Elsevier

Social Science & Medicine

Volume 58, Issue 2, January 2004, Pages 247-258
Social Science & Medicine

Poverty, out-of-pocket payments and access to health care: evidence from Tajikistan

https://doi.org/10.1016/S0277-9536(03)00008-XGet rights and content

Abstract

Most countries of the Former Soviet Union (FSU) have either initiated or are contemplating reform of the health sector. With negative real income growth and falling government revenues, a key concern of many governments is to secure additional finance through non-budgetary sources such as hypothecated payroll taxes, voluntary insurance, and increased private finance through patient cost-sharing. However, before such reforms can be considered, information is needed both on the current levels and distribution of household expenditures on health care, and the extent to which increased charges may affect access to health services, especially amongst the poor. This paper uses the Tajikistan Livings Standard Survey to investigate the level and distribution of out-of-pocket payments for health care in Tajikistan and to examine the extent to which such payments act as barriers to health-care access. The data show that there are significant differences in health-care utilisation rates across socio-economic groups and that these differences are related to ability to pay. Official and informal payments are acting both to deter people from seeking medical assistance and once advice has been sought, from receiving the most appropriate treatment. Despite informal exemptions, out-of-pocket payments for health care are exacting a high toll on household welfare with households being forced to sell assets or go into debt to meet the costs of care. Urgent action is needed to ensure equity in access to health care.

Introduction

Most countries of the Former Soviet Union (FSU) have either initiated or are contemplating reform of the health sector. With negative real income growth and falling government revenues, a key concern of many governments is to secure additional finance for health-care services through non-budgetary sources such as hypothecated payroll taxes, voluntary insurance, and increased private finance through patient cost-sharing. Alongside this, there is now a growing recognition that informal payments for health-care constitute a significant component of overall spending on health care in the FSU (Ensor & Savelyeva, 1998) and that such payments constitute a major impediment to health-care reform (Lewis, 1999). An attractive policy solution is to legitimise these informal payments and to incorporate them into the formal health-care financing stream (Delcheva, Balabanova, & McKee, 1997). This implies a much greater role for user charges than in the past. However before such reforms can be considered, information is needed both on the current levels and distribution of household expenditures on health care, and the extent to which increased charges may influence access to health care, especially amongst the poor. Given the importance of informal payments surprisingly little is known about them. This paper goes some way towards rectifying this by using the Tajikistan Livings Standard Survey to investigate the level and distribution of out-of-pocket payments for health care in Tajikistan and to examine the extent to which such payments are giving rise to inequalities in access to health care.

Section snippets

Background

At Independence in 1991, Tajikistan—located in the south-eastern corner of Central Asia, just north of Afghanistan—was the poorest of all the Soviet Republics, with a GDP per capita of just over USD$2000. Despite this, the country had relatively high human development indicators, reflecting the legacy of social development achieved during the Soviet period. Life expectancy at birth averaged 70 years and adult literacy was almost universal. In common with other countries of the Soviet Union, the

Data

The research in this paper is based on preliminary analysis of the Tajikistan Living Standards Survey (TLSS), a nationally representative household survey conducted in May 1999. Data on a wide range of demographic and socio-economic characteristics was collected from 2000 households containing 14,142 individuals. The health module included questions on whether each household member was perceived to have suffered from a chronic illness in the last 6 months or an acute illness or injury in the

Health status and health seeking behaviour

Health status varied by age and gender (Table 2). The majority of people in Tajikistan reported that their health status over the last year was ‘good’ or ‘very good’. Not surprisingly prevalence of both chronic and acute morbidity increased with age, and women generally reported higher levels of morbidity than men in the same age group.

Overall, a relatively low proportion of the overall population (6%) sought medical assistance in the 2 weeks prior to the survey or reported being hospitalised

Poverty and utilisation of health-care services

The findings from Table 3 already point to inequalities in access to health care in Tajikistan. In Table 5 the relationships between the financial resources of the household and health status and health seeking behaviour are examined. Households are ranked by total household expenditure (including the imputed value of home production, gifts and humanitarian assistance), and adjusted for household size. Those individuals living households in the bottom 20% of the distribution are viewed to be

Consultations

In principle consultations with state medical practitioners remain free but, as government subsidies for the health sector have declined, patients have increasingly been obliged to supplement inadequate health budgets by contributing informal payments. Although there is a tradition in Central Asia and the Caucasus of presenting monetary or in-kind gifts to caregivers as a mark of gratitude, this voluntary tradition is being supplanted by provider generated demands for payment as a precondition

Informal payments elsewhere in Central Asia

The situation in Tajikistan is not unique. Evidence, both empirical and anecdotal, suggests that informal payments for health care are widespread elsewhere in Central Asia, as very low salaries combined with generally low morale in the health sector have made the practice of charging patients almost universal. An in-depth study undertaken in a rural district of Turkmenistan found that over half of all respondents had paid a health-care professional for services in additional to the customary

Discussion

It is clear that private payments are now making a significant contribution to the costs of health care throughout the FSU. Indeed in Tajikistan it is estimated that households spend an average of US $8.58 per person per year on health care compared with per capita government expenditure on health of just US $3.75. Thus, out-of-pocket payments constitute two-thirds of all health spending (World Bank, 1999). However, the present system of unregulated prescription charges and payments for

Acknowledgements

The evidence presented in this paper is based upon an analysis of the Tajikistan Living Standards Survey, conducted by a team of national experts during May 1999 and sponsored by UNDP and the World Bank. The author wishes to acknowledge the indispensable contribution of the country researchers, particularly Barot Tureav, Deputy Director of the State Statistical Agency of Tajikistan, and Firuz Saidov, Deputy Director of the Centre for Strategic Studies, Dushanbe. Heartfelt thanks are also due to

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