Out-of-pocket (OOP) expenditure on health care has significant implications for poverty in many developing countries. The extent of direct payments for health services are producing severe consequences on both equity and efficiency, making health care services unaffordable for most people, and leading to underfunding of essential inputs. Even relatively modest out-of-pocket health expenditure frequently causes indebtedness and can lead to poverty. This study presents an outlook of the role of out-of-pocket payments for health services, formal and informal, in the Albania, Bangladesh, Eritrea, India and Nepal to generate and utilize evidences in broader understanding of patient payment policies. The main purpose of the study is to: (a) compare the health care systems of the countries based on patient payment policy perspectives (b) to analyze the differences and similarities that exist in regards to the role of out of pocket (formal & informal) in the countries. Based on reviewed literatures in five countries, the finding shows these all countries are low and upper middle income countries except Eritrea, which is a low income country. The health care systems vary from totally centralized (Albania, Eritrea, Bangladesh), Decentralized (India and Nepal). The coverage of Public Sector Social Health Insurance is non -existent in all the given countries except Albania and India. Regarding the private health insurance, the evidences show that there are limited private health insurance coverage in Nepal and Bangladesh and India; however no coverage in Eritrea, and around 53 % in Albania. In average, about 85 % of share of national health economy is contributed by out of pocket payment in each of these countries. In each of the countries, there is an exemption policy to alleviate the inaccessibility of groups in immediate needs of health care. The predominant effects of official fees are underutilization of health care especially among the vulnerable groups, poor quality of health to poor groups, inequity, over-prescription, increasing poverty, and creating fertile ground for informal payments and corruption.

1. COMPARATIVE PATIENT PAYMENT
POLICIES OF BAINE COUNTRIES
Presentation on Patient Payment Policy
(Group Work, BAINE)
1. Etleva Dervishi, Albania
2. Shoeb Ahmad Ilyas, India
3. Md. Mizanur Rahman, Bangladesh
4. Mohan Paudel, Nepal
5. Zemuy Ghirmay, Eritrea
19th
March, 2010
University of Corvinus
BAINE: Bangladesh, Albania, India, Nepal, Eritrea

2. Geographical location

3. CONTENT OF PRESENTATION
1. Patient Payment Policy
2. Types
3. Main Policy Objectives
4. Possible Effects
5. Health Care System and Country Comparison
5.1 Health and Socio-economic indicators
5.2 Similarities and Differences
5.3 Health Care Financing
5.4 Official Fees and Co-payments
5.5 Role of Out of Pocket Payments
6. Conclusion

4. PATIENT PAYMENT POLICY
Definition
All types of out-of-pocket payments that health
care consumers make at the time of using health
care services (e.g. out-patient and in-patient
services) or purchasing health care commodities
(e.g. appliances and pharmaceuticals) are called
patient payments
Formal Fees: Official fees
Informal charges: Indirect payments, under
the table payments

5. TYPES
 Co-payment: flat-rate patient payment made by
the patient when using health care service.
 Co-insurance: patient payment that is equal to a
percentage of the total costs of the service used.
 Deductibles: patient payment that covers the
service cost up to a fixed amount.

6. MAIN POLICY OBJECTIVES
• Macro-level objectives
– Controlling the overall health care
expenditure. cost-containment
– Generating additional resources for the health
care system
• Meso- and micro-level objectives
– Discouraging unnecessary use of health care
services
– Allowing hospitals/clinics to generate
additional resources. (improvement of service
quality)
– Increasing the income of individual health
care providers.
• informal patient payments

7. POSSIBLE EFFECTS
 Influence the behavior of health care consumers:
 cost-consciousness
 diminish the level of moral hazard on the side of the
consumers
 Reduce excess demand due to free heath care
 Decline in Health care utilization
 Generates additional revenue
 Can improve health sector service provision
 Can develop quality health care
 Simultaneously, it can create inequality among vulnerable
groups in low income context
 Applied in low- and middle-income countries
 Minimization of informal payments, make services affordable to
a large number of poor pop

8. HEALTH CARE SYSTEM AND COUNTRY
COMPARISON
• Health and Socio-economic indicators
• Similarities and Differences
• Health Care Financing
• Official Fees and Co-payments
• Role of Out of Pocket

9. HEALTH AND SOCIO-ECONOMIC
INDICATORS
Source: CIA 2009 est.

10. Source: WHO 2009
CONTD…………

11. Source: country data 2006/007

12. Source: WHO 2009

13. Source: WHO 2009
Health Care Financing

14. Contd………………..
Source: WHO 2009

15. Characteris
tics
Albania Banglade
sh
Eritrea India Nepal
Degree of
Regional
Responsibilit
y
Centralized Centralize
d
Centralize
d
Decentralized On
process
of
decentr
alizatio
n
Health
Insurance
Coverage
(Public)
There is
insurance
coverage
(88% public
employees
covered)
no health
insurance
no health
insurance
system
100% Central
government
health
insurance,
Central govt.
Health scheme.
(CGHS).
no
health
insura
nce
Health care system

16. CONTD………
Characte
ristics
Albania Banglade
sh
Eritrea India Nepal
Health
Insuranc
e
(Private)
53% of
the
employee
s in
private
sector
in 1999-
2000, only
0.02%
No
private
covera
ge
system
Different
states
have
different
types of
schemes
very
limited

17. OFFICIAL FEES AND CO-PAYMENTS
Countries Albania Banglade
sh
Eritria India Nepal
User Fees Yes Yes No for primary
health care, but
yes for
secondary and
tertiary care
Exempted for
PHC and for
district and city
hospitals user
fees apply but
exempted for
white card
holders
No for primary
health care, but
yes for
secondary and
tertiary care
Co-
Payments
Yes NA NA NA NA
Informal
Payment
No specific
data
Almost 9% of
total out-of-
pocket
expenditure
No specific data No specific
data
No specific data
Beneficia
ry
Ministry of
Health
Hospital State 50% to
treasury and
50% to the
Hospital
Secondary and
Tertiary Care
Hospital

18. Countrie
s
Albania Bangladesh Eritria India Nepal
Revenue
from
official
fees
24.6 of
total
health
expendit
ure from
pharmac
eutical
drugs’
sales.
No
specific
data for
other
health
care
sections.
roughly
12% of
annual
recurrent
expenditur
es for
district
hospitals
and 3% for
medical
college
hospitals
80% of the
revenue come
from
registration,
diagnostic
care fee at
MOH health
facilities, and
20% from drug
fee (World
bank,2004
100% of
revenue
from user
fees in few
states goes
to Hospital
Developme
nt Society
for
Maintenan
ce and
purchase
of drugs
and in
some
states only
50%
revenue
goes to
Hospital.
No specific
data

19. There is no specific peculiar differences among the
countries in regard to the effects of patient
payment. However, these are the common
attributes among the countries
1. Revenue generation
2. Extra burden for poor people, Extra administrative costs
and corruption for its collection
3. Declining utilization of health services
4. Informal fees and other costs associated with seeking
and receiving health services are not alleviated by
official fees
5. Un predictable nature of informal fees and other costs
will work against user fees exemption mechanism
6. Service and official fees barriers to health care
Effects of Patient Payment Policies

20. ROLE OF OUT OF POCKET PAYMENT
1. Major share of health economy in nationals
2. Inequality in accessing healthcare
3. increasing poverty burden
4. increasing the healthcare cost
5. increasing corruption
6. Declining use of health care facilities
7. Over prescription of drugs & unnecessary
interventions on patients
8. Increasing rate of hospitalization
9. Exposed poor people to poor quality of health care

21. CONCLUSION
1. According to the world bank classification, all the countries
are lower and upper middle income countries except
Eritrea.
2. There is no considerable difference in the life expectancy of
these countries except in Albania.
3. The health care system is tax based, however, the revenue
generated contributes to the health care facilities in many of
the countries except in Eritrea where it goes directly to
treasury.
4. There is no social health insurance except in Albania &
India. The role of out of Pocket Payment is above the 85 %
in all countries.
5. There are limited data on informal health spending &
revenue generation in all countries.
6. The magnitude of user fees in these countries are not
available, however they all implement user fee schemes
with exemption policies for vulnerable groups.

23. Any
Questions…………??????