DESK REVIEWS | 07.01.08. Do people with dementia experience out-of-pocket expense to access diagnosis or care?
DESK REVIEW | 07.01.08. Do people with dementia experience out-of-pocket expense to access diagnosis or care?
Public health services (SUS) are free of charge and include medication (anticholinesterases). Those using the private sector may have health insurance which can be paid by employers or privately by themselves. It is also usual, for those who can afford it, to go directly to a well-known specialist for diagnosis and to pay the doctor directly for the consultation (usually very expensive). Sometimes, people do that in the beginning but end up in the public services as they cannot afford subsequent consultations or exams.
Most dementia related services are financed through out-of-pocket payments (Bharat and Rao, 2013).
Bharath, S., Sadanand, S., Kumar, K.J., Balachandar, R., Joshi, H., Varghese, M., 2017. Clinical and neuropsychological profile of persons with mild cognitive impairment, a hospital based study from a lower and middle income country. Asian J. Psychiatr. 30, 185–189. https://doi.org/10.1016/j.ajp.2017.10.007
Apart from Makueni county and the four counties where Universal Health Care (UHC) has been implemented for the pilot (see Part 2, Health System Organisation for details on the exception of fees for people aged 70 and over), all persons requiring medical attention irrespective of their age or illness have to pay hospital fees (consultation, laboratory tests, medications, etc.) across Kenyan health facilities. Data from the 2013 nationally representative Kenya Household Expenditure and Utilization Survey revealed a mean annual spending of 5325.12 Kenya shillings and 941.04 Kenya shillings for outpatient services and hospital admissions respectively. Transport costs to and from the health facility (1966.67 Kenyan shillings) formed nearly a quarter of total costs incurred to access health care services (Barasa et al., 2017). These out-of-pocket expenses from the household survey are not specific to dementia but apply to any person accessing health care. The difference in cost of care depends on the level of hospital, distance to the hospital, and cost of medication. Patients do not pay at lower-level health facilities to receive care unless there are medications unavailable at the facility. If the latter case applies, they receive a prescription to buy the medications outside the health facility.
Even though the government has promised senior citizens free medical insurance, this has not taken effect since January 2018. This is due to a delay by the State Department of Social Protection in submitting the list of citizens aged 70 and above to the Ministry of Health. As a result, senior citizens are turned away on arrival at accredited health facilities if they are unable to pay for the services (Igadwah & Kabale, 2019). Other individuals (below 70 years) with dementia regardless of age still pay out-of-pocket expenses to cater for consultation, laboratory tests, and medications in health facilities where UHC is not being implemented unless they have a health insurance.
Barasa, E. W., Maina, T., & Ravishankar, N. (2017). Assessing the impoverishing effects, and factors associated with the incidence of catastrophic health care payments in Kenya. International Journal for Equity in Health, 16(1), 31. https://doi.org/10.1186/s12939-017-0526-x
Igadwah, L., & Kabale, N. (2019). Payroll hitch delays free NHIF for senior citizens. Business Daily, March 2019. Nairobi, Kenya. https://www.businessdailyafrica.com/bd/economy/payroll-hitch-delays-free-nhif-for-senior-citizens-2243904
As there are no public dementia care strategies in place, there is a large proportion of individuals who incur in large out-of-pocket payments by going to private services from the moment they experience memory concerns, and for the whole of their diagnosis, treatment and care. There is no data available on the size of out-pocket payments.
If access to adequate care and treatment via the public sector is not possible, people tend to seek help from the private sector at their own expense. There is however no data found on to what extent out-of-pocket expenses are undertaken with regard to accessing diagnosis, care and treatment for dementia specifically (no dementia and dementia-care surveillance in South Africa).