1. Access to health care, social protection, and household costs of illness proposal Cost of illness working group INDEPTH AGM 2009, Pune

2. Rationale 1.Illness is a major risk people’s livelihoods 2.Policies that reduce the costs of illness to households, to improve social protection from those costs, and to improve access to care… >> are key reducing the vulnerability of poor households, and to achieving the millennium development goals

3. Gaps in international knowledge Growing body of research, but 1.Often focus on a particular disease, not the full burden of all illnesses that a household has to cope in a particular time period; 2.Little information on transport costs, or on lost income 3.Little known about costs for different types of households in different settings 4.Few studies look at whether households are impoverished or not 5.Studies evaluate the coverage of social protection mechanisms but few examine whether they actually protect households.

4. Objectives of study 1.Measure household cost burdens of illness (loss of income and costs of seeking care) 2.Describe and explain household interactions with health system that generate those costs; 3.Determine extent to which existing health care financing or social protection mechanisms protect poor households from impoverishment due those costs >> sites in different country settings, with varying health care financing and social protection mechanisms…. 4.Contribute to national and international policy debates, providing policy recommendations as how to better protect poor households

5. Contrasting country contexts of sites Low & middle income; Africa & Asia Vietnam & Ghana – health insurance that covers more than 50% of population, but… Bangladesh – nominal fee for tax funded health care, but unofficial fees common; India & Burkina Faso– majority pay ‘out of pocket’ Tanzania – community health funds, but coverage is low…. (Agincourt / South Africa – already conducted study)

6. Conceptual framework: How the health system & health financing might lead to impoverishment Box 1: Health care financing mechanisms (user fees, informal fees, exemptions, community or social insurance, or free care); Availability of other social protection measures such as cash transfers; Availability of services; Acceptability of care; Box 6: Household Livelihood (assets, income, debt & access to basic needs) Box 2: Illness occurrence Box 5: Financial Coping strategies (borrowing, selling assets, reducing other basic needs expenditure ) Box 3: Health seeking behaviour & treatment strategies, (delaying or not seeking care, ‘healer shopping’, cheaper sources of care, taking partial doses ) Box 4: Health care expenditure & income losses Household Health system

7. Study design and methods: Phase 1 Cross-sectional household survey, random sample in each site, stratified by SES (n=1000 households), structured questionnaire Level of costs as a proportion of household expenditure over one month; Morbidity and treatment actions associated with costs; Access to social protection mechanisms & livelihood impact;

8. Study design and methods: Phase 2 30 case study households in each site, followed over 12 months Qualitative and quantitative data Descriptive data to understand how and why household choose the actions that generate costs Explanatory data describing household interactions with health system & processes associated with social protection Assessment of livelihood impact over time

9. Strengths of methodological approach 1.Frequency based estimates of costs combined with rich textual data to explain causal processes 2.Comparison of very different country settings; 3.Often comparing rural and urban within the same country; 4.Sampling of households based on the rigorous surveillance data of the sites

10. Answering policy questions 1.Are exemptions reaching the intended beneficiaries; if not, why not? 2.Is free care sufficient to protect poor households, and under what circumstances? What is the impact of unofficial fees? 3.What aspects of poor service delivery drive up costs? 4.Is insurance providing the expected protection, and if not, why not? >> policy recommendations better protect poor households, in different settings, from illness related impoverishment?

11. Policy engagement Growing focus on best practise in translating of research to policy & practice 1.Sites provided evidence that national stakeholders see these issues as important; 2.Engage at beginning of study, & shape study to meet local needs; 3.Develop local communication / knowledge exchange strategies tailored to local needs; 4.Sharing strategies across sites;

12. Thank you to all the individuals and sites who have contributed towards developing this proposal….