Madan, Jason, Lönnroth, Knut, Laokri, Samia and Squire, Stephen Bertel (2015) What can dissaving tell us about catastrophic costs? Linear and logistic regression analysis of the relationship between patient costs and financial coping strategies adopted by tuberculosis patients in Bangladesh, Tanzania and Bangalore, India. BMC Health Services Research, 15 (1). 476. doi:10.1186/s12913-015-1138-z

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Abstract

Background
Tuberculosis (TB) is a major global public health problem which affects poorest individuals the worst. A high proportion of patients incur ‘catastrophic costs’ which have been shown to result in severe financial hardship and adverse health outcomes. Data on catastrophic cost incidence is not routinely collected, and current definitions of this indicator involve several practical and conceptual barriers to doing so. We analysed data from TB programmes in India (Bangalore), Bangladesh and Tanzania to determine whether dissaving (the sale of assets or uptake of loans) is a useful indicator of financial hardship.

Methods
Data were obtained from prior studies of TB patient costs in Bangladesh (N = 96), Tanzania (N = 94) and Bangalore (N = 891). These data were analysed using logistic and linear multivariate regression to determine the association between costs (absolute and relative to income) and both the presence of dissaving and the amounts dissaved.

Results
After adjusting for covariates such as age, sex and rural/urban location, we found a significant positive association between the occurrence of dissaving and total costs incurred in Tanzania and Bangalore. We further found that, for patients in Bangalore an increase in dissaving of $10 USD was associated with an increase in the cost-income ratio of 0.10 (p < 0.001). For low-income patients in Bangladesh, an increase in dissaving of $10 USD was associated with an increase in total costs of $7 USD (p <0.001).

Conclusions
Dissaving is potentially a convenient proxy for catastrophic costs that does not require usage of complex patient cost questionnaires. It also offers an informative indicator of financial hardship in its own right, and could therefore play an important role as an indicator to monitor and evaluate the impact of financial protection and service delivery interventions in reducing hardship and facilitating universal health coverage. Further research is required to understand the patterns and types of dissaving that have the strongest relationship with financial hardship and clinical outcomes in order to move toward evidence-based policy making.

Item Type:	Journal Article
Subjects:	H Social Sciences > HN Social history and conditions. Social problems. Social reform R Medicine > RA Public aspects of medicine R Medicine > RA Public aspects of medicine > RA0421 Public health. Hygiene. Preventive Medicine R Medicine > RC Internal medicine
Divisions:	Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School
Library of Congress Subject Headings (LCSH):	Tuberculosis, Tuberculosis--Patients , Poor--Medical care--Economic aspects, Medical care, Cost of, Medical care, Cost of--Econometric models, Cost and standard of living--Econometric models
Journal or Publication Title:	BMC Health Services Research
Publisher:	Biomed central
ISSN:	1472-6963
Official Date:	22 October 2015
Dates:	Date Event 22 October 2015 Published UNSPECIFIED Available 9 October 2015 Accepted 30 March 2015 Submitted
Volume:	15
Number:	1
Article Number:	476
DOI:	10.1186/s12913-015-1138-z
Status:	Peer Reviewed
Publication Status:	Published
Access rights to Published version:	Open Access
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