Search

Study Question: How do households recover financially from direct out-of-pocket payment for government subsidized ART?Summary Answer: After a mean of 3.8 years, there was poor recovery from initiated financial coping strategies with the poorest households being disproportionatley affected.What Is Known Already: Out-of-pocket payment for health services can create financial burdens for households and inequities in access to care. A previous study conducted at a public-academic institution in South Africa documented that patient co-payment for one cycle of ART resulted in catastrophic expenditure for one in five households, and more frequently among the poorest, requiring diverse financial coping strategies to offset costs.Study Design, Size, Duration: An observational follow-up study was conducted ~4 years later to assess financial recovery among the 135 couples who had participated in this previous study. Data were collected over 12 months from 73 informants.Participants/materials, Setting, Method: The study was conducted at a level three referral hospital in the public-academic health sector of South Africa. At this institution ART is subsidized but requires patient co-payments. A purpose-built questionnaire capturing socio-economic information and recovery from financial coping strategies which had been activated was administered to all informants. Financial recovery was defined as the resolution of strategies initiated for the specific purpose of covering the original ART cycle. Results were analysed by strategy and household with the latter including analysis by tertiles based on socio-economic status at the time of the original expenditure. In addition to descriptive statistics, the Pearson Chi squared test was used to determine differences between socioeconomic tertiles and associations between recovery and other variables.Main Results and the Role Of Chance: The participation rate in this follow-up study was 54.1% with equal representation from the three socio-economic tertiles. The average duration of follow-up was 46.1 months (±9.78 SD) and respondents' mean age was 42 years (range 31-52). The recovery rate was below 50% for four of five strategies evaluated: 23.1% of households had re-purchased a sold asset; 23.5% had normalized a previous reduction in household spending, 33.8% had regained their savings, and 48.7% were no longer bolstering income through additional work. Two-thirds of households (60.0%) had repaid all loans and debts. The poorest households showed lower rates of recovery when compared to households in the richest tertile. Complete recovery from all strategies initiated was reported by only 10 households (13.7%): 1 of 19 in the lowest tertile, 3 of 30 in the middle and by 6 of 24 households in the richest tertile (P > 0.05). No association was found between the degree of financial recovery and additional cost burdens incurred, including related to babies born; or between the degree of recovery and ongoing pursuit of ART.Limitations, Reasons For Caution: The sample size was limited. The participation rate was just over 50%. Results were dependent on participants' narrative and recall.Wider Implications Of the Findings: The willingness of patients to pay for ART does not necessarily imply the ability to pay. As a result, the lack of comprehensive third-party funding for ART can create immediate and long-term financial hardship which is more pronounced among poorer households. While more data on the impact of out-of-pocket payment for ART are needed to illustrate the problem in other low resource settings, the results from South Africa provide useful information for similar developing countries. The current absence of more extensive data should therefore not be a barrier to the promotion of financial risk protection for infertile couples, especially the poorest, in need of ART.Study Funding/competing Interest(s): The study was supported by a Masters Student Grant from the Faculty of Health Sciences, University of Cape Town. The authors had no competing interests.Trial Registration Number: Not applicable. [ABSTRACT FROM AUTHOR]

STUDY QUESTION How often does out-of-pocket payment (OPP) for assisted reproduction techniques (ART) with conventional ovarian stimulation result in catastrophic expenditure for households? SUMMARY ANSWER Catastrophic cost was a frequent event affecting 51% of the poorest study participants and one in five couples in total. WHAT IS KNOWN ALREADY There is increasing concern about catastrophic spending on health by households in low resource settings, but to date no study has evaluated OPP for ART. STUDY DESIGN, SIZE, DURATION We conducted a prospective observational study comprising 135 couples undergoing ART between March 2009 and June 2011. PARTICIPANTS/MATERIALS, SETTING, METHODS The study was set at an urban, level 3 referral hospital in the public and academic health sector of South Africa. At this institution ART is subsidized but requires co-payment by patients. Couples undergoing ART with conventional ovarian stimulation using GnRH analogs were recruited. A questionnaire capturing information on socioeconomic status, monthly household expenditure, OPP for the index ART cycle and financial coping strategies was administered. Households were categorized into tertiles according to socio-economic status. In addition to descriptive statistics, annualized OPP for ART services as a percentage of annual non-food household expenditure was calculated to estimate catastrophic health care expenditure. The Pearson χ2 test and a logistic regression were used to identify factors related to incurring catastrophic spending. MAIN RESULTS AND THE ROLE OF CHANCE In total, one in five couples (22%) incurred catastrophic expenditure (P < 0.01), defined as an OPP of ≥40% of annual non-food expenditure. Households used a range of coping strategies including reduced expenditure on items such as clothing and food, use of savings, borrowing money and taking on extra work. Differences were observed between the socio-economic tertiles: in the poorest tertile, 51% of households faced catastrophic costs compared with only 2% of the richest tertile (P < 0.01). Participants in the poorest tertile were more likely to be black (P < 0.01), and less likely to have health insurance (P < 0.01) or female full-time employment (P < 0.01). Longer duration of infertility was an additional risk factor for catastrophic payment (P < 0.05). LIMITATIONS, REASONS FOR CAUTION No attempt was made to obtain proof of any payment or expenditure, and all information collected relied on participants' verbal account. WIDER IMPLICATIONS OF THE FINDINGS This is the first study to document the frequency of catastrophic expenditure for ART using conventional ovarian stimulation in a low resource setting. Our results show that not all couples unable to afford treatment forfeit infertility care; instead poor couples are willing to suffer catastrophic financial hardship in order to pay. ART counselling therefore needs to include financial risk counselling in the short term. Long-term interventions comprise cost-reducing strategies as well as health systems strategies that reduce or eliminate the need for OPP for ART wherever possible. Robust evidence on mild versus conventional stimulation for ART in low resource settings is also required in the form of local RCTs which address the many clinical and health economic variables and exclude bias. Our data cannot be extrapolated to patients undergoing ART elsewhere or to patients undergoing ART with mild ovarian stimulation. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by the Medical Research Council of South Africa and the University of Cape Town (University Research Committee and Faculty of Health Sciences Research Committee). The authors had no competing interests. TRIAL REGISTRATION NUMBER not applicable. [ABSTRACT FROM AUTHOR]

The article focuses on the constitutionality of the South African Value Added Tax Act. Topics mentioned include the Section 36 regarding the suspension of the payment of tax, the taxpayers' rights, and the Section 164 with reference to the collection of tax. The author also discusses the case of the company Metcash Trading Ltd. which accessed a court.