Abstract
Background:
For effective policy making, it is important to understand out of pocket costs incurred in neonatal admissions in public hospitals. This cross sectional study was conducted with an objective to estimate out of pocket expenses expended on neonates and attenders during neonatal hospitalizations in a tertiary care referral hospital.
Material and Methods:
The data were collected using a pretested and semi structured questionnaire in 298 neonates during July’2022. Expenditures were reported as median values with interquartile range (IQR) and compared using the Kruskal Wallis test.
Result:
On analyzing the results, there were no direct medical costs. The median cost spent on food per day, transport during the stay, non medical expenses per day, and total expenses per day were Rs. 300 (IQR 200, 500), Rs. 1000 (500, 1500), Rs. 500 (333, 896), and Rs. 1080 (800, 1533), respectively. Higher expenses were associated with preterm, low birth weight, neonatal seizures, and longer stay (P values <0.001, 0.028, <0.001, and <0.001, respectively). About 9.39% and 1% of the families were found to be catastrophic health expenditures at 10% and 25% threshold levels, respectively.
Conclusion:
To conclude, all the direct medical costs were borne by the caregiver. However, some non medical and indirect costs are associated with neonatal hospitalizations in public hospitals and cash benefit schemes can offset them.
Keywords: Back referral, catastrophic health expenditures, low birth weight, prematurity
INTRODUCTION
Out-of-pocket expenses (OOPE), which is the cost incurred by the beneficiary toward getting healthcare, are substantially high in low-middle-income countries.[1] The families are often pushed into poverty following catastrophic health expenditures (CHE) in these countries.[2] To address this financial hurdle in delivering maternal and neonatal care, the Government of India in 2011 launched the Janani Shishu Suraksha Karyakram (JSSK), where comprehensive services including pre-transportation, diagnostics, drugs, food for the mother, surgeries, blood transfusion, and post-discharge drop back are offered free of cost to the beneficiaries.[3]
Apart from the medical expenditures, non-medical expenditures are also incurred during the hospitalization of neonates.[4] These non-medical expenses are incurred for the food, accommodation, travel, and other expenses of the attenders staying with the mother and the neonate. These non-medical expenses exponentially increase as the number of days of hospitalization increases, especially in preterm neonates. The financial burden further increases due to indirect costs, such as the loss of wages, during the hospitalization of the neonate.[4] To compensate for the loss of wages and to provide adequate nutrition to the pregnant mother and also to encourage institutional deliveries, the Government of India launched the conditional cash benefit scheme “Pradhan Mantri Matru Vandana Yojana” (PMMVY) in 2013, where pregnant women were given Rs. 6000 as cash incentive.[5] Inclusive of this scheme, Tamilnadu has a unique cash benefit scheme—Dr. Muthulakshmi Reddy Maternity Benefit Scheme (MRMBS), where pregnant women were given a conditional cash benefit of Rs. 18,000 in installments along with nutrition kits.[6]
It should be a research priority to understand the non-medical and indirect OOPE costs incurred in public hospitals which will help in effective policy-making. The aim of the study is to estimate OOPE expended on neonates and attenders during neonatal hospitalizations in a public hospital and to examine their components.
MATERIALS AND METHODS
Study design, setting, and participants
This cross-sectional study was conducted in a tertiary referral hospital in Tamilnadu in July 2022. All the neonates admitted during the study period were included. The neonates whose parents were not willing or discharged against medical advice were excluded.
Variables and case definitions
For this study, the expenditures were broadly categorized as direct expenditures and indirect costs due to loss of wages. Further, the components of direct costs were classified as costs toward pre-transport, drugs, investigations, food, accommodation, transportation charges, post-discharge transport, and other non-medical expenses. In all the categories, except for drugs, costs expended by the attenders were also included. The socioeconomic class was categorized using the Modified BG Prasad scale. All expenditures were calculated per patient per day and expressed in Indian Rupees. Catastrophic health expenditures are defined as the costs expended by families during hospitalization that exceeds their annual income at two thresholds of 10% and 25%.
Data management and bias
The clinico-social data was collected. A pretested and semi-structured questionnaire was used to collect the expenditures associated with neonatal hospitalization. The responses were obtained through one-to-one interviews with the caregiver. The questionnaire was administered by the first author alone to avoid interviewer bias.
Sample size and ethics committee approval
A simple random sampling of all the neonates who were hospitalized during the study period was done. Informed written consent was taken and strict confidentiality was maintained. Institutional human ethics committee approval (6103/IEC/2022-021) was obtained. The caregivers were explained the nature of the study in the local language.
Statistical analysis
Statistical analysis was analyzed using R software. All categorical data were presented using frequency and percentages, and all continuous data were described using median and interquartile range (IQR). The normality assumption was assessed using the Shapiro–Wilk test. To study the association of clinical and demographic parameters with total expenses, an independent sample t-test or Mann–Whitney U test was applied for factors with two categories, and the Kruskal–Wallis test was applied for factors with more than two categories after checking the normality assumption. P value was considered significant at a 5% level of significance for all comparisons.
RESULTS
Out of 298 neonates enrolled for analysis, 16.11% were outborn neonates. 25% were preterm, 47% were born by cesarean section, and 33.22% had a birth weight below 2.5 kgs [Table 1]. Early discharge due to various reasons was noted in 3.36%. The mean duration of stay was 7.75 days and in 18.46% of the neonates, the duration of stay was more than 10 days. Of the 48 outborn neonates, 17 did not utilize the free pre-transport. The post-discharge drop-back facility was not utilized by 30.2%. The mean distance between the hospital and the residence of the families is 29.52 kilometers (Range 2–275 kms).
Table 1.
Baseline Parameters (n=298)
| Parameter | No of patients | Percentage (%) |
|---|---|---|
| Place of delivery | ||
| Inborn | 250 | 83.89 |
| Outborn | 48 | 16.11 |
| Gestational age | ||
| Preterm | 75 | 25.17 |
| Term | 223 | 74.83 |
| Mode of delivery | ||
| Assisted vaginal delivery | 5 | 1.68 |
| LSCS | 139 | 46.64 |
| Normal vaginal delivery | 154 | 51.68 |
| Birth weight | ||
| <2.5 kg | 99 | 33.22 |
| >2.5 kg | 199 | 66.78 |
| Duration of stay (in days) | ||
| <5 days | 126 | 42.28 |
| 6-10 days | 117 | 39.26 |
| >10 days | 55 | 18.46 |
| Socioeconomic status | ||
| Lower class | 13 | 4.36 |
| Lower middle class | 46 | 15.44 |
| Middle class | 129 | 43.29 |
| Upper middle class | 96 | 32.21 |
| Upper class | 14 | 4.7 |
| Number of attenders | ||
| Up to 2 | 186 | 62.42 |
| More than two | 112 | 37.58 |
| Pre-transport (outborn referral) (n=48) | ||
| Government ambulance | 31 | 64.58 |
| Own vehicle | 11 | 22.91 |
| Private ambulance | 6 | 12.51 |
| Diagnosis | ||
| Neonatal jaundice | 67 | 22.48 |
| Neonatal sepsis | 44 | 14.77 |
| Preterm (28–<37 weeks) | 56 | 18.79 |
| Transient Tachypnea of newborn | 21 | 7.05 |
| Meconium Aspiration Syndrome | 30 | 10.06 |
| Intrauterine growth restriction/low birth weight | 21 | 7.05 |
| Others | 59 | 19.80 |
| Post-discharge transport | ||
| Govt provided | 147 | 49.32 |
| Own vehicle | 61 | 20.47 |
| Private vehicle | 90 | 30.2 |
No expenditures were incurred for investigations or drugs which are offered free of cost [Table 2]. The median cost spent on food per day was Rs. 300 (IQR 200, 500). The median total cost spent on transport during their entire stay is Rs. 1000 (IQR 500, 1500). The median cost spent for non-medical expenses like baby diapers, paid resting rooms for attenders inside the hospital, paid accommodation outside the hospital, water bottles, parking fees, paid toilets, face masks, toiletries, etc., for the attenders per day is Rs. 500 per day (IQR 333, 896). The median overall OOPE incurred per day is Rs. 1080 (IQR 800, 1533). On analyzing the indirect cost of hospitalization due to loss of wages for the attenders, the median loss of wages was Rs. 500 per day (IQR 300, 560).
Table 2.
Summary of different costs
| Parameters | n | Median | IQR |
|---|---|---|---|
| Cost spent on food (per day in rupees) | 298 | 300 | (200, 500) |
| Total cost for transport (in rupees) | 298 | 1000 | (500, 1500) |
| Non-medical expenses (per day in rupees) | 298 | 500 | (333, 896) |
| Cost spent on drugs (per day in rupees) | 298 | 0 | (0, 0) |
| Cost spent on investigations (per day in rupees) | 298 | 0 | (0, 0) |
| Total expenses (per day in rupees) | 298 | 1080 | (800, 1533) |
| Loss of wages (per day in rupees) | 298 | 500 | (300, 560) |
On analysis of the association of OOPE with maternal and neonatal factors, it was found that the higher OOPE was associated with preterm, low birth weight babies, length of stay for more than 11 days, and conditions like neonatal seizures (P-values <0.001, 0.028, <0.001, and <0.001, respectively) [Table 3]. The loss of wages for the family was also found to significantly increase with an increasing number of attenders (P = 0.045). On estimating the CHE, 9.39% and 1% of the families were found to be facing CHE at 10% and 25% threshold levels, respectively. All these families having CHE were having longer hospitalization days.
Table 3.
Association of Total expenses with maternal parameters
| Parameters | n | Total expense (in Rupees) | P | |
|---|---|---|---|---|
|
| ||||
| Median | IQR | |||
| Gestational age at delivery* | ||||
| Preterm | 75 | 9750 | (6240, 15100) | <0.001 |
| Term | 223 | 6500 | (4800, 9800) | |
| Place of delivery | ||||
| Inborn | 250 | 6700 | (4800, 10000) | <0.001 |
| Ouborn | 48 | 9575 | (5550, 14525) | |
| Mode of delivery* | ||||
| LSCS | 139 | 7300 | (5300, 10800) | 0.127 |
| NVD | 159 | 6700 | (4700, 10100) | |
| Birth weight* | ||||
| <2.5 KG | 99 | 8300 | (5100, 12000) | 0.028 |
| >2.5 KG | 199 | 6500 | (4900, 9900) | |
| Socioeconomic status# | ||||
| Lower class | 13 | 5900 | (4500, 9400) | 0.134 |
| Lower middle | 46 | 6650 | (4800, 9200) | |
| Middle class | 129 | 6750 | (4800, 10500) | |
| Upper middle | 96 | 7125 | (5475, 10400) | |
| Upper class | 14 | 10900 | (6500, 13900) | |
| No. of attenders# | ||||
| More than two | 112 | 6800 | (5300, 10100) | 0.922 |
| Up to 2 | 186 | 7050 | (4900, 10300) | |
| Loss of wages for the family# | ||||
| More than 2 attenders | 112 | 500 | (325, 600) | 0.045 |
| Up to 2 attenders | 186 | 400 | (250, 500) | |
| Length of stay# | ||||
| 6–10 days | 117 | 7100 | (5100, 9950) | <0.001 |
| <=5 days | 126 | 5550 | (4250, 7600) | |
| >10 days | 55 | 14800 | (10800, 18800) | |
| Diagnosis# | ||||
| Intrauterine Growth Restriction/LBW | 21 | 8000 | (4500, 10000) | <0.001 |
| Meconium aspiration syndrome | 30 | 5850 | (4000, 7700) | |
| Neonatal jaundice | 67 | 6200 | (4700, 8900) | |
| Neonatal seizures | 8 | 13700 | (7750, 14600) | |
| Neonatal sepsis | 44 | 6800 | (5475, 10570) | |
| Others | 51 | 6800 | (4900, 9400) | |
| Preterm (28–<37 weeks) | 56 | 10500 | (7000, 16300) | |
| Transient tachypnea of newborn | 21 | 6000 | (4700, 9800) | |
*Independent sample t-test/Mann–Whitney test, #Kruskal–Wallis equality-of-populations rank test
DISCUSSION
The present study has included all the OOPE costs incurred on the neonate and attenders. Attenders are the essential link between the caregiver and patient, especially in HR-limited settings. Out-of-pocket expenses costs incurred by them were not studied and it is important to understand them for policy planning. In the present study, there was no reported expenditure on drugs and investigations by the beneficiaries. This finding re-emphasizes that the major component of the OOPE is taken care of by the caregiver. In this study, six (12.5%) neonates were transported in private ambulances as they were referred from private healthcare facilities. About one-third of the families in this study did not opt for the free drop-back facility which is comparable to other studies.[7] The cost of transport is substantially huge and contributes to a significant portion of OOPE in many other studies also.[8,9]
Though the meal for the mother is provided free, significant cost is expended on food for attenders. The median cost of other non-medical expenses expended on the neonates and attenders in the present study is Rs. 500 per day (333, 896). There were no studies to compare the cost of these components in OOPE. On analysis of the overall cost incurred during hospitalization, the median cost was Rs. 1080 per day (IQR 800, 1533). In a study byVenkatnarayanan et al.[10] in All India Institute of Medical Sciences, New Delhi, the median OOPE was Rs. 536.80 per day. The median cost was lower in that study because the non-medical expenses were not considered. The factors significantly associated with higher OOPE in the present study are low birth weight and prematurity. Many studies have reported additional factors like the number of referral points, distance from the hospital, and age of the neonate were significantly associated with higher OOPE.[8,9]
The introduction of the JSSK scheme is an important milestone in maternal and neonatal care in India, where the entire medical costs are offered free of cost. The CHE faced by the families in the present study is much lower than in a study done in Agra in a similar setting, which reported CHE of 80.9% and 55.8% at 10% and 25% thresholds, respectively.[8] On analysis of the indirect cost due to loss of wages, the median cost in the present study was Rs. 500 per day. In a study by Srivastava et al.,[11] the median loss of wages was Rs. 716.67 ± 686.47 per day. Though all the direct medical expenses are offered free of cost, there remain some non-medical expenses, which are not met by the caregivers. It is in this context, the cash benefit schemes like PMMVY and MRMBS gain importance. The concept of back referral from tertiary care hospital to a specialized neonatal care unit near the residence of the parents for step-down care is gaining importance recently and will help to reduce the OOPE.[12] This study has a few limitations. The costs may include the expenses for the mother to a certain extent. The costs shown in this study may seem to be high, especially in a public hospital which is due to the inclusion of non-medical costs on neonates and attenders. Further larger studies are needed to understand these costs.
CONCLUSION
The introduction of the JSSK scheme is an important milestone where the entire medical costs are offered free of cost. But there exist some non-medical and indirect costs. The possibility of reducing these costs by promoting back referrals should be researched further. Strengthening the pre-transport and post-discharge drop-back facility will help in reducing the OOPE. Cash benefit schemes can offset it and protect families from CHE.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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