Background
Methods
Data
Definition of key variables
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Seeking care when ill: a person was defined as seeking care when s/he reported seeking a consultation at any kind of healthcare provider in the 30 days prior to the survey.
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Seeking medical care: defined as seeking care at a public or private medical provider, thereby excluding the non-medical sector. Because up to two providers have been recorded for each care-seeking incidence since 2009, if either of those visits was to a public or private medical provider then it was considered to be medical care.
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Provider type: respondents reported the kind of healthcare provider for the first visit and (if more than one visit) the last visit only. The analysis combined all healthcare providers into eight categories, which are comparable across all years. The categories include: public health centres; public hospitals; private hospitals; private clinics; pharmacies and stores selling drugs; home care; traditional healers; and other providers. In addition to these eight categories, results were also more broadly categorised in public providers, private providers, and non-medical providers.
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Severity of illness: reported illnesses were categorised as mild, severe or chronic, with mild implying that the illness did not stop the individual from performing usual activities, while severe meant the inability to performing such activities for at least one day in the last 14 days. A condition was considered chronic or non-communicable if the individual suffered from this condition for more than one year.
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Disability: a person was considered disabled – defined in CSES as restricted or unable to perform an activity in a manner considered normal – when reporting one or more difficulties out of a list of nine activities (seeing; hearing; speaking; moving; feeling or sensing; psychological or behavioural functioning; learning; fits; and others). We removed seeing difficulties, as the rate was inconsistently high in 2009 (2.2 %, compared to 0.62 and 0.70 % in 2004 and 2014, respectively).
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Out-of-pocket health expenditures: defined as the total expenditures on health-related services, supplies and products in the 30 days prior to the survey. Expenditures were converted to monthly values by multiplying by 30.4.
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Health-related transportation expenditures: defined as the amount spent on transportation for healthcare seeking in the 30 days before the survey. This metric was only included in the CSES from 2009 onwards. These values were similarly converted to monthly values by multiplying by 30.4.
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Consumption: the sum of purchases, as well as the value of the consumption of one’s own produce, and goods received as gifts.
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Subsistence consumption: a food share-based reference line was used to estimate household subsistence expenditures. This reference line was defined as the weighted average of equalised food expenditures for households whose food expenditures as a share of total household expenditures were between the 45th and 55th percentile of the population.
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Capacity to pay (CTP): defined as a household’s non-subsistence spending, which equals the monthly household consumption minus subsistence expenditures. For households with food expenditures lower than their subsistence spending, non-food expenditures were considered as non-subsistence spending.
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Out-of-pocket health expenditures (OOPE): the sum of all household members’ expenditures on health care in the month preceding the survey.
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Catastrophic health expenditures: when the sum of a household’s total out-of-pocket health expenditures equals or exceeds a threshold of the household’s capacity to pay or non-subsistence spending. We used two different thresholds: 40 and 10 %.
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Impoverishment: a non-poor household is impoverished by health payments if it falls below the poverty line after deducting health expenditures. The national poverty line set by the Ministry of Planning for rural and urban settings were used.
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Indebtedness: defined as having at least one active loan whose main purpose was to pay for the care of an illness, injury or accident.
Statistical analysis
Results
Trends among older people: 2004-14
Demographics and health care utilisation
Variable | 2004 | 2009 | 2014 |
---|---|---|---|
Households | 11,993 | 11,971 | 12,090 |
Response rates (%) | 99.89 | 99.76 | 99.95 |
Individuals | 59,852 | 57,105 | 53,968 |
0–59 years (%) | 94.7 | 93.1 | 92.9 |
≥ 60 years (%) | 5.3 | 6.9 | 7.1 |
Gender people aged ≥ 60 years | |||
Men | 41.5 | 42.7 | 40.7 |
Women | 58.5 | 57.3 | 59.3 |
Mean age in years [SD] | |||
0–59 years | 21.4 [15.1] | 23.3 [15.6] | 24.8 [16.1] |
≥ 60 years | 68.8 [6.9] | 68.9 [7.4] | 68.8 [7.3] |
Households with older people (in %) | |||
One or more older people | 24.2 | 25.7 | 28.8 |
1 older person | 18 | 17.6 | 18.8 |
2 older persons | 6.2 | 5.9 | 7.4 |
Older people living alone (%) | 2.7 | 3.3 | 3.8 |
Having a disability only (%) | |||
0–59 years | 2.2 | 1.9 | 1.2 |
≥ 60 years | 18.1 | 12.1 | 8.3 |
Having NCD only (%) | |||
0–59 years | NA | 1.7 | 1.6 |
≥ 60 years | NA | 8.4 | 9.7 |
NCD and disability (%) | |||
0–59 years | NA | 0.4 | 0.3 |
≥ 60 years | NA | 5.6 | 3.7 |
Access to drinking water (%) | |||
0–59 years | 54.2 | 44.5 | 51.7 |
≥ 60 years | 54.7 | 45.6 | 52.0 |
Have toilet (%) | |||
0–59 years | 25.1 | 37.1 | 58.6 |
≥ 60 years | 26.2 | 42.6 | 64.1 |
Variable | 2004 | 2009 | 2014 |
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Incidence of illness in last 30 days | |||
People ≥ 60 years | 38.6 | 33.7 | 34.7 |
People < 60 years | 16.8 | 13.0 | 13.0 |
Seeks care when sick | |||
People ≥ 60 years | 86.7 | 92.2 | 97.3 |
People < 60 years | 90.8 | 91.3 | 98.2 |
Seeks medical care | 49.0 | 70.1 | 85.9 |
At public health facility | 10.7 | 18.4 | 23.4 |
At private provider | 31.9 | 56.9 | 64.1 |
OOPE for those seeking carea
| |||
People ≥ 60 years | 16.8 | 25.6 | 36.6 |
People < 60 years | 12.8 | 18.6 | 26.0 |
Transport for those who sought carea
| |||
Rural | NA | 2.8 | 3.9 |
Urban | NA | 1.6 | 5.1 |
Out-of-pocket health expenditures
Variable | 2004 | 2009 | 2014 |
---|---|---|---|
Capacity to pay (US$)a
| |||
Households without older people | 107.8 | 162.0 | 199.7 |
Households with older people | 102.1 | 164.2 | 189.6 |
Rural | 80.4 | 122.7 | 158.0 |
Urban | 221.5 | 345.4 | 308.4 |
Out-of-pocket payments as proportion of capacity to pay (%) | |||
Households without older people | 8.0 | 6.2 | 6.5 |
Households with older people | 10.8 | 9.7 | 9.6 |
Rural | 11.1 | 10.7 | 10.6 |
Urban | 9.3 | 5.5 | 5.9 |
Catastrophic expenses at 40 % threshold (%) | |||
Households without older people | 6.4 | 4.3 | 4.3 |
Households with older people | 9.2 | 7.7 | 6.5 |
Rural | 9.6 | 8.7 | 7.2 |
Urban | 7.3 | 3.1 | 3.6 |
Catastrophic expenses at 10 % threshold (%) | |||
Households without older people | 21.7 | 17.9 | 18.3 |
Households with older people | 29.3 | 27.6 | 28.3 |
Rural | 30.0 | 30.0 | 31.1 |
Urban | 25.5 | 16.7 | 17.7 |
Impoverishment (%) | |||
Households without older people | 3.2 | 2.3 | 0.9 |
Households with older people | 4.6 | 2.8 | 1.0 |
Rural | 4.8 | 3.0 | 0.9 |
Urban | 3.3 | 2.2 | 1.3 |
Indebted for paying health care costs (%) | |||
Households without older people | 5.0 | 4.0 | 2.5 |
Households with older people | 4.8 | 3.3 | 2.2 |
Rural | 5.3 | 3.6 | 2.5 |
Urban | 2.0 | 2.0 | 1.0 |
Determinants of catastrophic health expenditures for households with older people
Variables | 40 % Threshold | 10 % Threshold |
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OR (T-statistics) | ||
Household size | 0.94 (−1.29) | 0.94 (−2.01)* |
Number of children under five years old | 1.29 (1.37) | 1.48 (3.82)** |
Number of older members | 1.30 (1.43) | 1.28 (2.08)* |
Age head of household | 1.01 (1.34) | 1.01 (1.60) |
Education of head of household | ||
Primary education or more | 1.00 (.) | 1.00 (.) |
Less than primary education | 1.00 (−0.02) | 1.33 (2.28)* |
Gender of head of household | ||
Female | 1.00 (.) | 1.00 (.) |
Male | 0.71 (−1.74) | 0.84 (−1.32) |
Place of residence | ||
Urban | 1.00 (.) | 1.00 (.) |
Rural | 2.81 (3.09)** | 2.99 (5.83)** |
Household with priority access card | ||
No priority access card | 1.00 (.) | 1.00 (.) |
Priority access card | 1.43 (1.47) | 1.08 (0.44) |
Household member with a mild illness | ||
None | 1.00 (.) | 1.00 (.) |
At least one | 1.95 (2.83)** | 6.48 (15.06)** |
Household member with severe illness | ||
None | 1.00 (.) | 1.00 (.) |
At least one | 2.45 (3.84)** | 5.16 (7.77)** |
Household member with a disability | ||
None | 1.00 (.) | 1.00 (.) |
At least one | 1.02 (0.08) | 1.24 (1.60) |
Household member with a chronic disease | ||
None | 1.00 (.) | 1.00 (.) |
At least one | 5.04 (7.16)** | 13.85 (18.78)** |
Access to improved water source | ||
Unimproved | 1.00 (.) | 1.00 (.) |
Improved | 0.88 (−0.66) | 0.95 (−0.50) |
Household having a toilet | ||
No access | 1.00 (.) | 1.00 (.) |
Access | 0.54 (−3.16)** | 0.97 (−0.25) |
Remittances from relatives | ||
No remittances | 1.00 (.) | 1.00 (.) |
Receives remittances | 1.15 (0.75) | 1.15 (1.29) |
Pension, social welfare benefits | ||
No pension or social welfare benefits | 1.00 (.) | 1.00 (.) |
Receives pension or social welfare benefits | 0.63 (−1.05) | 0.73 (−1.16) |
Transfers from NGO or other institutions | ||
No transfers | 1.00 (.) | 1.00 (.) |
Receives transfers | 0.57 (−0.86) | 0.73 (−0.87) |