Review article Ability to pay for health care: concepts and evidence

224 Steven RussellY 5 Y1 -/—Figure 4.<strong>to</strong> <strong>pay</strong>Soutc* adapted from Hancock"Health expendMure/consumptionHHealth <strong>care</strong> expenditureA ta unaf<strong>for</strong>dableTo estabf<strong>to</strong>h It the householdis able <strong>to</strong> <strong>pay</strong> <strong>for</strong> <strong>health</strong> <strong>care</strong>,fac<strong>to</strong>rs influencing expendituredecisions require analysisCan <strong>pay</strong> or won't <strong>pay</strong>? Problems with judging abilityhousehold is located in these portions of C <strong>and</strong> Drequire further analysis.First, taking the dotted portion of Region D, ahousehold at point d has enough resources <strong>to</strong> consumethe <strong>health</strong> <strong>care</strong> it needs <strong>and</strong> more than minimumlevels of other commodities. But the household movesalong its consumption possibility line <strong>to</strong> position dl- it has taken a decision <strong>to</strong> prioritize expenditure ongoods <strong>and</strong> services externally defined as 'nonessential',<strong>for</strong>cing it <strong>to</strong> reduce expenditure on <strong>health</strong><strong>care</strong> <strong>to</strong> sub-minimum levels (i.e. less than HI). Thehousehold may have made this decision <strong>for</strong> thefollowing reasons:• In<strong>for</strong>med choice: decision-makers within thehousehold are aware that the <strong>health</strong> <strong>care</strong>purchased does not meet <strong>health</strong> needs, <strong>and</strong> thatthe decision <strong>to</strong> purchase other 'non-essential'commodities will be detrimental <strong>to</strong> <strong>health</strong>.• Ignorance: the household is <strong>to</strong>tally unaware ofthe <strong>health</strong> problem <strong>and</strong> the benefits of investmentin prevention or cure.• Perceived need differs from actual need:<strong>pay</strong>ments <strong>for</strong> externally defined 'non-essential'commodities may be perceived by the household<strong>to</strong> be essential. In Figure 4, the household at pointdl may be sacrificing needed <strong>health</strong> <strong>care</strong> <strong>to</strong> spendmoney on 'non-essentials' like cigarettes. Thismay be considered a 'perverse choice' by outsiders,but smoking by women, <strong>for</strong> example, hasbeen demonstrated <strong>to</strong> be a responsible <strong>and</strong> rationaldecision which on balance promotes well-being<strong>for</strong> women <strong>and</strong> their families. 33 As another example,a household may feel it necessary <strong>to</strong> <strong>pay</strong>rent on expensive property <strong>to</strong> keep it in the family<strong>for</strong> emotional <strong>and</strong> kinship reasons. The propertycannot be sacrificed <strong>to</strong> <strong>health</strong> <strong>care</strong> needs. In somecultures, households may have <strong>to</strong> sacrifice <strong>health</strong><strong>care</strong> <strong>to</strong> <strong>pay</strong> <strong>for</strong> perceived social necessities (marriageceremonies or dowry <strong>pay</strong>ments) <strong>and</strong> <strong>to</strong> investin future claims (e.g. through various 'gifts').• Intra-household resource allocation decisions:the household must be disaggregated <strong>to</strong> underst<strong>and</strong>why non-essentials are given higher prioritythan <strong>health</strong> <strong>care</strong>. A male household head mayprioritize personal consumption of non-essentials(e.g. alcohol) over <strong>health</strong> expenditure on childrenor his spouse, resulting in a consumption positionsimilar <strong>to</strong> point dl in Figure 4. He may stillhave enough money <strong>to</strong> spend on <strong>health</strong> <strong>care</strong> <strong>for</strong>himself, but not <strong>for</strong> those considered less of apriority, perhaps because they are economicallyunproductive. A study in Haiti, 36 <strong>for</strong> example,found that two mothers had not taken theirchildren <strong>for</strong> immunization because their husb<strong>and</strong>shad expensive surgery which depleted theirfinances <strong>and</strong> required wives <strong>to</strong> devote considerabletime <strong>to</strong> <strong>care</strong>. While the household can'af<strong>for</strong>d' <strong>health</strong> <strong>care</strong>, individuals within it who donot have a voice in resource allocation cannot.When resources are limited intra-household conflictswill become more intense. At point a inFigure 2 or point c in Figure 3 the household asa unit cannot af<strong>for</strong>d adequate <strong>health</strong> <strong>care</strong> <strong>for</strong> allits members: some may receive the <strong>health</strong> <strong>care</strong>they need, but others will not.• Expense of accessing distant providers: <strong>to</strong> purchasethe treatment needed the costs of transport<strong>and</strong> time lost may <strong>for</strong>ce the household <strong>to</strong> purchasecheaper alternatives closer <strong>to</strong> home which are notadequate <strong>to</strong> meet the <strong>health</strong> <strong>care</strong> needed.• Perceived severity of illness: the illness may beperceived <strong>to</strong> be so severe that <strong>pay</strong>ment <strong>for</strong> treatmentis not considered worthwhile. If the qualityof <strong>care</strong> is perceived <strong>to</strong> be poor <strong>and</strong> ineffective,non-essentials may also be purchased at the expenseof <strong>health</strong> <strong>care</strong>.The range <strong>and</strong> complexity of dem<strong>and</strong> <strong>and</strong> supply fac<strong>to</strong>rswhich might influence a household's expenditure