Taslima Rahman

Background
Urban-rural inequality in accessing quality antenatal care (ANC) is a well-documented challenge in low- and middle-income countries like Bangladesh and Pakistan, hindering maternal healthcare utilization and progress towards the Sustainable Development Goals. This study explores the key factors contributing to this inequality in Bangladesh and Pakistan and highlights inter-country differences.

Methods
We analyzed data from Demographic Health Surveys (2017–2018) of Bangladesh and Pakistan for women aged 15–49 who had at least one live birth in the three years preceding the survey. To identify the extent and sources of inequality, we decomposed urban-rural differences in quality ANC utilization into explained (attributable to variations in socioeconomic and demographic characteristics) and unexplained (reflecting differences in the effects of these characteristics) components using Blinder-Oaxaca type models adapted for nonlinear response variables.

Results
Urban women were significantly more likely to receive quality ANC than rural women in both Bangladesh and Pakistan, with disparities of about 20%-25% points. Most of the inequality was explained by differences in socioeconomic and educational characteristics rather than behavioral factors. Wealth status was the dominant contributor, explaining nearly 58% of the inequality in Bangladesh and 46% in Pakistan, followed by women’s and husbands’ education, media exposure, and women’s autonomy. The pattern of predictors was broadly consistent across both countries, though education contributed more in Pakistan, while media exposure and husband’s education played a larger role in Bangladesh.

Conclusion
Significant urban-rural inequality exists in Bangladesh and Pakistan, which is more pronounced in Pakistan. Among the common significant predictors for both countries, wealth disparity has the highest contribution percentage. In Pakistan, women’s education is the second largest contributor to inequality, whereas in Bangladesh, both media exposure and husband’s education played notable roles. Reducing urban-rural inequality in quality ANC requires targeted policies addressing wealth and educational disparities, along with interventions that promote media access and women’s autonomy to ensure equitable maternal healthcare utilization.

Abstract
Background

The burden of out-of-pocket (OOP) healthcare expenses for pregnancy-related conditions is a significant concern in resource-prone countries. Bangladesh and Pakistan, two historically connected countries with similar socioeconomic standings, rank among the highest globally in OOP share in total health expenditures. Excessive OOP costs pose financial barriers to maternal healthcare utilisation, leading to catastrophic health expenditures (CHE) and deepening poverty. Our study aims to compare pregnancy-related OOP expenditures between Bangladesh and Pakistan, examining key disparities in spending patterns and financial burden.

Methods

This study utilises data from the Bangladesh Household Income and Expenditure Survey (HIES) 2022 and published secondary evidence for Pakistan in the absence of primary data. For Bangladesh, we included all women of reproductive age who reported pregnancy-related health issues in the past 30 days or were hospitalised in the last 12 months. We estimated the share of OOP in total household expenditure on pregnancy-related healthcare, assessed CHE using budget share, actual, and normative food expenditure methods, and evaluated impoverishment effects. Descriptive and equity-based analyses were conducted to examine expenditure variations across socioeconomic groups.

Results

In Bangladesh, pregnancy-related OOP expenditures (USD 434.4) accounted for 50% of total household healthcare spending (USD 892.6). The share of OOP in total household expenditure was significantly higher for private healthcare facilities (USD 417.1) and among rural women (USD 384.8). Low-income households spent a greater proportion (two-thirds) of their total expenditure on pregnancy-related care. The CHE incidence was around 94.6%-80.9% among the lowest quintile households and 26.8%-66.5% among rural households under normative capacity-to-pay (CTP) method. Impoverishment rates were highest, with 31.7% low-income and 3.9% rural households falling into poverty due to OOP expenses. In Pakistan, OOP costs for pregnancy care were significantly higher in private facilities (USD 209.88-255.49) than in public facilities (USD 23.30-63.87).

Conclusion

Pregnancy-related OOP healthcare costs constitute a significant financial burden in Bangladesh and Pakistan, with higher expenses in private facilities. Low-income and rural families in Bangladesh face the greatest hardship, often leading to financial catastrophe and poverty. Strengthening public healthcare funding, expanding maternal health insurance, and regulating private sector pricing could reduce OOP costs and improve maternal healthcare equity.

Background Rural‒urban disparity in catastrophic healthcare expenditure (CHE) is a well-documented challenge in low-and middle-income countries, including Bangladesh, limiting financial protection and hindering the achievement of the Universal Health Coverage target of the United Nations Sustainable Development Goals. However, the factors driving this divide remain poorly understood. Therefore, this study aims to identify the key determinants of the rural‒urban disparity in CHE incidence in Bangladesh and their changes over time. Methods We used nationally representative data from the latest three rounds of the Bangladesh Household Income and Expenditure Survey (2005, 2010, and 2016). CHE incidence among households seeking healthcare was measured using the normative food, housing, and utilities method. To quantify covariate contributions to the rural‒urban CHE gap, we employed the Oaxaca-Blinder multivariate decomposition approach, adapted by Powers et al. for nonlinear response models. Results CHE incidence among rural households increased persistently during the study period (2005: 24.85%, 2010: 25.74%, 2016: 27.91%) along with a significant (p-value ≤ 0.01) rural‒urban gap (2005: 9.74%-points, 2010: 13.94%-points, 2016: 12.90%-points). Despite declining over time, substantial proportions of CHE disparities (2005: 87.93%, 2010: 60.44%, 2016: 61.33%) are significantly (p-value ≤ 0.01) attributable to endowment differences between rural and urban households. The leading (three) covariate categories consistently contributing significantly (p-value ≤ 0.01) to the CHE gaps were composition disparities in the lowest consumption quintile (2005: 49.82%, presence of chronic illnesses in households emerged as a significant factor in 2016 (9.14%, p-value ≤ 0.01), superseding the contributions of composition differences in household heads with no education (4.40%, p-value ≤ 0.01) and secondary or higher education (7.44%, p-value ≤ 0.01), which were the fourth and fifth significant contributors in 2005 and 2010. Conclusions Rural‒urban differences in household economic status, educational attainment of household heads, and healthcare sources were the key contributors to the rural‒urban CHE disparity between 2005 and 2016 in Bangla-desh, with chronic illness emerging as a significant factor in the latest period. Closing the rural‒urban CHE gap necessitates strategies that carefully address rural‒urban variations in the characteristics identified above.

This study assesses the financial risk protection (FRP) of heart disease‐affected households in Bangladesh by analyzing three rounds of Household Income and Expenditure Survey data (2005, 2010, and 2016). Amidst a global surge in cardiovascular diseases, particularly in low‐ and middle‐income countries, Bangladesh encounters an escalating burden of heart disease, with an over‐reliance on out‐of‐pocket (OOP) healthcare expenses. Our findings reveal a substantial increase in annual OOP spending for households affected by heart disease, from USD 307.4 in 2005 to USD 346.1 in 2010, and then surging to USD 650.5 in 2016. Concurrently, catastrophic health expenditure (CHE) and impoverish-ment incidences rose (17.6% to 18.2% to 29.3% and 3.2% to 2.2% to 3.3%, respectively), with a notable increase post‐2010. These expenses and CHE incidences were consistently higher than those in households with any ailment, underscoring a disparity in FRP, especially among economically disadvantaged, rural households and those headed by individuals without formal education. The study contributes to the literature by providing a first‐time analysis of FRP dynamics against heart disease in Bangladesh using comprehensive national data. It uncovers the worsening FRP status among affected households and highlights the need for targeted interventions to enhance FRP, particularly among the most vulnerable groups. Additionally, it emphasizes the importance of strategic public health investments to mitigate the financial repercussions of heart disease care, providing insights that are globally applicable to similar contexts.

Background

The importance of non-communicable diseases (NCDs) in Nigeria is reflected in their growing burden that is fast overtaking that of infectious diseases. As most NCD care is paid for through out-of-pocket (OOP) expenses, and NCDs tend to cause substantial income losses through chronic disabilities, the rising NCD-related health burden may also be economically detrimental. Given the lack of updated national-level evidence on the economic burden of NCDs in Nigeria, this study aims to produce new evidence on the extent of financial hardship experienced by households with NCDs in Nigeria due to OOP expenditure and productivity loss.

Methods

This study analysed cross-sectional data from the most recent round (2018–19) of the Nigeria Living Standard Survey (NLSS). Household-level health and consumption data were used to estimate catastrophic health expenditure (CHE) and impoverishing effects due to OOP health spending, using a more equitable method recently developed by the World Health Organization European region in 2018. The productivity loss by individuals with NCDs was also estimated from income and work-time loss data, applying the input-based human capital approach.

Results

On average, a household with NCDs spent ₦ 122,313.60 or $ 398.52 per year on NCD care, representing 24% of household food expenditure. The study found that OOP on cancer treatment, mental problems, and renal diseases significantly contribute to the cost of NCD care. The OOP expenditure led to catastrophic and impoverishing outcomes for households. The estimations showed that about 30% of households with NCDs experienced CHE in 2018, using the WHO Europe method at the 40% threshold. The study also found that the cost of NCD medications was a significant driver of CHE among NCD-affected households. The results showed heterogeneity in CHE and impoverishment across states and geographical regions in Nigeria, with a higher concentration in rural and North East geopolitical locations. The study also found that 20% of NCD-affected households were impoverished or further impoverished by OOP payment, and another 10% were on the verge of impoverishment. The results showed a negligible rate of unmet needs among households with NCDs.

Conclusions

The study highlights the significant effect of NCDs on Nigerian households and the need for effective policy interventions to address this challenge, particularly among the poor and vulnerable.

This study surveys 622 Bangladeshi civil servants of all administrative jurisdictions and elicits their preference for health insurance schemes. The latter vary in the amount of sum assured as well as in terms of premium sharing rules with the government. The paper also explores the financial burden that the premium subsidy may impose on the exchequer and the state’s fiscal capacity to shoulder it. We discover a very high willingness to join the scheme. Though all three premium-sharing options posit flat rates common for all employment ranks, respondents appear to prefer premiums proportional to their basic salary.

Background

Ensuring financial risk protection in health care and achieving universal health coverage (UHC) by 2030 is one of the crucial Sustainable Development Goals (SDGs) targets for many low- and middle-income countries (LMICs), including Bangladesh. We examined the critical trajectory of financial risk protection against out-of-pocket (OOP) health expenditure in Bangladesh.

Methods

Using Bangladesh Household Income and Expenditure Survey data from 2005, 2010, and 2016, we examined the levels and distributions of catastrophic health expenditure (CHE) and impoverishment incidences. We used the normative food, housing, and utilities method, refining it by categorizing households with zero OOP expenses by reasons.

Results

OOP expenditure doubled between 2005 and 2016 (USD 115.6 in 2005, USD 162.1 in 2010, USD 242.9 in 2016), accompanied by rising CHE (11.5% in 2005, 11.9% in 2010, 16.6% in 2016) and impoverishment incidence (1.5% in 2005, 1.6% in 2010, 2.3% in 2016). While further impoverishment of the poor households due to OOP expenditure (3.6% in 2005, 4.1% in 2010, 3.9% in 2016) was a more severe problem than impoverishment of the non-poor, around 5.5% of non-poor households were always at risk of impoverishment. The poorest households were the least financially protected throughout the study period (lowest vs. highest quintile CHE: 29.5% vs. 7.6%, 33.2% vs. 7.2%, and 37.6% vs. 13.0% in 2005, 2010, and 2016, respectively). The disparity in CHE among households with and without chronic illness was also remarkable in 2016 (25.0% vs. 9.1%).

Conclusion

Financial risk protection in Bangladesh exhibits a deteriorated trajectory from 2005 to 2016, posing a significant challenge to achieving UHC and, thus, the SDGs by 2030. The poorest and chronically ill households disproportionately lacked financial protection. Reversing the worsening trends of CHE and impoverishment and addressing the inequities in their distributions calls for implementing UHC and thus providing financial protection against illness.

Background

Demographic and epidemiological transitions are changing the disease burden from infectious to noncommunicable diseases (NCDs) in low- and middle-income countries, including Bangladesh. Given the rising NCD-related health burdens and growing share of household out-of-pocket (OOP) spending in total health expenditure in Bangladesh, we compared the country’s trends and socioeconomic disparities in financial risk protection (FRP) among households with and without NCDs.

Methods

We used data from three recent waves of the Bangladesh Household Income and Expenditure Survey (2005, 2010, and 2016) and employed the normative food, housing (rent), and utilities method to measure the levels and distributions of catastrophic health expenditure (CHE) and impoverishing effects of OOP health expenditure among households without NCDs (i.e. non-NCDs only) and with NCDs (i.e. NCDs only, and both NCDs and non-NCDs). Additionally, we examined the incidence of forgone care for financial reasons at the household and individual levels.

Results

Between 2005 and 2016, OOP expenses increased by more than 50% across all households (NCD-only: USD 95.6 to 149.3; NCD-and-non-NCD: USD 89.5 to 167.7; non-NCD-only: USD 45.3 to 73.0), with NCD-affected families consistently spending over double that of non-affected households. Concurrently, CHE incidence grew among NCD-only families (13.5% to 14.4%) while declining (with fluctuations) among non-NCD-only (14.4% to 11.6%) and NCD-and-non-NCD households (12.9% to 12.2%). Additionally, OOP-induced impoverishment increased among NCD-only and non-NCD-only households from 1.4 to 2.0% and 1.1 to 1.5%, respectively, affecting the former more. Also, despite falling over time, NCD-affected individuals more frequently mentioned prohibiting treatment costs as the reason for forgoing care than the non-affected (37.9% vs. 13.0% in 2016). The lowest quintile households, particularly those with NCDs, consistently experienced many-fold higher CHE and impoverishment than the highest quintile. Notably, CHE and impoverishment effects were more pronounced among NCD-affected families if NCD-afflicted household members were female rather than male, older people, or children instead of working-age adults.

Conclusions

The lack of FRP is more pronounced among households with NCDs than those without NCDs. Concerted efforts are required to ensure FRP for all families, particularly those with NCDs.