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DHS-8-PGSSC-OOP-Template [message #16792] Mon, 04 March 2019 17:09 Go to next message
PGSSC is currently offline  PGSSC
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Thank you for reviewing our proposal for new indicators within the Demographic and Household Survey (DHS) regarding emergency and essential surgical care. The collection of these indicators is a critical step towards the delivery of safe, affordable, equitable access to surgical services as a component of universal health coverage and we consider the DHS as the best forum to derive these data points.

The questions we propose are a product of the Lancet Commission on Global Surgery (LCoGS), a body of work spanning three years involving 25 commissioners and a diverse group of academic, governmental and civil society collaborators from 110 countries. Of the six indicators proposed by the LCoGS, four were published in the World Development Indicators by the World Bank and all six are included in the World Health Organization's Global Reference List of 100 Core Health Indicators. Nevertheless, there currently are no mechanisms in place to collect the data required for these indicators, creating a critical gap in knowledge for surgical care strengthening.

The new indicators in this proposal span four existing DHS modules. For clarity, they are listed in the table below. Of particular interest are the questions on out-of-pocket expenditure and household expenditure to enable the calculation of financial risk protection for all medical interventions captured by the DHS (both surgical and medical), a core component of Sustainable Development Goal 3.8. The remaining questions were taken from a successful pilot DHS survey in Zambia. In the development of this application, we have been fortunate to count on a number of international partners to provide expert review and the indicators proposed are a culmination of these consensus building discussions. Please refer to Appendix A for a full list of international stakeholders who support this application.

Proposed Indicators:
1. Risk of impoverishing and catastrophic expenditure

Data Utility:
1. World Bank: World Development Indicators
Re: DHS-8-PGSSC-OOP-Template [message #16989 is a reply to message #16792] Thu, 14 March 2019 20:04 Go to previous messageGo to next message
taylorwurdeman is currently offline  taylorwurdeman
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In order to support the development of national surgical plans and the growing influence of global surgery on supporting health systems, I highly recommend including this measure in the DHS survey. Out of pocket expenditure is vital to understanding HOW patients seek care. Even in the most advanced surgical systems, if patients cannot afford surgery, they will not be able to access it. This measure expands our understanding of surgical access and should be included to support the study of NCDs.
Re: DHS-8-PGSSC-OOP-Template [message #17074 is a reply to message #16792] Fri, 15 March 2019 10:41 Go to previous messageGo to next message
Scott Corlew is currently offline  Scott Corlew
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I applaud the initiative by DHS to update its core and supplemental surveys. There are a number of datapoints that are critical for monitoring and improving many aspects of health care. In recent years major new components of universal health care have been brought to light by the Lancet Commission on Global Surgery, and there are several key indicators that can best be followed by the survey tools of the DHS.

Specifically, the issue of financial risk protection is critical for all of healthcare, but it has been identified as a major barrier to access to surgical care in LMICs. The granular level of the household survey is the best (only?) way to learn specific information about how people are affected financially by their surgical needs. There have been very laudable modeling efforts aimed at determining how financial risk protection, or the lack thereof, affects people in LMICs, but the inclusion of the questions submitted here for consideration would be the first major method to obtain these data globally.
Re: DHS-8-PGSSC-OOP-Template [message #17082 is a reply to message #17074] Fri, 15 March 2019 11:28 Go to previous messageGo to next message
Cstrader1 is currently offline  Cstrader1
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Hi all, I am very impressed , but am wondering about what this is capturing and specifically how amount spent is standardized across different incomes/financial situations. I am wondering if a question from the financial risk protection survey of "Did your household have to sell and land or possessions
(including livestock) to pay for this hospitalization?". I know space is limited, but perhaps as a submission for follow up question?
Re: DHS-8-PGSSC-OOP-Template [message #17116 is a reply to message #16792] Fri, 15 March 2019 13:55 Go to previous messageGo to next message
vsanthirapala is currently offline  vsanthirapala
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As this application points out the DHS has collected costs from direct medical billing but has not included direct nonmedical costs such as transport, accommodation and so forth. Without the second component, it will not be possible to use the data for financial risk protection calculations, a critical part of SDG target 3.8. The contained questions proposed would overcome this barrier. The inclusion of a surgical question would enable those who are looking at medical vs surgical FRP to do subsidiary analyses.
Re: DHS-8-PGSSC-OOP-Template [message #17120 is a reply to message #17116] Fri, 15 March 2019 14:20 Go to previous messageGo to next message
djumbam is currently offline  djumbam
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I commend the team for their proposal for the inclusion of out-of-pocket expenditure for surgical care in the DHS surveys. As access to surgical care is improved around the globe, it is crucial that the potential financial costs to the patients and their families for surgical care not be forgotten. Some studies have in fact shown that increasing access can lead patients and their families into poverty because they are forced to give up significant portions of their income for surgical care. Inclusion of this indicator in the DHS platform will ensure that we track the effects of improving SDG 3 (Health) against SDG 1 (Poverty). This will allow policy makers to determine effective solutions to scaling up surgical services while preventing patients from being impoverished.

Kudos to the team!!
Re: DHS-8-PGSSC-OOP-Template [message #17143 is a reply to message #16792] Fri, 15 March 2019 15:03 Go to previous messageGo to next message
ptruche is currently offline  ptruche
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An understanding of cost due to noncommunicable diseases is critical to ensuring that health care systems in low and middle income countries are designed to promote economic growth and well being from a financial standpoint. This indicator would be incredibly valuable as a way to better understand health systems in the context of non-communicable diseases and help promote better access to safe and affordable surgery across the world. It also stresses a commitment from the DHS and health policy advocates to address the perceived burden of surgical cost using real world data.
Re: DHS-8-PGSSC-OOP-Template [message #17147 is a reply to message #16792] Fri, 15 March 2019 15:05 Go to previous messageGo to next message
JohnMeara is currently offline  JohnMeara
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I fully support this indicator. The Lancet Commission on Global Surgery demonstrated that 81 million people suffer catastrophic expense seeking surgery every year.
Re: DHS-8-PGSSC-OOP-Template [message #17163 is a reply to message #17147] Fri, 15 March 2019 15:21 Go to previous messageGo to next message
anm156 is currently offline  anm156
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Assessment of a population's out of pocket expenditure due to health care is essential to understanding a country's ability to achieve Universal Health Coverage. Out of pocket expenditure is an often overlooked part of health care access, even though data shows that out of pocket expenditures directly influence patient and household decisions in seeking care and delaying care. Moreover, the threat of impoverishment or catastrophic expenditure after care endanger population health outcomes, economic productivity, and overall country GDP down the line. In order to understand and achieve SDG Universal Health Care, a proper accounting of out of pocket expenditure and its influence in the health system must take place. This is only possible with systemic, widespread collection of this data, which the DHS can help to achieve.
Re: DHS-8-PGSSC-OOP-Template [message #17167 is a reply to message #16792] Fri, 15 March 2019 15:24 Go to previous messageGo to next message
AlexPetersMD is currently offline  AlexPetersMD
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As a general surgeon and public health researcher, I fully support these efforts. If we are going to drive forward Universal Health Coverage, its critical to better understand what seeking comprehensive care, including surgical care, costs patients. Collecting OOP health expenditures around surgical care will better inform policy that can advance access to emergency and essential surgical care as part of Universal Health Coverage.
Re: DHS-8-PGSSC-OOP-Template [message #17173 is a reply to message #16792] Fri, 15 March 2019 15:27 Go to previous messageGo to next message
Vicente Gracias is currently offline  Vicente Gracias
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I completely support this endeavor. without economic impact analyses the true downstream effects related to erroneous allocation of system resources and health expenditure can not be accurately categorized
Re: DHS-8-PGSSC-OOP-Template [message #17175 is a reply to message #16792] Fri, 15 March 2019 15:28 Go to previous messageGo to next message
Jordan Pyda is currently offline  Jordan Pyda
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I worked as surgical care coordinator at a high volume surgical hospital in rural Haiti which served the rural poor. This was in the summer of 2010 and for 13 months between 2012-2013. One of the lasting impressions from that time as an administrative and clinical volunteer, was the incredibly thin financial margin that separated patients between a state of well being or health and severe illness and more frequently death. We saw many patients with traumatic injuries but also very simple, easily treatable conditions such as inguinal hernias. After a few months of the same heart wrenching scenes, I started to talk to patients and families more about their costs. I interviewed about 16 patients who received elective inguinal hernia repairs at our hospital and calculated that on average patients paid 140-160USD for all the out of pocket costs combined. Now while this may seem trivial at first, but this hospital was providing fee free care. FREE care. And yet a simple elective hernia repair cost 150USD when average per capita income was/is still 700-800 USD. There were numerous individual patients who I literally had to hike out to bring for their surgical appointment and the stories were all too similar- can't hire anyone to look after my kids or family, can't hire someone to toil the plot of land, can't leave my other source of income (madame sarah), can't afford the trip...

The proportion of patients who incur impoverishing expenditure for surgery is 58%, 55% or so of those costs are catastrophic.. means families are completely ruined.

This data is very limited, and our understanding of these horrible situations is so incomplete. If we could collect this kind of data on a systematic basis and in organized manner we would have the concrete arguments to direct investments into surgical care recognizing how vitally important it is to the socio-economic viability of people, families, communities, and nations - and yes our world.

Out of pocket health expenditures for surgical care is an absolute imperative for data collection- please, strongly urge USAID to consider inclusion in the DHS.

Jordan Pyda MD, MPH
jpyda@bidmc.harvard.edu
Re: DHS-8-PGSSC-OOP-Template [message #17184 is a reply to message #17175] Fri, 15 March 2019 15:32 Go to previous messageGo to next message
Vicente Gracias is currently offline  Vicente Gracias
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this work is critical to achieve the goal of safe equitable care for all.
Re: DHS-8-PGSSC-OOP-Template [message #17206 is a reply to message #16792] Fri, 15 March 2019 16:08 Go to previous messageGo to next message
RPatterson is currently offline  RPatterson
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Patients often suffer untenable expenses seeking surgery in systems that provide inadequate health financing. Yet, this problem is not well understood across different contexts, and it is unclear how substantially patients are affected across the world. DHS has a valuable opportunity to provide critical information that will help to describe the burden of out-of-pocket expenditure on those seeking surgery.
Re: DHS-8-PGSSC-OOP-Template [message #17207 is a reply to message #16792] Fri, 15 March 2019 16:08 Go to previous messageGo to next message
rachelne is currently offline  rachelne
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This information is needed to further progress universal healthcare and coverage for the entire world. Applaud the efforts and cannot wait to see what results are obtained.
Re: DHS-8-PGSSC-OOP-Template [message #17208 is a reply to message #17184] Fri, 15 March 2019 16:08 Go to previous messageGo to next message
shehnaz Alidina is currently offline  shehnaz Alidina
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Measurement of out of pocket expenditure is an important step towards ensuring equitable access to surgical services. I fully support this measure.

Re: DHS-8-PGSSC-OOP-Template [message #17212 is a reply to message #17074] Fri, 15 March 2019 16:10 Go to previous messageGo to next message
shrime
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I fully support the efforts by the DHS to begin to collect out of pocket expenditures in health. This is crucially important to universal health coverage.
Re: DHS-8-PGSSC-OOP-Template [message #17213 is a reply to message #17147] Fri, 15 March 2019 16:11 Go to previous messageGo to next message
blakealkire is currently offline  blakealkire
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The capital and operating costs in surgery have repeatedly been shown to be dwarfed by the positive benefits surgical systems bring to the economy and, more importantly, to improved population health. Unfortunately, those costs continue to be passed on to patients with devastating consequences. These data are essential to measuring progress to true UHC, which requires that patients are not impoverished for paying for surgery.
Re: DHS-8-PGSSC-OOP-Template [message #17214 is a reply to message #16792] Fri, 15 March 2019 16:11 Go to previous messageGo to next message
rachelne is currently offline  rachelne
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This information is so necessary and lacking from many areas to fully understand limitations for people all over the world to obtain and access healthcare including surgical care
Re: DHS-8-PGSSC-OOP-Template [message #17218 is a reply to message #16792] Fri, 15 March 2019 16:15 Go to previous messageGo to next message
bujarqerreti is currently offline  bujarqerreti
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Out-of-pocket payments are a massive problem in the global surgical healthcare, therefore, including OOP in the DHS program is essential for a larger Universal Health Coverage.
Re: DHS-8-PGSSC-OOP-Template [message #17226 is a reply to message #16792] Fri, 15 March 2019 16:18 Go to previous messageGo to next message
ocahearn is currently offline  ocahearn
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I fully support collecting data on OOP costs in the DHS survey in order to prioritize and improve access to affordable surgical care.
Re: DHS-8-PGSSC-OOP-Template [message #17231 is a reply to message #17226] Fri, 15 March 2019 16:20 Go to previous messageGo to next message
cjuillard is currently offline  cjuillard
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I support this indicator given the significant burden of surgical disease globally and the importance of improving access to surgical care, both financially and otherwise.
Re: DHS-8-PGSSC-OOP-Template [message #17240 is a reply to message #17218] Fri, 15 March 2019 16:22 Go to previous messageGo to next message
dominiquevervoort is currently offline  dominiquevervoort
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Every year, 81 million people face catastrophic expenditure due to requiring surgical care. Where public insurance/governmental coverage is low, out-of-pocket payment share is high. In low- and middle-income countries, poorer parts of the population, and settings with high costs of healthcare, the socioeconomic implications are enormous, potentially affecting billions of people worldwide.
Re: DHS-8-PGSSC-OOP-Template [message #17257 is a reply to message #16792] Fri, 15 March 2019 16:28 Go to previous messageGo to next message
kgarringer is currently offline  kgarringer
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Data regarding OOP expenditure will provide valuable information on a large scale regarding a patient's ability to access and attain quality surgical services.
Re: DHS-8-PGSSC-OOP-Template [message #17261 is a reply to message #16792] Fri, 15 March 2019 16:29 Go to previous messageGo to next message
SebastianShu is currently offline  SebastianShu
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During my medical training in a LMIC, I witness from first hand the impact of health expenditures in the poorest. In spite of this reality, there is no good quality data on how much is being expend by the patients or relatives outside the health care facilities. I even experience that some health care providers help support the cost of the patient in charge. Out of the Pocket Health expenditures will definitely bring a better view of the real cost of health care.

Re: DHS-8-PGSSC-OOP-Template [message #17262 is a reply to message #16792] Fri, 15 March 2019 16:31 Go to previous messageGo to next message
Haitham.Shoman is currently offline  Haitham.Shoman
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There is lots of differences on OOP payments spent on health care and surgeries in particular. This could lead to catastrophic and impoverishing expenditures. It is hence important to understand how much and what do countries spend to explore where can the gaps be bridged.
Re: DHS-8-PGSSC-OOP-Template [message #17265 is a reply to message #16792] Fri, 15 March 2019 16:32 Go to previous messageGo to next message
gmenon is currently offline  gmenon
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As out of pocket expenditure continues to be ruinous in many parts of the world, I fully support the inclusion of this item on the survey.
Re: DHS-8-PGSSC-OOP-Template [message #17266 is a reply to message #16792] Fri, 15 March 2019 16:33 Go to previous messageGo to next message
Adelina Mazhiqi is currently offline  Adelina Mazhiqi
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81 million people face catastrophic expenditure each year due to requiring surgical care, with the burden mainly being shouldered by LMICs. However, because this information is mainly found through modeled data, the DHS tool plays a crucial role, enabling us to obtain accurate and representative data on the household level and consequently on the national and global level.
Re: DHS-8-PGSSC-OOP-Template [message #17286 is a reply to message #17173] Fri, 15 March 2019 16:47 Go to previous messageGo to next message
Cstrader1 is currently offline  Cstrader1
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When convincing ministries, governments, or private donors, it is the bottom line that must be addressed. Addressing this issue is timely and necessary for us to make meaningful headway.

[Updated on: Fri, 15 March 2019 16:47]

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Re: DHS-8-PGSSC-OOP-Template [message #17294 is a reply to message #16792] Fri, 15 March 2019 16:56 Go to previous messageGo to next message
SBari is currently offline  SBari
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This is a very informative indicator that is important to collect regularly, systematically, and globally.
Re: DHS-8-PGSSC-OOP-Template [message #17295 is a reply to message #16792] Fri, 15 March 2019 16:56 Go to previous messageGo to next message
CLReddy is currently offline  CLReddy
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Excess out of pocket expenses prevent people from obtaining surgery when they need it. The sheer cost of surgery (notwithstanding the indirect costs) makes surgery largely inaccessible for the majority of the world population living in LMIC's. This gap between surgical health care costs and affordability is expected to increase. This information is indispensable to protecting people from excess health care costs due to surgery under UHC.
Re: DHS-8-PGSSC-OOP-Template [message #17303 is a reply to message #16792] Fri, 15 March 2019 17:13 Go to previous messageGo to next message
Rachel Koch is currently offline  Rachel Koch
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I support this We must have a better understanding of what patients are asked to pay for health care, including surgical care in order to help policy makers find better strategies to truly make health care universal. Even free surgery is not free as most patients are also required to pay for transportation, food and many have to borrow money to pay for expenses related to care-seeking.
Re: DHS-8-PGSSC-OOP-Template [message #17304 is a reply to message #17295] Fri, 15 March 2019 17:16 Go to previous messageGo to next message
Ulrick Sidney is currently offline  Ulrick Sidney
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People become poor or poorer because they were unfortunate enough to suffer from a surgical disease and they do not have access to Universal Health Coverage. Out-of-pocket payment for healthcare is an aberration. We need to work together to get policy makers to take decisions that will help put an end to this. One very effective way is research. It is very difficult to argue against strong scientific evidence therefore collection of data on out-of-pocket expenditure can go a long way to impact the lives of billions of people that do not have access to Universal Health Coverage and who go broke as a result.

Ulrick Sidney
InciSioN International Team
Re: DHS-8-PGSSC-OOP-Template [message #17309 is a reply to message #16792] Fri, 15 March 2019 17:23 Go to previous messageGo to next message
Dr. Ernest Barthélemy is currently offline  Dr. Ernest Barthélemy
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As a neurosurgeon working in Haiti, I strongly support the inclusion of this indicator in the DHS. Timely, affordable access to surgical care is not only an indispensable component of healthcare, but also an important aspect of the pathway towards poverty reduction and socioeconomic development. It is therefore critical to generate structures for financial accountability as national health systems strategize to scale up access to surgical care, especially in low- and middle-income countries. This indicator will enable such financial accountability.

PGSSC wrote on Mon, 04 March 2019 17:09
Thank you for reviewing our proposal for new indicators within the Demographic and Household Survey (DHS) regarding emergency and essential surgical care. The collection of these indicators is a critical step towards the delivery of safe, affordable, equitable access to surgical services as a component of universal health coverage and we consider the DHS as the best forum to derive these data points.

The questions we propose are a product of the Lancet Commission on Global Surgery (LCoGS), a body of work spanning three years involving 25 commissioners and a diverse group of academic, governmental and civil society collaborators from 110 countries. Of the six indicators proposed by the LCoGS, four were published in the World Development Indicators by the World Bank and all six are included in the World Health Organization's Global Reference List of 100 Core Health Indicators. Nevertheless, there currently are no mechanisms in place to collect the data required for these indicators, creating a critical gap in knowledge for surgical care strengthening.

The new indicators in this proposal span four existing DHS modules. For clarity, they are listed in the table below. Of particular interest are the questions on out-of-pocket expenditure and household expenditure to enable the calculation of financial risk protection for all medical interventions captured by the DHS (both surgical and medical), a core component of Sustainable Development Goal 3.8. The remaining questions were taken from a successful pilot DHS survey in Zambia. In the development of this application, we have been fortunate to count on a number of international partners to provide expert review and the indicators proposed are a culmination of these consensus building discussions. Please refer to Appendix A for a full list of international stakeholders who support this application.

Proposed Indicators:
1. Risk of impoverishing and catastrophic expenditure

Data Utility:
1. World Bank: World Development Indicators
Re: DHS-8-PGSSC-OOP-Template [message #17317 is a reply to message #16792] Fri, 15 March 2019 17:31 Go to previous messageGo to next message
PGSSC is currently offline  PGSSC
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We would like to thank everyone who have been supporting our submission. We have read all your replies and we are delighted to see such support and commitment from the Global Surgery and Global Health community.

Attached is a list of signatories who also have provided their support towards our submission:

1. Professor Chris Lavy - University of Oxford
2. Mr. Andrew Leather - Kings College London
3. Dr. Lars Hagander - Lund University
4. Dr. Hampus Holmer - Lund University
5. Dr. Martin Veller - University of Witwatersrand
6. Dr. Emannuel Ameh - Abuja National Hospital
7. Dr. Margaret Kruk - Harvard TH Chan School of Public Health

The Program in Global Surgery and Social Change (PGSSC)
Harvard Medical School
Re: DHS-8-PGSSC-OOP-Template [message #17329 is a reply to message #16792] Fri, 15 March 2019 17:44 Go to previous messageGo to next message
Kee Park is currently offline  Kee Park
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The out of pocket health expenditure data helps inform the financial burdens for accessing healthcare and therefore health equity especially for the poorest.
Re: DHS-8-PGSSC-OOP-Template [message #17349 is a reply to message #17329] Fri, 15 March 2019 18:06 Go to previous messageGo to next message
LukeCaddell is currently offline  LukeCaddell
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Inclusion of this measure is critical. OOP expenditure is that unappreciated component of health cost that is so difficult to capture within the health system. While the cost to the provider or health system are comparatively simple to tabulate based of facility data, OOP expenditure requires dedicated interaction with the patient to document their experience. It is for this reason that the DHS survey mechanism is the perfect solution to investigating OOP expenditure.
Re: DHS-8-PGSSC-OOP-Template [message #17356 is a reply to message #17349] Fri, 15 March 2019 18:31 Go to previous messageGo to next message
Aboatin is currently offline  Aboatin
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Without financial risk protection against improvising or catastrophic health expenditures universal health care is unachievable and we will fall short as a global community in achieving SDG 3. Measuring out of pocket expenditures and total health expenditure is critical to understand progress made towards achieving financial risk protection. The DHS presents an optimal way to collect this information which has yet to be collected in a standardized manner and on a large scale.
Re: DHS-8-PGSSC-OOP-Template [message #17364 is a reply to message #16792] Fri, 15 March 2019 19:18 Go to previous messageGo to next message
LRoa is currently offline  LRoa
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Financial risk protection is an essential component of UHC. I commend DHS initiative to include out
Of pocket expenditures
Re: DHS-8-PGSSC-OOP-Template [message #17368 is a reply to message #16792] Fri, 15 March 2019 19:58 Go to previous messageGo to previous message
hfoster is currently offline  hfoster
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I fully support the inclusion of this indicator. It is important to consider the financial costs that patients and their family incur for surgical care.
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