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International Journal of Public Health

, Volume 56, Issue 4, pp 397–406 | Cite as

The inequity in out-of-pocket expenditures for healthcare in Tajikistan: evidence and implications from a nationally representative survey

  • Nazim N. HabibovEmail author
Original Article

Abstract

Objective

Out-of-pocket expenditures (OPE) for healthcare are a widespread and enduring phenomenon in post-communist countries. However, evidence regarding their effect on health equity is limited, especially in the low-income countries of Central Asia. With this in mind, the current paper presents the results of an analysis of the impact of OPE on equity in Tajikistan, one of the poorest transitional countries.

Methods

Utilizing a sample from a nationally representative household survey, this paper presents a systematic examination of the effect of OPE on equity using concentration curve, quintile analysis and concentration indices. The impact was disaggregated by inpatient and outpatient services, and medication purchase. Further disaggregation was performed according to spatial dimensions, by types of providers, condition or disease, by place of medication purchase, and by type of facility and treatment received.

Results

Overall, OPE in Tajikistan are equally distributed across the population, with the poorest and the wealthiest, in most cases, bearing a similar level of burden. However, the poor bear the heaviest burden in terms of expenditures for medication and other supplies in inpatient services. There is considerable spatial variation in the expenditures burden, with regional variation being more substantial than rural–urban variation. More importantly, the poor experience a larger proportion of burden with regard to expenditures in vital areas such as those of infectious diseases and maternal health.

Conclusions

While current economic constraints and the ongoing health sector reform in Tajikistan promote OPE for healthcare utilization, the lack of financial protection against the risk of these conditions should be of major concern to policy-makers. In particular, the problems of OPE, which have been found to place a higher burden on the poor, should be taken into consideration during healthcare reform in Tajikistan.

Keywords

Health policy Inequality Poverty Central Asia Tajikistan 

References

  1. Aarva P, Ilchenko I, Gorobets P, Rogacheva A (2009) Formal and informal payments in health care facilities in two Russian cities, Tyumen and Lipetsk. Health Policy Plan 24:395–405PubMedCrossRefGoogle Scholar
  2. Abdelkrim A, Duclos J-Y (2009) User manual for stata package DASP: version 2.1. PEP, CIRPEE. World Bank and United Nations Development Programme, MontrealGoogle Scholar
  3. Balabanova D, McKee M, Pomerleau J et al (2004) Health service utilization in the Former Soviet Union: evidence from eight countries. Health Serv Res 39:1927–1950PubMedCrossRefGoogle Scholar
  4. Belli P, Gotsadze G, Shahriari H (2004) Out-of-pocket and informal payments in health sector: evidence from Georgia. Health Policy 70:109–123PubMedCrossRefGoogle Scholar
  5. Bennett S, Kelley AG, Silvers B et al (2004) 21 Questions on CBHF. An overview of community-based health financing. Partners for Health Reformplus, BethesdaGoogle Scholar
  6. Bonilla-Chacin M, Murrugarra E, Temourov M (2005) Health care during transition and health system reform: evidence from the poorest CIS countries. Social Policy Admin 39:381–408CrossRefGoogle Scholar
  7. Carrin G, James C (2005) Social health insurance: key factors affecting the transition towards universal coverage. Int Soc Sec Rev 58:45–64CrossRefGoogle Scholar
  8. Carrin G, Zeramdini G, Musgrove P et al (2001) The impact of the degree of risk-sharing in health financing on health system attainment. HPN Discussion Paper, World Bank, Washington, DCGoogle Scholar
  9. Cockcroft A, Andersson A, Paredes-Solís S et al (2008) An inter-country comparison of unofficial payments: results of a health sector social audit in the Baltic States. BMC Health Serv Res 8:1–12CrossRefGoogle Scholar
  10. Ekman B (2004) Community-based health insurance in low-income countries: a systematic review of the evidence. Health Policy Plan 19:249–270PubMedCrossRefGoogle Scholar
  11. Ensor T, Savelyeva L (1998) Informal payments for healthcare in the former Soviet Union: some evidence from Kazakhstan. Health Policy Plan 13:41–49PubMedCrossRefGoogle Scholar
  12. Falkingham J (2004) Poverty, out-of-pocket payments and access to health care: evidence from Tajikistan. Soc Sci Med 58:247–258PubMedCrossRefGoogle Scholar
  13. Fan L, Habibov N (2009a) Determinants of accessibility and affordability of health care in post-socialist Tajikistan: evidence and policy options. Global Public Health 4:561–574PubMedCrossRefGoogle Scholar
  14. Fan L, Habibov N (2009b) Determinants of maternity health care utilization in Tajikistan: learning from a national living standards survey. Health Place 16:952–960CrossRefGoogle Scholar
  15. Gaal P, McKee M (2006) Informal payment for health care and the theory of “INXIT”. Int J Health Plann Manage 19:163–178CrossRefGoogle Scholar
  16. Gaal P, Evetovits T, McKee M (2006) Informal payment for health care: evidence from Hungary. Health Policy 77:86–102PubMedCrossRefGoogle Scholar
  17. Gotsadze G, Bennett S, Ranson K, Gzirishvili D (2005) Health care-seeking behaviour and out-of-pocket payments in Tbilisi, Georgia. Health Policy Plan 20:222–242CrossRefGoogle Scholar
  18. Government of Tajikistan (2005) Poverty reduction strategy paper, Second Progress Report. Government of the Republic of Tajikistan, DushanbeGoogle Scholar
  19. Habibov N (2009a) Determinants of out-of-pocket expenditures on prescribed medications in Tajikistan: implications for healthcare sector reform. J Health Org Manage 23:170–182CrossRefGoogle Scholar
  20. Habibov N (2009b) What determines healthcare utilization and related out-of-pocket expenditures in Tajikistan? Lessons from a national survey. Int J Public Health 54:260–266PubMedCrossRefGoogle Scholar
  21. Habibov N (2010) Hospitalization in Tajikistan: determinants of admission, length of stay, and out-of-pocket expenditures. Results of a national survey. Int J Health Plan Manage 25(3):251–269Google Scholar
  22. Kakwani N (1977) Application of Lorenz curves in economic analysis. Econometrica 32:77–91Google Scholar
  23. Konings P, Harper S, Lynch J, Berkvens D, Hosseinpoor A, Lorant V, Geckova A, Speybroeck N (2010) Analysis of socioeconomic health inequalities using the concentration index. Int J Public Health 55:71–74PubMedCrossRefGoogle Scholar
  24. Lohlein D, Jütting J, Wehrheim P (2003) Rural Russia in transition: what determines access to health care services? Post Sov Aff 19:80–94CrossRefGoogle Scholar
  25. McKee M, Figueras J, Laurent C (1998) Health sector reform in the former Soviet Republics of Central Asia. Int J Health Plan Manage 13:131–147CrossRefGoogle Scholar
  26. Mirzoev T, Green A, Newell J (2007) Progress towards health reforms in Tajikistan. J Health Organ Manage 24:495–505CrossRefGoogle Scholar
  27. O’Donnell O, van Doorslaer E, Wagstaff A, Lindelow M (2008) Analyzing health equity using household survey data. World Bank, WashingtonGoogle Scholar
  28. Parfitt B, Cornish F (2007) Implementing family health nursing in Tajikistan: from policy to practice in primary health care reform. Soc Sci Med 65:1720–1729PubMedCrossRefGoogle Scholar
  29. Poletti T, Balabanova D, Ghazaryan O, Kocharyan H, Hakobyan M, Arakelyan K, Normand C (2007) The desirability and feasibility of scaling up community health insurance in low-income settings: lessons from Armenia. Soc Sci Med 64:509–520PubMedCrossRefGoogle Scholar
  30. Polonsky J, Balabanova D, McPake B, Poletti T, Vyas S, Ghazaryan O, Yanni MK (2009) Equity in community health insurance schemes: evidence and lessons from Armenia. Health Policy Plan 24:209–216PubMedCrossRefGoogle Scholar
  31. Sari N, Langenbrunner J, Lewis M (2000) Affording out-of-pocket payments for health services: evidence from Kazakhstan. Eurohealth 16:37–39Google Scholar
  32. Szende A, Culyer A (2006) The inequity of informal payments for health care: the case of Hungary. Health Policy 75:262–271PubMedCrossRefGoogle Scholar
  33. Thompson R, Witter S (2000) Informal payments in transitional economies: implications for health sector reforms. Int J Health Plan Manage 15:169–187CrossRefGoogle Scholar
  34. van Doorslaer C, Masseria C, Koolman X (2006) Inequalities in access to medical care by income in developed countries. Can Med Assoc J 174:177–183CrossRefGoogle Scholar

Copyright information

© Swiss School of Public Health 2010

Authors and Affiliations

  1. 1.School of Social Work, University of WindsorWindsorCanada

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