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The Impact of Out-of-Pocket Expenditures on Families and Barriers to Use of Maternal and Child Health Services in Timor-Leste

The Impact of Out-of-Pocket Expenditures on Families and Barriers to Use of Maternal and Child Health Services in Timor-Leste

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This country brief examines the impact of out-of-pocket expenditures for maternal and child services based on analysis of the Timor-Leste Surveys of Living Standards 2001 and 2007.
This country brief examines the impact of out-of-pocket expenditures for maternal and child services based on analysis of the Timor-Leste Surveys of Living Standards 2001 and 2007.

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Published by: Asian Development Bank on Feb 19, 2013
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The Impact of Out-of-Pocket Expenditures on Families and Barriers to Use of Maternal and Child Health Services in Timor-Leste
 
Out-of-Pocket Spending on Maternal and Child Health in Asia and the Pacific
The Impact of Out-of-Pocket Expenditureson Families and Barriers to Use of Maternaland Child Health Services in Timor-Leste
Evidence from the Timor-Leste Surveys of LivingStandards 2001 and 2007
COUNTRY BRIEF
 
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Background
Despite substantial improvements in health conditions since itsindependence in 2002, the Timor-Leste population continuesto face a heavy burden regarding maternal and child health.One woman in 16 dies during pregnancy, and one in 10 diesfrom pregnancy or related causes (Ministry of Health 2007),which is among the highest rates in Asia. In addition, one in20 children still die before their fifth birthday (UNICEF 2011).The Government of Timor-Leste is committed to reaching theMillennium Development Goals and to improving the accessof its people to adequate healthcare services. The NationalHealth Sector Strategic Plan prioritizes the improvement of quality and coverage of preventive and curative health servicesfor women and children to accelerate progress toward thehealth Millennium Development Goals. Key developmentpartners, such as the Asian Development Bank, Australian Agency for International Development, and World Bank,support this focus on improving access to basic maternal andchild health services and on reducing barriers to access.The government, with financial support from its developmentpartners, is the primary funder of the Timor-Leste health
Summary
•Asayoungnation,Timor-Lestehasmadeconsiderableadvancesinrebuildingitshealthsystem,but
overall utilization of health services remains low by regional standards.
•Largedisparitiesexistinuseofcriticalmaternalandchildhealthservicesbetweenrichandpoor,and
across districts, and these correlate with maternal and child health outcomes.
•Expandingtheuseoffacility-basedmaternalandchildhealthservicesiscriticaltoimprovingmaternal
and child health outcomes in Timor-Leste. Expanding access to inpatient services is also critical toimprove rates of skilled birth attendance.
•Inmostcountries,themainbarrierstouseofmaternalandchildhealthservicesarefinancialcostsof
treatment and physical access. In Timor-Leste, the main problem is the lack of physical access due tothe large distances that many people have to travel to access medical care. This barrier is greatest inrural areas and certain districts, such as Bobonaro and Lautem.
•Out-of-pocketspendingonhealthcareislowinTimor-Leste,andsofewhouseholdsexperiencefinancially
catastrophic burdens. Catastrophic and impoverishing expenditures for health are much lower than inmost countries in the region, and so should not be the main focus for improving equity.
•Publicsectorfacilitiesare,inpractice,freetomostpatients,andinformalpaymentsarerareunlikeinother
countries, such as Indonesia. This strength of the healthcare system should be safeguarded.
•Thelowlevelofspendingdoesnotmeanthatthehealthcaresystemensuresgoodcoverage.Itismore
a reflection of the fact that most families, especially those in rural areas, lack access to any medicalfacilities, so they do not even have the option of making payments at private providers.
•ToimproveaccessandoutcomesinTimor-Leste,thefirstpriorityshouldbetofocusonexpanding
the service delivery network in rural areas so that more lower- and mid-level healthcare facilities,including those with inpatient services, are closer to families.
•Thesecondpriorityshouldbetostrengthenthesystemoffreecareservicesbyimprovingthesupplyand
availability of medicines in government facilities. A frequent shortage of medicines is the one area where familiesdo experience some financial burdens in obtaining care, and this is most common in the case of inpatient care.
system. According to World Health Organization estimates,overall health spending in Timor-Leste has been high incomparison with comparable countries in the region: 9.1%of gross domestic product in 2010, compared with 2.6% inIndonesia, and 3.6% in Papua New Guinea. Of this, 44%is contributed by private financing. In per capita terms,total spending was almost $58 per capita in 2007 and$57 in 2010. Undeniably, spending has been declining inrecent years, with a reduction in external assistance for thehealth sector. During 2007–2010, it declined from 15.4%to 9.0% of gross domestic product. As a percentage of government spending, health is on a declining trend from19.0% of government expenditures in 2007 to only 4.7%in 2010.Healthcare services are mostly provided by governmentfacilities, consisting of health posts, community health centers,and regional and national hospitals, supplemented since2008 by SISCa (Sistema Integradu Saude Communitaria)mobile clinics. There is very limited private provision incontrast to other Asian countries, and this is mostly traditionalproviders, in rural areas, and a small number of church,nongovernment organization, and private doctor clinicsmostly in urban areas.
 
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The Impact of Out-of-Pocket Expenditures on Families and Barriers to Use of Maternal and Child Health Services in Timor-Leste
Overall levels of healthcare utilization are low by regionalstandards (OECD 2010), equivalent to only two outpatientvisits per capita per year to medical providers, and two inpatientadmissions per 100 capita. These low levels of use are reflectedin low, though increasing, levels of skilled birth attendance anduse of available maternal and child health services (NSD 2010).
Data Sources
This brief presents findings from analysis of the Timor-LesteSurveys of Living Standards (TLSLS) 2001 and 2007, which wereundertaken by the Government of Timor-Leste (National StatisticsDirectorate 2001 and 2007). These surveys permit examinationof how inequalities in healthcare utilization changed during a6-year period marked by many changes in the country.The TLSLS 2001 is a nationally representative household survey of 1,800 households (9,117 individuals), with fieldwork taking placefrom August to November 2001. The TLSLS 2007 is a survey of 4,477 households (25,000 individuals) that was originally scheduledfor 2006, with actual fieldwork taking place from January 2007 toDecember 2008. Both surveys collected information on householdconsumption and included a healthcare module that asks abouthealthcare utilization and expenditures. Some differences in thequestion design of the health modules, particularly relating tohealthcare utilization, mean that some comparisons from the twosurveys are not reliable. Detailed information in each survey onhousehold consumption was used to categorize the population intoequal, ranked quintiles, using consumption per adult-equivalent asthe measure of relative living standards.
Perception of Illness and Treatment Seeking
Both TLSLS surveys asked individuals whether they had been ill inthe past 30 days. This is a standard question in many surveys butis not a reliable measure of the level of illness, since the reportingof sickness depends on the tolerance of people to symptoms andawareness of what might constitute illness. In most countries,the poor and less educated are less likely to report that they aresick when they are ill, but this improves as people become morehealth aware, with frequently more people reporting they are sick.The proportions of individuals who reported that they were sick inthe past 30 days changed little between the TLSLS rounds 2001 and2007, but the proportions of children (i.e., less than age 5 years)reported as sick increased substantially from 22% to 43% in thesame period. Some part of this probably reflects increasing healthawareness, as other data indicate improving child health outcomes(NSD 2010). The poor in 2001 were far less likely to report havingbeen sick in the past 30 days than the nonpoor (concentration indexsignificant at 1%), but this difference had been eliminated by 2007.The same pattern is seen both in adults and in children (Figure 1).This suggests that the poor are less responsive to sickness than thenonpoor, but that responsiveness and health awareness improvedfaster in the poor than the nonpoor between the surveys.Being sick does not automatically lead to seeking medicaltreatment. In many countries, the poor, when sick, are less likelyto obtain treatment than the rich. In Timor-Leste, however, thisdisparity is not seen. The likelihood of a sick person seekingmedical care increased substantially from 51% in 2001 to 74% in2007. Increases occurred at all income levels, and in adults andchildren, with little evidence of significant disparities by incomelevel. In general, children were more likely to be taken for carethan adults when sick (Figure 2). However, in both surveys, sickadults and children were significantly less likely to be taken for treatment in rural than urban areas (Figure 3).
Figure 1: Illness Reporting of Children in Timor-Leste, bySocioeconomic Status, 2001 and 2007Figure 2: Treatment Seeking When Sick in Timor-Leste,by Socioeconomic Status, 2007
PoorestRichestQ2Q3Q4
9080706050403020100
   %   o   f  s   i  c   k   i  n   d   i  v   i   d  u  a   l  s  s  e  e   k   i  n  g  c  a  r  e
 All ChildrenQ = quintileSource: Authors’ analysis of TLSLS 2007 data set.
Quintile
50454035302520151050
PoorestRichestQ2Q3Q4
   %   o   f  c   h   i   l   d  r  e  n  r  e  p  o  r   t  e   d  s   i  c   k   i  n   t   h  e  p  a  s   t   3   0   d  a  y  s
2001 2007Q = quintileSources: Authors’ analysis of TLSLS 2001 and 2007 data sets.
Quintile
Excluding the cases where the illness was not consideredserious enough, the overwhelming reason why sick personsdo not seek treatment in both surveys is that health facilitiesare too distant (68% overall and 46% for children in 2007).

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