally and support the government's health financing strategy (2012-2032).
在孟加拉国，家庭自付医疗支出占总医疗支出的68.5%。自2016年以来，孟加拉国政府一直在实施一项名为“Shasthyo Surokhsha Karmasuchi”（SSK）的试点健康保护计划，以保护贫困线以下人口在获得住院治疗时免受更高的经济负担。本研究旨在估计和比较参加SSK计划的患者与未参加该计划的患者之间的自付费用，并确定影响孟加拉国住院治疗自付费用的因素。
我们在2021年进行了一项采用出院患者调查的准实验研究。使用预定义的标准方法确定研究人群，并在其中随机选取314名患者进行访谈。采用简单统计方法呈现数据。应用Kruskal-Wallis检验、Wilcoxon秩和检验以及多重对数线性回归模型来评估SSK计划的效果并确定影响因素。然后将回归结果转换为指数系数，以便于解释对自付医疗支出的影响。
SSK患者的自付医疗支出显著更低，在SSK机构寻求住院治疗的SSK患者与非SSK患者相比，自付费用低3.15倍；在非SSK机构的SSK患者与非SSK患者相比，自付费用低3.92倍。在对协变量进行调整后，SSK患者的自付医疗支出仍然显著降低，在SSK机构的SSK患者与非SSK患者相比，自付费用低3.71倍；在非SSK机构的SSK患者与非SSK患者相比，自付费用低4.36倍。不同患者组住院治疗自付费用的差异主要由直接医疗自付费用部分导致。药品部分被确定为各患者组自付费用的主要驱动因素。城镇居民以及在医院仅住一晚的患者住院治疗的自付费用显著降低。在其他变量中，城镇居民以及在医疗机构仅住一晚的患者住院治疗的自付费用显著更低。
研究结果表明，SSK计划降低了受益人的自付费用，并对非受益人产生了溢出效应。确保服务的可获得性和可及性对于最大化其效益至关重要。鉴于其积极影响，扩大SSK计划的规模可以在全国范围内进一步降低自付费用，并支持政府的卫生筹资战略（2012 - 2032年）。
