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    Benefit incidence analysis of healthcare in Bangladesh - equity matters for universal health coverage
    (© 2017 Oxford University Press, 2017) Khan, Jahangir Am; Ahmed, Sayem; MacLennan, Mary E.; Sarker, Abdur Razzaque; Sultana, Marufa; Rahman, Hafizur E.M.R.; BRAC James P Grant School of Public Health
    Background: Equity in access to and utilization of healthcare is an important goal for any health system and an essential prerequisite for achieving Universal Health Coverage for any country. Objectives: This study investigated the extent to which health benefits are distributed across socioeconomic groups; and how different types of providers contribute to inequity in health benefits of Bangladesh. Methodology: The distribution of health benefits across socioeconomic groups was estimated using concentration indices. Health benefits from three types of formal providers were analysed (public, private and NGO providers), separated into rural and urban populations. Decomposition of concentration indices into types of providers quantified the relative contribution of providers to the overall distribution of benefits across socioeconomic groups. Eventually, the distribution of benefits was compared to the distribution of healthcare need (proxied by 'self-reported illness and symptoms') across socioeconomic groups. Data from the latest Household Income and Expenditure Survey, 2010 and WHO-CHOICE were used. Results: An overall pro-rich distribution of healthcare benefits was observed (CI = 0.229, t-value = 9.50). Healthcare benefits from private providers (CI = 0.237, t-value = 9.44) largely favoured the richer socioeconomic groups. Little evidence of inequity in benefits was found in public (CI = 0.044, t-value = 2.98) and NGO (CI = 0.095, t-value = 0.54) providers. Private providers contributed by 95.9% to overall inequity. The poorest socioeconomic group with 21.8% of the need for healthcare received only 12.7% of the benefits, while the richest group with 18.0% of the need accounted for 32.8% of the health benefits. Conclusion: Overall healthcare benefits in Bangladesh were pro-rich, particularly because of health benefits from private providers. Public providers were observed to contribute relatively slightly to inequity. The poorest (richest) people with largest (least) need for healthcare actually received lower (higher) benefits. When working to achieve Universal Health Coverage in Bangladesh, particular consideration should be given to ensuring that private sector care is more equitable.
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    Willingness-to-pay for community-based health insurance among informal workers in urban Bangladesh
    (© 2016 Public Library of Science, 2016) Ahmed, Sayem; Enamul Hoque, Mohammad; Razzaque Sarker, Abdur; Sultana, Marufa; Islam, Ziaul; Gazi, Rukhsana; A. M. Khan, Jahangir; BRAC James P Grant School of Public Health
    Introduction Reliance on out-of-pocket payment for healthcare may lead poor households to undertake catastrophic health expenditure, and risk-pooling mechanisms have been recommended to mitigate such burdens for households in Bangladesh. About 88% of the population of Bangladesh depends on work in the informal sector. We aimed to estimate willingness-to-pay (WTP) for CBHI and identify its determinants among three categories of urban informal workers rickshaw-pullers, shopkeepers and restaurant workers. Methods The bidding game version of contingent valuation method was used to estimate weekly WTP. In three urban locations 557 workers were interviewed using a structured questionnaire during 2010 and 2011. Multiple-regression analysis was used to predict WTP by demographic and household characteristics, occupation, education level and past illness. Results WTP for a CBHI scheme was expressed by 86.7% of informal workers. Weekly average WTP was 22.8 BDT [Bangladeshi Taka; 95% confidence interval (CI) 20.9-24.8] or 0.32 USD and varied significantly across occupational groups (p = 0.000) and locations (p = 0.003). WTP was highest among rickshaw-pullers (28.2 BDT or 0.40 USD; 95% CI: 24.7-31.7), followed by restaurant workers (20.4 BDT 0.29 USD; 95% CI: 17.0-23.8) and shopkeepers (19.2 BDT or 0.27 USD; 95% CI: 16.1-22.4). Multiple regression analysis identified monthly income, occupation, geographical location and educational level as the key determinants of WTP. WTP increased 0.196% with each 1% increase in monthly income, and was 26.9% lower among workers with up to a primary level of education versus those with higher than primary, but less than one year of education. Conclusion Informal workers in urban areas thus are willing to pay for CBHI and socioeconomic differences explain the magnitude of WTP. The policy maker might think introducing communitybased model including public-community partnership model for healthcare financing of informal workers. Decision making regarding the implementation of such schemes should consider worker location and occupation.