The project works on improving estimation of Out-Of-Pocket expenditure (OOP)  in a household survey and develop a set of questions to facilitate OOP  specific disease measurement.

Summary of the iHOPE Project

The world spent nearly $7 trillion on health care in 2011 and of this, domestic resources account for over 75% of total health spending even in developing countries.  Many countries, as well as global development partners, are now requesting WHO to estimate the Out-of-Pocket (OOP) health expenditures in WHO National Health Account (NHA) disease specific account in order to track the investments and the financial burdens on key healthcare priority interventions.

National household surveys are generally used for estimating household Out-Of-Pocket payments. However, the infrequency of household surveys in addition to the non-sampling errors of current survey instruments are a major concern for the purpose of tracking health care expenditure across countries and by beneficiary characteristics. The primary purpose of this project is to improve the measurement of household out-of-pocket health expenditure on health by beneficiary characteristics (e.g. disease). In addition the project aims at delivering household health expenditure modules that can increase the cost-effectiveness of Household budget and health surveys by making better use of existing tools that require refinements to be repurposed and facilitate integration across different type of surveys (household budget/HCES and Health Surveys). By the end of this study, it is expected that there will be a standardize set of questions to improve the measurement of OOPs, specifically its level and distribution by beneficiary characteristics (e.g. diseases, provider).

For the disease attribution, this project will attempt to improve the measurement of OOPs by disease under the constraint that biomarkers cannot be used and only information on symptoms and diagnosis can be gathered. One way to do this is to rely on ICPC-2, the advantage being that such classification is recommended to be used in primary care settings and it is possible to map ICPC-2 to ICD-10. This additional step will not be undertaken within this project. Rather ICPC-2 will be used to validate the household responses with the provider responses.

The provider level patient data records will be taken as the most accurate data in that efforts will be made to ensure information on reasons for seeking care, insurance status and cost of service paid by an individual are available on a timely and consistent manner that minimizes measurement error. To this end, there will be a brief intervention to improve the recording of such data at the provider level. A generic template has been developed for the different types of health providers in primary care settings without any recording system. This contains basic information and identifiers (name, address, phone number, referral status, reason for consultation and cost of treatment/service) that will make it possible for the project to obtain the provider level data and also track the patients/clients back to their communities to collect household data. Due to the complex nature of patient flow in the traditional hospitals (mostly public or government hospitals), it will be extremely difficult to introduce a standardized template to collect the provider information, for this reason, patient folders will be reviewed and a standardized survey template used to extract the desired information for the Projects’ purpose

To develop and test the interim approaches, the households in the general and health surveys will be re-interviewed through telephone on the out-pocket health expenditure at certain intervals call SWIFT.   The project (iHOPE) is already in contact with the World Bank team conducting SWIFT (surveys of well-being via instant and frequent tracking). The data collection method will follow the SWIFT approach and technical guidelines. Data will be collected on periodic intervals over a one year period and taking into account different recall periods

The INDEPTH Network platform provides a unique opportunity to implement research designs such as the iHOPE project that seek to validate results and assess which questions are best suited to measuring out-of-pocket health expenditures.   The Network is one of the world’s biggest longitudinal data gathering Network. It has currently 53 Health and Demographic Surveillance System sites (HDSSs) in 20 countries across Africa, Asia and the Pacific region. The Ouagadougou HDSS, Burkina Faso, Navrongo HDSS, Ghana and FilaBavi HDSS, Vietnam are the three selected INDEPTH network sites involved in this project. These sites have already some experience in collecting expenditure data and are already familiar with the health care providers in their site

The data collection approaches to be applied are face-to-face tablet interview by trained data collectors, self-administered recording system for the providers,   record review, paper diary and telephone interview depending upon whether we are collecting household information or provider information. All household questionnaires and providers’ diary have been developed. These questionnaires will be pre-tested in the three settings before a broader application.   Data collection for the household expenditure (HCES pure expenditure type) and health survey (HHS) will be conducted simultaneously by two different field teams in the first round (June-September, 2016) of data collection. A call center will be setup at each site to conduct telephone interviews, the frequency of these interview will be twice a month maximum for a period of one year (June 2016 - May 2017). As the study consists of different levels of data collection approaches, a field manual and a supervisor manual will be prepared and applied to make all the procedures to be standard.

All household cross-sectional surveys will be conducted with tablets.  The survey instruments will be programmed into the tablets using Open Data Kit (ODK) platform. Each instrument will be programmed and uploaded into a cloud server (SurveyCTO) and downloaded onto the tablets via internet connectivity for data collection. The frontend of the tablets will see a SurveyCTCO data collection tool. Data will be electronically transferred to a central data management unit at the INDEPTH Secretariat in Accra, Ghana. Each site’s investigators in integration with persons from INDEPTH will be responsible for quality assurance and maintenance of confidentiality. Data will be collated, standardized and integrated into common formats (e.g., STATA Version 13, STATA Corp) before analysis.

On ethics, the earlier version of this protocol has already been approved by the three implementing sites’ ethical review committees (ERCs).