Out-of-pocket and catastrophic expenditure among Schizophrenia patients and CBHI enrollment at St. Amanuel Mental Specialized Hospital (ST.AMSH): a hospital based comparative study

Out-of-pocket and catastrophic expenditure among Schizophrenia patients and CBHI enrollment at St. Amanuel Mental Specialized Hospital (ST.AMSH): a hospital based comparative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Out-of-pocket and catastrophic expenditure among Schizophrenia patients and CBHI enrollment at St. Amanuel Mental Specialized Hospital (ST.AMSH): a hospital based comparative study Samuel Erko, Mrs Berhan Tassew, Dr Anagaw Dereseh This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7217174/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background In Ethiopia, limited mental health service coverage and financial protection expose households to severe economic consequences from psychiatric disorders. One of the most common and increasing disorders being Schizophrenia, schizophrenic patients and caregivers face treatment costs, income loss, unemployment, and social stigma, highlighting the need to evaluate out-of-pocket (OOP) expenditures and the protective role of Community-Based Health Insurance (CBHI). Methods A hospital-based cross-sectional study was conducted at St. Amanuel Mental Specialized Hospital, Addis Ababa, including 348 schizophrenia patients (50% CBHI-enrolled) on follow-up. Data were collected via face-to-face interviews using structured questionnaires. Direct/indirect costs were measured using human capital approach, with catastrophic health expenditure (CHE) assessed at 10%, 15%, 25%, and 40% thresholds. Multivariable logistic regression analyzed CBHI's effect on CHE. Results Participants mean age was 35 years (62.9% male). The mean annual OOP costs were: medical (2,260.83 ETB/41.23 USD), non-medical (760.12 ETB/13.87 USD), and productivity loss (3,258.29 ETB/59.29 USD). CHE incidence at 15% non-food threshold was 36.7% for CBHI members versus 48% for non-members (p < 0.05). Conclusions CBHI significantly reduces CHE incidence among schizophrenia patients, though indirect costs remain burdensome. Policy interventions to expand insurance coverage and address productivity losses are urgently needed. Schizophrenia catastrophic health expenditure out-of-pocket costs health insurance Ethiopia Introduction Background information Schizophrenia is a severe and chronic mental disorder which manifests a wide variety of psychological symptoms. A major symptom is inability to discern his/her own thoughts and ideas from reality, perception, and improper emotions. Others include hallucinations, delusions, jumbled thinking, loss of interest in daily tasks, lack of concern for personal hygiene, and a desire to avoid others, including friends and family. The disease strikes in late adolescence or early adulthood and progresses in a variety of ways, from complete clinical recovery to chronic or recurrent illness with lingering symptoms and incomplete social rehabilitation. Schizophrenia is classified in the category of severe mental illnesses that include psychosis and schizoaffective disorders. it was noticed in Ethiopia as early as the 1960s. According to a study, the prevalence of these serious mental diseases in Ethiopia was between 1.3% and 1.6% in the early 1960s(1). A study on 321 cases of schizophrenia in Butajira provided an estimated lifetime prevalence of 4.7/1,000) (2). several national population-based statistics that reveal the number of persons now suffering from these disorder and have highlighted the rising prevalence of schizophrenia. According to estimates, 5.8% of Ethiopia's population of almost 100 million suffers from neuropsychiatric diseases (3).Schizophrenia and depression are two of the ten most debilitating diseases in a region that is primarily rural, accounting for 11% of the total disease burden(4). Due to the chronic duration of schizophrenia patients and families endure a long lasting economic burden. Costs that are directly related to the treatment of schizophrenia include cost of hospitalization (short- and long-term), outpatient follow-up, pharmaceutical interventions, and laboratory testing, whereas the indirect costs are mainly related to the loss of productivity. A study in Nigeria shows that the mean overall cost of schizophrenia was 2951.4 naira (US$ 35.9) in the six-month period (5). In another study conducted at a Nigerian university the mean total annual cost and mean annual direct cost of treating schizophrenia was $818.5 (±684.35).and $349.6 (±296.04) respectively. The largest component of the direct costs was accounted for by medications; this constituted 51.2% of the direct cost and 21.9% of the total cost (6). Catastrophic health expenditure (CHE) occurs when out of pocket payment payments for health services consume large portion of a household’s income. dependence on out of pocket payment for medical and health care bills will leaves households exposed to risk of catastrophic expenses whenever a household member falls ill. Specially household with psychological and mental health disorders will be on the shorter end(7). It is estimated that 150 million people face some financial catastrophe due to OOP and that 100 million are pushed into poverty every year, as a result of CHE(8).CHE are heavily influenced by the method of financing. The healthcare sector of Ethiopia uses multiple sources for financing the different systems and units within, including loans and donations (46.8%), the Ethiopian Government (16.5%), out-of-pocket (OOP) payments (35.8%), and others (0.9%) (9). Even if Ethiopia is one of the fastest growing nations in Africa it still has a small and unstructured formal sector from which health insurance premiums could be collected with relative ease.in addition most of the population is employed under the non-informal sector of the economy which also makes it a necessary for people to pay for their medical and health care expenses from the patient’s own pockets. Besides, the informal sector is characterized by low wages and salaries. Most households are therefore dependent on uninsured medical expenditures to finance health care. Financing health care through this method can pose a major threat to living standards particularly in low- and middle-income countries (LIMIC). Being a chronic illness schizophrenia is considered as one of the most costly of all mental disorders. The annual cost of treatment estimate could go as high as approximately 2-fold higher than the cost of major depression and more than 4-fold higher than any anxiety disorder (10).other factors that will increases the treatment costs are genetic factors and medication adherence (11,12), various clinical and demographic factors are associated with higher risk of relapse and hospitalization, events that are predictive of higher costs (13).Other factors also contributing to the higher COT are lower educational level, unemployment, higher illness chronicity, co-occurring alcohol and substance abuse, a history of depression and/or suicide attempts, a history of violence and/or arrests, and recent hospitalization (14–16) Methodology Study area and study period Hospital based comparative cross-sectional study was conducted at St. Amanuel Mental Specialized Hospital (St. AMSH). The hospital is a specialized mental health governmental hospital in the country and was established in 1930. It is located in the western part of Addis Ababa in Addis Ketema sub city. St. AMSH provides care for patients coming from the entire nation of Ethiopia. The study was conducted from 10 th April to 15 May 2022. Source population The source population was all schizophrenia patients who are attending follow up in St. Amanuel mental specialized hospital. and the study population was all previously diagnosed schizophrenia inpatients and outpatients that were available during data collection period at the health facility. Inclusion and exclusion criteria . All schizophrenia patients who are diagnosed , with regular follow up and present during the data collection period and who are willing and stable to reply to the questions in addition data was collected from willing care givers present during the data collection period to verify and insure reliability of information provided. participants who were excluded were patients who were unable to respond and present without a care giver, who are under 18 age and whom were present without a caregiver or an adult. Sample size The sample size was determined by using both single and double population proportion formulas. To find the level of CHE in a cross sectional study this study used a single population proportion .and a proportion of CHE (32.2%) , 95% confidence interval, power 80%, 5% degree of precision which was taken from study conducted on SMD patients and households in rural Ethiopia(17). where the total sample size was determined and finally used came to 368 schizophrenic patients. whereas for the double population proportion with the assumption of one to one ratio for a comparative study taking the proportion of CHE study conducted in Assela which is 30.6% and 47 % among CBHI member and non CBHI members respectively(18) giving as a total of 330 participants. Sampling Procedure The sampling frame will include patients who have been diagnosed as schizophrenia patient and been on follow up as an inpatient or outpatient. After checking whether they are enrolled in CBHI or not in order to get a representative sample, systematic random sampling was applied to select eligible study participants according to a 1:1 ratio. Data collection tool and data collection technique A structured questionnaire was developed from other relevant literature . The data was collected by face to face interview. Questionnaire was developed both in Amharic and English but was administered in Amharic using a paper based approach and was filled by the interviewer or data collector to ensure correct entry it was later translated to English for entry purposes. The questioner included variables like socio-demographic and socio-economic characteristics, clinical characteristics, also cost items household expenditures, monthly out of pocket health expenditures and enrolment status of community-based health insurance. 5.8 Data collection, entry, Processing and analysis After data was collected using paper based approach was checked by the primary researcher every two days .the collected responses are stored properly for later reference if needed. On the final date of data collection, the data was checked and entered to using Epidata 3.1 and cleaned and analyzed using STATA version 16. Summary statistics, including mean, median, standard deviation and proportion, has been performed to summarize the data and explain the study variables. Measurement and valuation Measurement and Cost valuation was done by using micro costing approach to determine the direct medical and non direct medical cost. The direct medical costs included costs for registration ,bed, drugs, laboratory and imaging during one month period.. The non direct medical costs were food, transportation, other non-medical supplies, and services on the way to the treatment facility incurred during visitation to the hospital by the patients and caregivers for a one month period . All direct cost information was collected in Ethiopian Birr (ETB). Indirect costs or lost time of productivity due to certain illness were measured in terms of a number of forgone working days of the patients and caregivers if they are formal employees and for the unemployed or once with out permanet jobs, unskilled labor and farmers the lost time was calculated using a pre estimated daily wage rate. Estimation of catastrophic health expenditure In this study in order to measure the amount of catastrophic health expenditure by patients the method of Wagstaff and Van Doorslaer, (2002) was used . This method uses non-food household expenditure as the denominator in order to estimate catastrophic health expenditure Headcount, Overshoot and Mean positive overshoot. The different threshold recommended by Wagstaff and Van Doorslaer, (2002) to be used to check for incidence and severity of CHE are at 15%, 25% and 40% of nonfood expenditure, 10% and 15% of total expenditure. And lastly to find the effect insurance status has on CHE a cut point of 15% of non-food expenditure was used. This method uses Headcount, Overshoot and Mean positive overshoot to measure the inceidence and severity of catastrophic health expenditure faced by individuals and households. Headcount (HC) is defined as the incidence of households percentage whose out of pocket expenses compared as a proportion of their total income or non-food expenditure exceed a certain threshold. While the severity of CHE is measured by Overshoot(OS) which is the mean amount by which OOP expenditure exceed the respectable thresholds for all the sample households, and the mean positive overshoot (MPO) is the average amount for those whose household experienced CHE divided by the level the CHE exceeded the respectable thresholds. Estimation of effect of CBHI on CHE In this study PSM was used to identify the effect of the treatment variable community based health insurance enrolment status on catastrophic health expenditure. the widely used method to determine impact or effect evaluation for many studies is Propensity score matching. PSM uses statistical technic to construct a control group by matching each treated individual (individuals enrolled in the CBHI ) with a non-treated or uninsured individuals with of similar observable characteristics. After which by using these matches, we can estimate the impact of an intervention.or CBHI on CHE. The initial step in PSM is estimation by using either logit or probit which helps to find the likelihood of being enrolled in CBHI by using socio-demographic and economic variables as covariates. Then the variables and individual observations have to be restricted by using two major assumptions the first assumption is common support or overlap. The common support or overlap assumption ensures that individual observations with the same covariate values have a positive probability of being both treated(insured) and untreated (uninsured). To identify for this assumption we will run a density-distribution plots of propensity scores and a visualization of both groups by histogram .secondly to check for the validity of our PSM we will check for the conditional independence assumption also called confoundedness which states that probability of being in the treated group should only be based on observed treatment outcomes. If unobserved outcome determines the probability of individuals being grouped in the intervention then selection bias is apparent or the , conditional independence is violated. And in order to restrict this we will run balancing test. Among the commonly used standardized bias, the T test, and pseudo R 2 .the results in this tests will determine which matching algorism we will be using. After estimation of the propensity score we will precede to selection our matching algorism. Here the individual observations in the treatment group (CBHI members) will be matched with the counterfactual observation or non-CBHI members with similar propensity scores or probability of being in the intervention program or CBHI. In this study we chose the kernel matching test because of the higher number of matched observation (n=348) and lower mean bias(4.4) and Pseudo R 2 (0.004) Finally we estimate the effect or impact of the intervention program by using the mean difference in outcome between the insured and their matched uninsured counterparts. Results Socio-demographic and economic characteristics The study involved 348 participants with response rate of 94%. The majority 245(64.1%) of study participant were male. Age of respondents range from 18 to 70 with mean of 35. 46 ± 9.76. Most of participant 185(53.2%) were orthodox in religion and 229(669.96%) were single. Among participant 216(62.1%) are urban resident. The household size vary from 1 to 12 with mean (SD) of 4.6( ± 2.9) and 122(51.3%) had five or more household member. The mean (SD) of distance from St Ammanuel mental specialized Hospital was 61( ± 60.3) and 112(32.2%) of them were in categories of 25–50 KM. Regarding educational status and occupation of participants, 113(32.4%) had tertiary education level(above 12th grade) and 104(30.4%) are unemployed. The majority 223(64.1%) of study participants HH had monthly income of less than 2500 Ethiopian birr. Table 1 should be here CBHI enrolment status Among study participant 174(50%) are CBHI member. The mean duration since becoming member was 26.8( ± 11.5) months. Most of 120(69%) participants enrolled CBHI by household contribution. Among the participants 152(87.4%) believe that they benefit from CBHI scheme and the most commonly mentioned benefit was reduced cost of health care by 146(91.2%). 138(79.3%) of participant stated as they get medical service free of charge in hospital. Table 1 should be here Variable Category Frequency Percent Sex Male 219 62.9 Female 129 37.1 Religion Orthodox 185 53.2 Muslim 129 37.1 Protestant 34 9.7 Marital status Single 235 67.5 Married 43 12.36 Widowed 10 2.87 Separated 43 12.36 Divorced 17 4.89 Residence Urban 216 62.1 Rural 132 37.9 Number of family member in the HH 5 122 51.3 Distance from St AMSH 1–25 88 25.3 25–50 112 32.2 50–75 17 4.9 76–100 71 20.4 > 100 60 17.2 Educational status Unable to read and write 28 8.1 read and write 69 19.8 primary education 83 23.8 Secondary education ( 9 – 12 ) 55 15.8 Tertiary education (above12) 113 32.5 Occupation Farmer 34 9.8 Employee 60 17.2 Self-employed 31 8.9 Unemployed 104 29.9 Merchant 41 11.9 daily labourer 23 6.6 house wife 17 4.9 Student 31 8.9 Retired 7 2 Average months Household income 10000 13 3.7 Wealth Quintiles Poorest 77 22.1 Q2 64 18.4 Q3 88 25.3 Q4 50 14.4 Richest 69 19.8 Table 2 Variable Category Frequency Percent CBHI member Yes 174 50 No 174 50 Who paid for enrolment fee Household contribution 120 69 Local government (coverage or Indigent 54 31 Benefited from CBHI No 22 12.6 Yes 152 87.4 Types of Benefit Increased access to health 103 64.4 Reduced costs of health care 146 91.2 Reduced concerns about expected health care costs 57 35.6 Get service in Hospital currently Free of charge 138 79.3 Partial OOP payment 31 17.8 Substantially OOP 5 2.9 Clinical characteristics Among the study participant 198(56.9%) were in patients. The mean duration since diagnosed for illness was 34.2 ± 22.62. The majority 314(90%) of participants had regular follow up. Among them 119(37.9%) had follow up every three months as indicated in (Table) . Table 3 Variable Category Frequency Percent Patient admission Inpatient 150 43.1 Out Patients 198 56.9 Regular follow up Yes 314 90.2 No 34 9.7 Benefited from CBHI No 22 12.6 Yes 152 87.4 Follow Up appointment Every Month 97 30.9 Every Two Months 78 24.8 Every Three Months 119 37.9 Every Six Months 20 6.4 Cost of treatment of schizophrenia and Catastrophic Health Expenditure Out of pocket expenditure for treatment of schizophrenia the average medical cost was 2260.83 ETB(41.23USD), While OOP for non-medical cost was 760.12ETB (13.87USD). The average OOP medical cost among CBHI member and non-member was 216.92( ± 1000.46) and 5884.74 ( ± 4304.73) respectively. The OOP non-medical expenditure for non-medical cost was 752.66( ± 1222.88) and 767.581( ± 1673.87) for CBHI and non-CBHI members respectively. The mean loss productive as result of schizophrenia was estimated to 3258.291 ( ± 5011.122). The estimated average lost productivity among CBHI member and non-member was 2800.63 ( ± 4108.074) and 3715.950 ( ± 5750.674). The incidence of catastrophic health expenditure among study participant was 48% and 34.8% at 15% of non-food and total household expenditure. The incidence of CHE decline as the threshold rise from 10–40%, for instance when the threshold raise from 10–40% of non-food expenditure the incidence of CHE decline from 54.3–28.7%. The catastrophic overshoot and mean positive overshoot was 32.4% and 67.5% at 15% of non-food threshold. The incidence of CHE among CBHI member was 36.7% at 15% non-food threshold while it was 59.2% for non-CBHI member. The overshoot and mean positive overshoot was 14.2% and 38.7% at 15% of non-food threshold while it was 32.4% and 67.5% for non-members . Effect of community based health insurance on Catastrophic health expenditure Table 4 Incidence of CHE Treated Controls Difference S.E. T-stat Non-food 10% .431034483 .697836455 − .266801973 .058734819 -4.54* 15% .367816092 .651072645 − .283256553 .059302646 -4.78* 25% .247126437 .601552122 − .354425686 .057529794 -6.1* 40% .143678161 .479694875 − .336016714 .054010867 -6.22* Total HH expenditure 10% .316091954 .657783971 − .341692017 .058233167 -5.87* 15% .195402299 .549100366 − .353698068 .056192176 -6.29* 25% .091954023 .426350498 − .334396475 .051113423 -6.54* 40% .068965517 .277107039 − .208141522 .046807138 -4.45* The effect of community-based health insurance on catastrophic health expenditures was estimated using kernel matching at different levels of threshold. There was a significant difference in the incidence of CHE among CBHI members and non-members. Enrollment in CBHI members lowers the incidence of CHE for instances at the 15% threshold of non-food expenditure; the incidence of CBHI was 37% lower among insured. This difference was significant using a different method and threshold. Coping Mechanism Regarding coping mechanism used to finance their medical expenses about 112(32.2%) and 93(26.7%) used CBHI and own money, respectively. While 56(16.1%) borrowed. Among those who borrowed 28(68.3%) borrowed from family.. this is similarly seen in a study that shows a person with SMD if uninsured has a higher tendency to borrow and sell asset this is evidence in a study showing the low level of ownership of assets by household with SMD(56).The majority 64.4% of insured patients used CBHI and only 17.2% used own money. Discussion This study aimed to identify the catastrophic out of pocket payment faced by schizophrenia patients, assessing total direct and indirect costs, identifying the variables that influence this costs and the effect of being insured or uninsured by community based health insurance has on the catastrophic out of pocket payment. As stated in the results section the mean out of pocket annual total direct medical costs per patient was 2260.83 ETB(41.23USD), While OOP for non-medical cost was 760.12 ETB(13.87USD) and the combined total OOP expenditure is 3020.95ETB (50.09USD). The costs incurred in this study were lower than seen in other studies ( 6 , 19 , 20 ) this may be due to the differences in the socioeconomic and medical costs in Ethiopia. a study conducted in rural Ethiopia shows households with members that had a schizophrenic family member spent $ 16.52 out-of-pocket for a year and on average they had lost 3.12 (sd = 4.54) days of work in one month( 21 ). In another study conducted in china the mean annual total direct medical costs per patient was CNY41,972.4 (US $ 6852.5)( 19 ). In another study conducted in Taiwan shows that annual average of direct costs for each schizophrenic patient was US $ 2115 and an indirect cost of (US $ 14,461). The largest cost was indirect cost or loss of productivity and medication cost which is about (US $ 944.8) ( 20 ). In a similar study conducted in Nigeria teaching hospital the average annual total, direct, and indirect costs of the treatment were $ 818.48, $ 349.59, and $ 468.89, respectively, per patient( 6 ). All the above studies show a total out of pocket costs greater than observed in this study. What we can infer from most studies conducted to find the OOP expenditure of schizophrenia and other mental disorders point to the fact that out of the total costs indirect costs or productivity loss and hospitalization costs has the greatest share. This shows one of the negative effects of mental disorder. Particularly schizophrenia is found to be highly associated with unemployment, loss of working days, lack of well-being and poor levels of social functioning these will result in loss of productivity borne by patients, caregivers and increase in indirect cost as seen in this study. The amount of indirect cost was 3258.291ETB (59.69 USD) which is more than the direct cost incurred by patients. In a study conducted in a Nigerian teaching hospital the indirect cost of treatment is $ 468.89 (57.3%) which is higher. In other study conducted in Mexico the productivity loss cost is even higher as much as USD 5,760 including a caregiver’s loss of productivity of USD460(22). In conclusion all this shows the debilitating effect of schizophrenia and the economic burden caused due to the loss of productivity and the medical expenditure caused by schizophrenia. Not many studies are done comparing out of pocket treatment costs of insured versus uninsured but in this study the direct cost of treatment for insured patients comes to 216.92 ETB(3.96 USD) which is significantly lower than uninsured patients OOP which is about 4303.73ETB (59.59USD) ,comparing this to a study conducted in Mexico which shows patients that are uninsured face a direct out of pocket cost of $ 510(23). in another study conducted in Assella referral hospital to find the effects of CBHI on CHE with chronic patients of 336 out of which 35 psychiatric patients shows insured members had a lower incidence of catastrophic health spending than non-CBHI members, 31% and 47% respectively ( 18 ). In addition to the difference in the occurrence of direct costs there is a significant difference in the indirect cost between insured and uninsured patients. Insured patients productivity cost is 2800.633 ETB (51.07USD) meanwhile uninsured patients have a productivity cost of 3715.95 ETB (67.76USD). In this study, uninsured patients had 65% of their 10% their monthly non-food expenditures, and 60.9% of their total household expenditure. Comparatively insured patients will spend 43% of their 10% monthly non-food expenditures, and 31.2% of their total household expenditure. this shows the need to increase for the accessibility and inclusivity of community Based health insurance. This study also shows the severity of catastrophic health expenditure among schizophrenic patients as overshoot and mean positive overshoot. The average exciding overshoot from 10% 15% 25% 40% of nonfood expenditure in the total study population was 34.9%,32.4%, 28.1%, 23% respectively, showing a reduction in overshoot as the threshold increases. While the average overshoot for insured at this threshold was 16.2%, 14.2%, 11.1%, 8.4% respectively, this shows a significant reduction in the severity of catastrophic expenditure. On the other hand uninsured patients showed a 53.7%, 50.6%, 44.9%,37.5% respective MPO results, which is a significant increase in the severity of catastrophic expenditure. Community based health insurance member patients had a lower incidence of catastrophic health spending than non-CBHI members, 48% and 34.8% at 15% of non-food and total household expenditure. The incidence of CHE among CBHI member was 36.7% at 15% non-food threshold while it was 48% for non-CBHI member. Which is very similar to a study conducted in Butajira where the incidence of catastrophic OOP payments was 32.2% for households of a person with SMD( 17 ). Another study shows an incidence of 16.6% of OOP CHE in uninsured household this may be due to the low number of study participants in the study(23). Even if CBHI member patients had shown a lower incidence of catastrophic expenditure they are still subjected to increased non medical expenditure which will lead to a lower quality of life and eventually lead to financial inadequacy of the households and care givers. Conclusion As shown in the study, schizophrenia patients and their caregivers face a huge financial difficulty since the incidence and severity of catastrophic health spending are high among house hold of uninsured patients. The incidence varies from 65.5–43.1%. .and for both insured and uninsured household it is between 34.9–23% overshoot. All this can be as a result of unemployment of the patients which is 29.9% in this study, lower wealth index of patients and caregivers(2.5%, where 25.5 lie in Q3 ) and specially due to the status of being uninsured in CBHI and also due to the high cost of living, high cost of medical and medication costs, low accessibility and lengthened time of diagnosis in Ethiopia. as indicated in this study in order to alleviate this financial burden CBHI plays a key role.in order to find a solution the government of Ethiopia has to make sure that the CBHI program gets to all patients and families. As seen in this study the financial security offered by community-based health has a very strong impact.as compared in the study non-CBHI members had a substantially higher incidence and intensity of catastrophic health expenditure than CBHI members, In conclusion this study recommends that expanding the coverage of community-based health insurance schemes helps to strengthen financial Security and increase life quality of schizophrenic patients and their families. Abbreviations CBHI Community-Based Health Insurance CHE Catastrophic Health Expenditure ETB Ethiopian Birr OOP Out-of-Pocket PSM Propensity Score Matching USD United States Dollar Declarations Ethics approval and consent to participate Ethical approval was obtained from the Institutional Research Ethics Review Board (IRB) of Addis Ababa University, School of Public Health (Ref: [Insert reference number if available]). Written informed consent was obtained from all participants or their caregivers (for patients under 18 or unable to respond). The study adhered to the principles of the Declaration of Helsinki. Consent for publication Not applicable (no individual person’s data, images, or videos are included). Availability of data and materials The datasets used and analyzed during this study are available from the corresponding author upon reasonable request. Competing interests The authors declare no competing interests. Funding This research received funding from Addis Ababa university school of public health Clinical trial number Clinical trial number: not applicable Authors' contributions Samuel Berhanu: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing original draft. Mrs Berhan Tassew: Supervision, Validation, Writing review & editing. Dr Anagaw Dereseh: Supervision, Methodology, Validation. All authors read and approved the final manuscript. Acknowledgements We thank St. Amanuel Mental Specialized Hospital staff, data collectors, and study participants for their cooperation. Special gratitude to Addis Ababa University for technical support. Authors' information (optional) SB: MSc Candidate in Health Economics, Addis Ababa University. Mrs Berhan Tassew: MPH, Public Health Specialist. Dr Anagaw Dereseh: PhD, Health Economist. Authors' Information Samuel Berhanu :holds a Bachelor of Science degree in public health and is an MSc candidate in Health Economics at Addis Ababa University. His research focuses on health financing and economic burdens of mental health disorders in low-resource settings. Mrs Berhan Tassew (MPH): is a public health specialist with expertise in health systems research and policy analysis. She serves as a lecturer and research advisor at Addis Ababa University. Dr Anagaw Dersch (PhD) : is a Health Economist and senior researcher specializing in healthcare financing and insurance systems. 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Direct medical costs for patients with schizophrenia: A 4-year cohort study from health insurance claims data in Guangzhou city, Southern China. Int J Ment Health Syst. 2018;12:72. Lee IH, Chen PS, Yang YK, Liao YC, Lee YD, Yeh TL, et al. The functionality and economic costs of outpatients with schizophrenia in Taiwan. Psychiatry Res.2008;158(3):306–15. Giref AZ. Economic burden of schizophrenia and bipolar disorders in Ethiopia. Ethiop J Health Dev. 2008;22(3):1–12. Cabello-Rangel H, Arredondo A, Díaz-Castro L, Reyes-Morales H, Medina-Mora ME. An estimate of the economic burden of schizophrenia in Mexico: a retrospective study in the psychiatric hospital setting. J Glob Health Neurol Psychiatry. 2022. https://joghnp.scholasticahq.com/article/32312. Accessed 12 Jun 2023. Reyes-Morales H, Cabello-Rangel H, Medina-Mora ME, Arredondo-López A. Out-of-pocket and catastrophic expenses in households of patients with schizophrenia lacking social security. Salud Publica Mex. 2021;63(4):547–53. Footnotes 1. Exchange rate used: 1 USD = 55 ETB (Ethiopian Birr), based on the National Bank of Ethiopia's 2022 average rate. 2. The human capital approach quantifies productivity loss by valuing lost workdays at the individual's income level. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7217174","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":506007819,"identity":"f6860be3-7536-459d-8c1f-7db11a6f6997","order_by":0,"name":"Samuel Erko","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAklEQVRIiWNgGAWjYJCCw0CcAGEeYJADUw9I0WIMphIIaGFG1pLYwIDgYgXy7acTDxdU3Mvjn91j+LjijE36/LDDD4G22MnpNmDXYnAmd8PhGWeKiyXunDE2PHMjLXfj7TQDoJZkY7MDOLQwALXwtiUkNtzIMZNs+HA4d+PsBJCWA4nbcGiR738L1PIvIXH+jRzzn0At6Yaz0z/g1cJwA2RLQ0LiBqAtjA03DifIS+fgt8XgBtCWGccSEjfeSCuWbDiTZrhBOqfgQIIBbr/I9+du/lxQk5A470byxo8Nx2zk5Wenb/7wocJODpcWLPYegAQLCUC+gRTVo2AUjIJRMBIAABSwb/psU6WtAAAAAElFTkSuQmCC","orcid":"","institution":"Addis Ababa University","correspondingAuthor":true,"prefix":"","firstName":"Samuel","middleName":"","lastName":"Erko","suffix":""},{"id":506007820,"identity":"9b94b3ec-32e6-4edb-8b08-7e3d696fc3a2","order_by":1,"name":"Mrs Berhan Tassew","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Mrs","middleName":"Berhan","lastName":"Tassew","suffix":""},{"id":506007821,"identity":"dbad47e9-ec46-4523-93b7-191d3ef8d110","order_by":2,"name":"Dr Anagaw Dereseh","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"Dr","firstName":"Anagaw","middleName":"","lastName":"Dereseh","suffix":""}],"badges":[],"createdAt":"2025-07-25 20:53:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7217174/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7217174/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90645840,"identity":"c3e84e03-73fd-421f-834d-adae26e244ca","added_by":"auto","created_at":"2025-09-05 07:47:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":996552,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7217174/v1/9567bfe8-7a25-45b7-a382-6315aaad3e9f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Out-of-pocket and catastrophic expenditure among Schizophrenia patients and CBHI enrollment at St. Amanuel Mental Specialized Hospital (ST.AMSH): a hospital based comparative study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBackground information\u0026nbsp;\u003c/p\u003e\n\u003cp id=\"_Toc136470571\"\u003eSchizophrenia is a severe\u0026nbsp;and chronic mental disorder which manifests a wide variety of psychological symptoms. A major\u0026nbsp;symptom\u0026nbsp;is inability\u0026nbsp;to discern his/her\u0026nbsp;own thoughts and ideas from reality, perception, and improper emotions.\u0026nbsp;Others\u0026nbsp;include hallucinations, delusions, jumbled thinking, loss of interest in daily tasks, lack of concern for personal hygiene, and a desire to avoid others, including friends and family. The disease strikes in late adolescence or early adulthood and progresses in a variety of ways, from complete clinical recovery to chronic or recurrent illness with lingering symptoms and incomplete social rehabilitation.\u003c/p\u003e\n\u003cp\u003eSchizophrenia is classified in the category of severe mental illnesses that include psychosis and schizoaffective disorders. it was noticed in Ethiopia as early as the 1960s. According to a study, the prevalence of these serious mental diseases in Ethiopia was between 1.3% and 1.6% in the early 1960s(1). A study on 321 cases of schizophrenia in Butajira provided an estimated\u0026nbsp;lifetime prevalence of 4.7/1,000)\u0026nbsp;(2).\u003c/p\u003e\n\u003cp\u003eseveral national population-based statistics that reveal the number of persons now suffering from these disorder and have highlighted the rising prevalence of schizophrenia. According to estimates, 5.8% of Ethiopia\u0026apos;s population of almost 100 million suffers from neuropsychiatric diseases\u0026nbsp;(3).Schizophrenia and depression are two of the ten most debilitating diseases in a region that is primarily rural, accounting for 11% of the total disease burden(4).\u003c/p\u003e\n\u003cp\u003eDue to the chronic duration of schizophrenia patients and families endure a long lasting economic burden. Costs that are directly related to the treatment of\u0026nbsp;schizophrenia include cost of hospitalization (short- and long-term), outpatient follow-up, pharmaceutical interventions, and laboratory testing, whereas the indirect costs are mainly related to the loss of productivity. A study in Nigeria\u0026nbsp;shows that the mean overall cost of schizophrenia was 2951.4 naira (US$ 35.9) in the six-month period\u0026nbsp;(5).\u003c/p\u003e\n\u003cp\u003eIn another study conducted at a Nigerian university the mean total annual cost and mean annual direct cost of treating schizophrenia was $818.5 (\u0026plusmn;684.35).and $349.6 (\u0026plusmn;296.04) respectively. The largest component of the direct costs was accounted for by medications; this constituted 51.2% of the direct cost and 21.9% of the total cost\u0026nbsp;(6).\u003c/p\u003e\n\u003cp\u003eCatastrophic health expenditure (CHE) occurs when out of pocket payment payments for health services consume large portion of a household\u0026rsquo;s income. dependence on out of pocket payment for medical and health care bills will leaves households exposed to risk of catastrophic expenses whenever a household member falls ill. Specially household with psychological and mental health disorders will be on the shorter end(7). It is estimated that 150 million people face some financial catastrophe due to OOP and that 100 million are pushed into poverty every year, as a result of CHE(8).CHE are heavily influenced by the method of financing.\u0026nbsp;The healthcare sector of Ethiopia uses multiple sources for financing the different systems and units within, including loans and donations (46.8%), the Ethiopian Government (16.5%), out-of-pocket (OOP) payments (35.8%), and others (0.9%)\u0026nbsp;(9).\u003c/p\u003e\n\u003cp\u003eEven if Ethiopia is one of the fastest growing nations in Africa it still has a small and unstructured formal sector from which health insurance premiums could be collected with relative ease.in addition most of the population is employed under the non-informal sector of the economy which also makes it a necessary for people to pay for their medical and health care expenses from the patient\u0026rsquo;s own pockets. Besides, the informal sector is characterized by low wages and salaries. Most households are therefore dependent on uninsured medical expenditures to finance health care. Financing health care through this method can pose a major threat to living standards particularly in low- and middle-income countries (LIMIC).\u003c/p\u003e\n\u003cp\u003eBeing a chronic illness schizophrenia is considered as one of the most costly of all mental disorders. The annual cost of treatment estimate could go as high as approximately 2-fold higher than the cost of major depression and more than 4-fold higher than any anxiety disorder (10).other factors that will increases the treatment costs are genetic factors and medication adherence (11,12), various clinical and demographic factors are associated with higher risk of relapse and hospitalization, events that are predictive of higher costs (13).Other factors also contributing to the higher COT are lower educational level, unemployment, higher illness chronicity, co-occurring alcohol and substance abuse, a history of depression and/or suicide attempts, a history of violence and/or arrests, and recent hospitalization \u0026nbsp; \u0026nbsp; \u0026nbsp;(14\u0026ndash;16)\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e\u003cstrong\u003eStudy area and study period\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHospital based comparative cross-sectional study was conducted at\u0026nbsp;St. Amanuel Mental Specialized Hospital (St. AMSH). The hospital is a specialized mental health governmental hospital in the country and was established in 1930. It is located in the western part of Addis Ababa in Addis Ketema sub city. St. AMSH provides care for patients coming from the entire nation of Ethiopia. The study was conducted from 10\u003csup\u003eth\u003c/sup\u003e April to 15 May 2022.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003epopulation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe source population was all schizophrenia patients who are attending follow up in\u0026nbsp;St. Amanuel mental specialized hospital. and the study population was all previously diagnosed schizophrenia inpatients \u0026nbsp;and outpatients that were available during data collection period at the \u0026nbsp;health facility.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion and exclusion criteria\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll schizophrenia patients who are diagnosed , with regular follow up and present during \u0026nbsp;the data collection period and who are willing and stable to reply to the questions in addition data was collected from willing care givers present during the data collection period to verify and insure reliability of information provided. participants who were excluded were patients who were unable to respond and present without a care giver, who are under 18 age and whom were present without a caregiver or an adult.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample size\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sample size was determined by using both single and double population proportion formulas. To find the level of CHE in a cross sectional study this study used a single population proportion .and a\u0026nbsp;proportion of CHE (32.2%) , 95% confidence interval, power 80%, 5% degree of precision which was taken from study conducted on SMD patients and households in rural Ethiopia(17). where the total sample size was determined and finally used came to 368 schizophrenic patients. whereas for the double population proportion with \u0026nbsp;the assumption of \u0026nbsp;one to one ratio for a comparative study taking the proportion of CHE study conducted in Assela which is 30.6% and 47 % among CBHI member and non CBHI members respectively(18) giving as a total of 330 participants.\u003c/p\u003e\n\u003cp id=\"_Toc139067265\"\u003e\u003cstrong\u003eSampling Procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sampling frame will include patients who have been diagnosed as schizophrenia patient and been on follow up as an inpatient or outpatient. After checking whether they are enrolled in CBHI or not in order to get\u0026nbsp;a representative sample, systematic random sampling was applied to select eligible study participants according to a 1:1 ratio.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection tool\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;and data collection technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA structured questionnaire was developed from other relevant literature\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003eThe data was collected by face to face interview. Questionnaire was developed both in Amharic and English but was administered in Amharic using a paper based approach and was filled by the interviewer or data collector to ensure correct entry it was \u0026nbsp;later translated to English for entry purposes. The questioner included variables like socio-demographic and socio-economic characteristics, clinical characteristics, also cost items household expenditures, monthly out of pocket health expenditures \u0026nbsp;and enrolment status of community-based health insurance.\u0026nbsp;\u003c/p\u003e\n\u003ch2 id=\"_Toc139067267\"\u003e5.8\u0026nbsp;Data collection, entry, Processing and analysis\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eAfter data was collected using paper based approach was checked by the primary researcher every two days .the collected responses are stored properly for later reference if needed. On the final date of data collection, the data was checked and entered to using Epidata 3.1 \u0026nbsp; and cleaned and analyzed using STATA version 16. Summary statistics, including mean, median, standard deviation and proportion, has been performed to summarize the data and explain the study variables.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasurement and valuation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMeasurement and Cost valuation was done by using micro costing approach to determine the direct medical and \u0026nbsp;non direct medical cost. The direct medical costs included costs for registration ,bed, drugs, laboratory and imaging during one month period.. The non direct medical costs were food, transportation, other non-medical supplies, and services on the way to the treatment facility incurred during visitation to the hospital by the patients and caregivers for a one month period . All direct cost information was collected in Ethiopian Birr (ETB). Indirect costs or lost time of productivity due to certain illness were measured in terms of a number of forgone working days of the patients and caregivers if they are formal employees and for the unemployed or once with out permanet jobs,\u0026nbsp;unskilled labor\u0026nbsp;and farmers the lost time was calculated using a pre estimated daily wage rate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEstimation of catastrophic health expenditure\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study in order to measure the amount of catastrophic health expenditure by patients the method of Wagstaff and Van Doorslaer, (2002) was used . This method uses non-food household expenditure as the denominator in order to estimate catastrophic health expenditure Headcount, Overshoot and Mean positive overshoot. The different threshold recommended by Wagstaff and Van Doorslaer, (2002) \u0026nbsp;to be used to check for \u0026nbsp;incidence and severity of CHE are at 15%, 25% and 40% of nonfood expenditure, 10% and 15% of total expenditure. And lastly to find the effect insurance status has on CHE a cut point of 15% of non-food expenditure was used.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis method uses Headcount, Overshoot and Mean positive overshoot to measure the inceidence and severity of catastrophic health expenditure faced by individuals and households. Headcount (HC) is defined as the\u0026nbsp;incidence of households percentage whose out of pocket expenses compared as a proportion of their total income or non-food expenditure exceed a certain threshold.\u0026nbsp;While the severity of CHE is measured by Overshoot(OS) which is the mean amount by which OOP expenditure exceed the respectable thresholds for all the sample households, and the mean positive overshoot (MPO) is the average amount for those whose household experienced CHE divided by the level the CHE exceeded the respectable thresholds.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEstimation of effect of CBHI on CHE\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study PSM was used to identify the effect of the treatment variable community based health insurance enrolment status on catastrophic health expenditure. the widely used method to determine impact or effect evaluation for many studies is Propensity score matching. PSM uses statistical technic\u0026nbsp;to construct a control group by\u0026nbsp;\u003ca href=\"https://dimewiki.worldbank.org/Matching\" title=\"Matching\"\u003ematching\u003c/a\u003e each treated individual (individuals enrolled in the CBHI ) with a non-treated or uninsured individuals with of similar observable characteristics. After which by using these matches, we can estimate the impact of an intervention.or CBHI on CHE. The initial step in PSM is\u0026nbsp;estimation by using either logit or probit \u0026nbsp;which helps to find the likelihood of being enrolled in CBHI by using socio-demographic and economic variables as covariates. Then the variables and individual observations have to be restricted by using two major assumptions the first assumption is\u0026nbsp;common support or overlap. The common support or overlap \u0026nbsp;assumption ensures that individual observations with the same covariate values have a positive probability of being both treated(insured) and untreated (uninsured). To identify for this assumption we will run a\u0026nbsp;density-distribution plots of propensity scores and a visualization of both groups by histogram .secondly to check for the validity of our PSM we will check for the conditional independence assumption also called confoundedness\u0026nbsp;which states that probability of being in the treated group should only be based on observed treatment outcomes. If unobserved outcome determines the probability of individuals being grouped in the intervention then selection bias is apparent or the\u0026nbsp;, conditional independence is violated. And in order to restrict this we will run balancing test. Among \u0026nbsp;the commonly used\u0026nbsp;standardized bias, the T test, and pseudo R\u003csup\u003e2\u003c/sup\u003e.the results in this tests will determine which matching algorism we will be using.\u003c/p\u003e\n\u003cp\u003eAfter estimation of the propensity score we will precede to selection our matching algorism. Here the individual observations in the treatment group (CBHI members) will be matched with the counterfactual observation or non-CBHI members with similar propensity scores or probability of being in the intervention program or CBHI. In this study we chose the kernel matching test because of the higher number of matched observation (n=348) and lower mean bias(4.4) and Pseudo\u0026nbsp;R\u003csup\u003e2\u003c/sup\u003e (0.004) Finally we estimate the effect or impact of the intervention program by using the mean difference in outcome between the insured and their matched uninsured counterparts.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eSocio-demographic and economic characteristics\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study involved 348 participants with response rate of 94%. The majority 245(64.1%) of study participant were male. Age of respondents range from 18 to 70 with mean of 35. 46\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;9.76. Most of participant 185(53.2%) were orthodox in religion and 229(669.96%) were single. Among participant 216(62.1%) are urban resident. The household size vary from 1 to 12 with mean (SD) of 4.6(\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;2.9) and 122(51.3%) had five or more household member. The mean (SD) of distance from St Ammanuel mental specialized Hospital was 61(\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;60.3) and 112(32.2%) of them were in categories of 25\u0026ndash;50 KM. Regarding educational status and occupation of participants, 113(32.4%) had tertiary education level(above 12th grade) and 104(30.4%) are unemployed. The majority 223(64.1%) of study participants HH had monthly income of less than 2500 Ethiopian birr.\u003c/p\u003e\u003ch2\u003eTable 1 should be here\u003c/h2\u003e\u003cp\u003e\u003cb\u003eCBHI enrolment status\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAmong study participant 174(50%) are CBHI member. The mean duration since becoming member was 26.8(\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;11.5) months. Most of 120(69%) participants enrolled CBHI by household contribution. Among the participants 152(87.4%) believe that they benefit from CBHI scheme and the most commonly mentioned benefit was reduced cost of health care by 146(91.2%). 138(79.3%) of participant stated as they get medical service free of charge in hospital.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eshould be here\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFrequency\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePercent\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e219\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e62.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e129\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e37.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eReligion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOrthodox\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e185\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e53.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMuslim\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e129\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e37.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProtestant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eMarital status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e235\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e67.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.36\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWidowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.87\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSeparated\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.36\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDivorced\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.89\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eResidence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e216\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e62.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e132\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e37.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNumber of family member in the HH\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;=5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e116\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e48.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e122\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e51.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eDistance from St AMSH\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u0026ndash;25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25\u0026ndash;50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e112\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e32.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50\u0026ndash;75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e76\u0026ndash;100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eEducational status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnable to read and write\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eread and write\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eprimary education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSecondary education (\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTertiary education (above12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e113\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e32.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e\u003cp\u003eOccupation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFarmer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmployee\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSelf-employed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnemployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e104\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMerchant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003edaily labourer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ehouse wife\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStudent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRetired\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eAverage months Household income\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;=2500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e223\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e64.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2501\u0026ndash;5000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5001\u0026ndash;7500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7501\u0026ndash;10000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;10000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eWealth Quintiles\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePoorest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQ2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQ3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQ4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRichest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFrequency\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePercent\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCBHI member\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e174\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e174\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eWho paid for enrolment fee\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHousehold contribution\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e120\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLocal government (coverage or Indigent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eBenefited from CBHI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e152\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e87.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eTypes of Benefit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIncreased access to health\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e103\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e64.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReduced costs of health care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e146\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e91.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReduced concerns about expected health care costs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e35.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eGet service in Hospital currently\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFree of charge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e138\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e79.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePartial OOP payment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSubstantially OOP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eClinical characteristics\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAmong the study participant 198(56.9%) were in patients. The mean duration since diagnosed for illness was 34.2\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;22.62. The majority 314(90%) of participants had regular follow up. Among them 119(37.9%) had follow up every three months as indicated in (Table) .\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFrequency\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePercent\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePatient admission\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInpatient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e150\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e43.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOut Patients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e198\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e56.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eRegular follow up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e314\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e90.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eBenefited from CBHI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e12.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e152\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e87.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eFollow Up appointment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEvery Month\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e30.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEvery Two Months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e24.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEvery Three Months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e119\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e37.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEvery Six Months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eCost of treatment of schizophrenia and Catastrophic Health Expenditure\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOut of pocket expenditure for treatment of schizophrenia the average medical cost was 2260.83 ETB(41.23USD), While OOP for non-medical cost was 760.12ETB (13.87USD). The average OOP medical cost among CBHI member and non-member was 216.92(\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;1000.46) and 5884.74 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;4304.73) respectively. The OOP non-medical expenditure for non-medical cost was 752.66(\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;1222.88) and 767.581(\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;1673.87) for CBHI and non-CBHI members respectively. The mean loss productive as result of schizophrenia was estimated to 3258.291 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;5011.122). The estimated average lost productivity among CBHI member and non-member was 2800.63 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;4108.074) and 3715.950 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;5750.674).\u003c/p\u003e\u003cp\u003eThe incidence of catastrophic health expenditure among study participant was 48% and 34.8% at 15% of non-food and total household expenditure. The incidence of CHE decline as the threshold rise from 10\u0026ndash;40%, for instance when the threshold raise from 10\u0026ndash;40% of non-food expenditure the incidence of CHE decline from 54.3\u0026ndash;28.7%. The catastrophic overshoot and mean positive overshoot was 32.4% and 67.5% at 15% of non-food threshold.\u003c/p\u003e\u003cp\u003eThe incidence of CHE among CBHI member was 36.7% at 15% non-food threshold while it was 59.2% for non-CBHI member. The overshoot and mean positive overshoot was 14.2% and 38.7% at 15% of non-food threshold while it was 32.4% and 67.5% for non-members .\u003c/p\u003e\u003cp\u003e\u003cb\u003eEffect of community based health insurance on Catastrophic health expenditure\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIncidence of CHE\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTreated\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eControls\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDifference\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eS.E.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eT-stat\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-food\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.431034483\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.697836455\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.266801973\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.058734819\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-4.54*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.367816092\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.651072645\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.283256553\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.059302646\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-4.78*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e25%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.247126437\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.601552122\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.354425686\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.057529794\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-6.1*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e40%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.143678161\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.479694875\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.336016714\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.054010867\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-6.22*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal HH expenditure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.316091954\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.657783971\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.341692017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.058233167\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-5.87*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.195402299\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.549100366\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.353698068\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.056192176\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-6.29*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e25%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.091954023\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.426350498\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.334396475\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.051113423\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-6.54*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e40%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.068965517\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.277107039\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.208141522\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.046807138\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-4.45*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe effect of community-based health insurance on catastrophic health expenditures was estimated using kernel matching at different levels of threshold. There was a significant difference in the incidence of CHE among CBHI members and non-members. Enrollment in CBHI members lowers the incidence of CHE for instances at the 15% threshold of non-food expenditure; the incidence of CBHI was 37% lower among insured. This difference was significant using a different method and threshold.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCoping Mechanism\u003c/b\u003e\u003c/p\u003e\u003cp\u003eRegarding coping mechanism used to finance their medical expenses about 112(32.2%) and 93(26.7%) used CBHI and own money, respectively. While 56(16.1%) borrowed. Among those who borrowed 28(68.3%) borrowed from family.. this is similarly seen in a study that shows a person with SMD if uninsured has a higher tendency to borrow and sell asset this is evidence in a study showing the low level of ownership of assets by household with SMD(56).The majority 64.4% of insured patients used CBHI and only 17.2% used own money.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to identify the catastrophic out of pocket payment faced by schizophrenia patients, assessing total direct and indirect costs, identifying the variables that influence this costs and the effect of being insured or uninsured by community based health insurance has on the catastrophic out of pocket payment.\u003c/p\u003e\u003cp\u003eAs stated in the results section the mean out of pocket annual total direct medical costs per patient was 2260.83 ETB(41.23USD), While OOP for non-medical cost was 760.12 ETB(13.87USD) and the combined total OOP expenditure is 3020.95ETB (50.09USD). The costs incurred in this study were lower than seen in other studies (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) this may be due to the differences in the socioeconomic and medical costs in Ethiopia. a study conducted in rural Ethiopia shows households with members that had a schizophrenic family member spent \u003cspan\u003e$\u003c/span\u003e16.52 out-of-pocket for a year and on average they had lost 3.12 (sd = 4.54) days of work in one month(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). In another study conducted in china the mean annual total direct medical costs per patient was CNY41,972.4 (US\u003cspan\u003e$\u003c/span\u003e6852.5)(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In another study conducted in Taiwan shows that annual average of direct costs for each schizophrenic patient was US\u003cspan\u003e$\u003c/span\u003e2115 and an indirect cost of (US\u003cspan\u003e$\u003c/span\u003e14,461). The largest cost was indirect cost or loss of productivity and medication cost which is about (US\u003cspan\u003e$\u003c/span\u003e944.8) (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). In a similar study conducted in Nigeria teaching hospital the average annual total, direct, and indirect costs of the treatment were \u003cspan\u003e$\u003c/span\u003e818.48, \u003cspan\u003e$\u003c/span\u003e349.59, and \u003cspan\u003e$\u003c/span\u003e468.89, respectively, per patient(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). All the above studies show a total out of pocket costs greater than observed in this study. What we can infer from most studies conducted to find the OOP expenditure of schizophrenia and other mental disorders point to the fact that out of the total costs indirect costs or productivity loss and hospitalization costs has the greatest share. This shows one of the negative effects of mental disorder. Particularly schizophrenia is found to be highly associated with unemployment, loss of working days, lack of well-being and poor levels of social functioning these will result in loss of productivity borne by patients, caregivers and increase in indirect cost as seen in this study. The amount of indirect cost was 3258.291ETB (59.69 USD) which is more than the direct cost incurred by patients. In a study conducted in a Nigerian teaching hospital the indirect cost of treatment is \u003cspan\u003e$\u003c/span\u003e468.89 (57.3%) which is higher. In other study conducted in Mexico the productivity loss cost is even higher as much as USD 5,760 including a caregiver’s loss of productivity of USD460(22). In conclusion all this shows the debilitating effect of schizophrenia and the economic burden caused due to the loss of productivity and the medical expenditure caused by schizophrenia.\u003c/p\u003e\u003cp\u003eNot many studies are done comparing out of pocket treatment costs of insured versus uninsured but in this study the direct cost of treatment for insured patients comes to 216.92 ETB(3.96 USD) which is significantly lower than uninsured patients OOP which is about 4303.73ETB (59.59USD) ,comparing this to a study conducted in Mexico which shows patients that are uninsured face a direct out of pocket cost of \u003cspan\u003e$\u003c/span\u003e510(23). in another study conducted in Assella referral hospital to find the effects of CBHI on CHE with chronic patients of 336 out of which 35 psychiatric patients shows insured members had a lower incidence of catastrophic health spending than non-CBHI members, 31% and 47% respectively (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). In addition to the difference in the occurrence of direct costs there is a significant difference in the indirect cost between insured and uninsured patients. Insured patients productivity cost is 2800.633 ETB (51.07USD) meanwhile uninsured patients have a productivity cost of 3715.95 ETB (67.76USD).\u003c/p\u003e\u003cp\u003eIn this study, uninsured patients had 65% of their 10% their monthly non-food expenditures, and 60.9% of their total household expenditure. Comparatively insured patients will spend 43% of their 10% monthly non-food expenditures, and 31.2% of their total household expenditure. this shows the need to increase for the accessibility and inclusivity of community Based health insurance.\u003c/p\u003e\u003cp\u003eThis study also shows the severity of catastrophic health expenditure among schizophrenic patients as overshoot and mean positive overshoot. The average exciding overshoot from 10% 15% 25% 40% of nonfood expenditure in the total study population was 34.9%,32.4%, 28.1%, 23% respectively, showing a reduction in overshoot as the threshold increases. While the average overshoot for insured at this threshold was 16.2%, 14.2%, 11.1%, 8.4% respectively, this shows a significant reduction in the severity of catastrophic expenditure. On the other hand uninsured patients showed a 53.7%, 50.6%, 44.9%,37.5% respective MPO results, which is a significant increase in the severity of catastrophic expenditure.\u003c/p\u003e\u003cp\u003eCommunity based health insurance member patients had a lower incidence of catastrophic health spending than non-CBHI members, 48% and 34.8% at 15% of non-food and total household expenditure. The incidence of CHE among CBHI member was 36.7% at 15% non-food threshold while it was 48% for non-CBHI member. Which is very similar to a study conducted in Butajira where the incidence of catastrophic OOP payments was 32.2% for households of a person with SMD(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Another study shows an incidence of 16.6% of OOP CHE in uninsured household this may be due to the low number of study participants in the study(23).\u003c/p\u003e\u003cp\u003eEven if CBHI member patients had shown a lower incidence of catastrophic expenditure they are still subjected to increased non medical expenditure which will lead to a lower quality of life and eventually lead to financial inadequacy of the households and care givers.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAs shown in the study, schizophrenia patients and their caregivers face a huge financial difficulty since the incidence and severity of catastrophic health spending are high among house hold of uninsured patients. The incidence varies from 65.5–43.1%. .and for both insured and uninsured household it is between 34.9–23% overshoot.\u003c/p\u003e\u003cp\u003eAll this can be as a result of unemployment of the patients which is 29.9% in this study, lower wealth index of patients and caregivers(2.5%, where 25.5 lie in Q3 ) and specially due to the status of being uninsured in CBHI and also due to the high cost of living, high cost of medical and medication costs, low accessibility and lengthened time of diagnosis in Ethiopia. as indicated in this study in order to alleviate this financial burden CBHI plays a key role.in order to find a solution the government of Ethiopia has to make sure that the CBHI program gets to all patients and families. As seen in this study the financial security offered by community-based health has a very strong impact.as compared in the study non-CBHI members had a substantially higher incidence and intensity of catastrophic health expenditure than CBHI members,\u003c/p\u003e\u003cp\u003eIn conclusion this study recommends that expanding the coverage of community-based health insurance schemes helps to strengthen financial Security and increase life quality of schizophrenic patients and their families.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCBHI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCommunity-Based Health Insurance\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCHE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCatastrophic Health Expenditure\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eETB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEthiopian Birr\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eOOP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eOut-of-Pocket\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePSM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePropensity Score Matching\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUSD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUnited States Dollar\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Institutional Research Ethics Review Board (IRB) of Addis Ababa University, School of Public Health (Ref: [Insert reference number if available]). Written informed consent was obtained from all participants or their caregivers (for patients under 18 or unable to respond). The study adhered to the principles of the Declaration of Helsinki. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable (no individual person’s data, images, or videos are included). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during this study are available from the corresponding author upon reasonable request. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received funding from Addis Ababa university school of public health\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSamuel Berhanu: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing original draft. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMrs Berhan Tassew: Supervision, Validation, Writing review \u0026amp; editing. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDr Anagaw Dereseh: Supervision, Methodology, Validation. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank St. Amanuel Mental Specialized Hospital staff, data collectors, and study participants for their cooperation. Special gratitude to Addis Ababa University for technical support. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' information (optional)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSB: MSc Candidate in Health Economics, Addis Ababa University. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMrs Berhan Tassew: MPH, Public Health Specialist. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDr Anagaw Dereseh: PhD, Health Economist. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' Information\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSamuel Berhanu :holds a Bachelor of Science degree in public health and is an MSc candidate in Health Economics at Addis Ababa University. His research focuses on health financing and economic burdens of mental health disorders in low-resource settings. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMrs Berhan Tassew (MPH): is a public health specialist with expertise in health systems research and policy analysis. She serves as a lecturer and research advisor at Addis Ababa University. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDr Anagaw Dersch (PhD) : is a Health Economist and senior researcher specializing in healthcare financing and insurance systems. He has contributed to multiple national health policy reforms in Ethiopia. \u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBirhanu Z, Tucho GT, Anand S, Agenagnew L, Snr GA, Getnet M, et al. Barriers and facilitators for implementing mental health services into the Ethiopian health extension program: A qualitative study. Risk Manag Healthc Policy. 2021;14:1199\u0026ndash;210. \u003c/li\u003e\n\u003cli\u003eKebede D, Alem A. Major mental disorders in Addis Ababa, Ethiopia. I. Schizophrenia, schizoaffective and cognitive disorders. Acta Psychiatr Scand. 1999;100:11\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eSuleiman TG, Ohaeri JU, Lawal RA, Haruna AY, Orija OB. Financial cost of treating out-patients with schizophrenia in Nigeria. Br J Psychiatry.1997;171(4):364\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eOloniniyi IO, Akinsulore A, Aloba OO, Mapayi BM, Oginni OA, Makanjuola R. Economic cost of schizophrenia in a Nigerian Teaching Hospital. J Neurosci Rural Pract. 2019;10(1):39\u0026ndash;47. \u003c/li\u003e\n\u003cli\u003eXu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJ. Household catastrophic health expenditure: a multicountry analysis. Lancet. 2003;362(9378):111\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eMarzban S, Rajaee R, Gholami S, Keykale MS, Najafi M. Study of Out-of-Pocket Expenditures for Outpatient Imaging Services in Imam-Khomeini Hospital in 2014. Electron Physician. 2015;7(4):1183\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Primary health care systems (PRIMASYS). 2017. http://apps.who.int/bookorders. Accessed 10 May 2023. \u003c/li\u003e\n\u003cli\u003eAndlin-Sobocki P, J\u0026ouml;nsson B, Wittchen HU, Olesen J. Cost of disorders of the brain in Europe. Eur J Neurol.2005;12 Suppl 1:1\u0026ndash;27. \u003c/li\u003e\n\u003cli\u003eWeiden PJ, Olfson M. Cost of relapse in schizophrenia. Schizophr Bull. 1995;21(3):419\u0026ndash;29. \u003c/li\u003e\n\u003cli\u003eKnapp M, King D, Pugner K, Lapuerta P. Non-adherence to antipsychotic medication regimens: associations with resource use and costs. Br J Psychiatry.2004;184:509\u0026ndash;16. \u003c/li\u003e\n\u003cli\u003eGibson PJ, Damler R, Jackson EA, Wilder T, Ramsey JL. The impact of olanzapine, risperidone, or haloperidol on the cost of schizophrenia care in a Medicaid population.Value Health. 2004;7(1):22\u0026ndash;35. \u003c/li\u003e\n\u003cli\u003eCarr VJ, Lewin TJ, Neil AL, Halpin SA, Holmes S. Premorbid, psychosocial and clinical predictors of the costs of schizophrenia and other psychoses. Br J Psychiatry. 2004;184:517\u0026ndash;25. \u003c/li\u003e\n\u003cli\u003eAlmond S, Knapp M, Francois C, Toumi M, Brugha T. Relapse in schizophrenia: costs, clinical outcomes and quality of life. Br J Psychiatry. 2004;184:346\u0026ndash;51. \u003c/li\u003e\n\u003cli\u003eHaro JM, Novick D, Suarez D, Alonso J, L\u0026eacute;pine JP, Ratcliffe M, et al. Remission and relapse in the outpatient care of schizophrenia: three-year results from the Schizophrenia Outpatient Health Outcomes study. J Clin Psychopharmacol. 2006;26(6):571\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eHailemichael Y, Hailemariam D, Tirfessa K, Docrat S, Alem A, Medhin G, et al. Catastrophic out-of-pocket payments for households of people with severe mental disorder: a comparative study in rural Ethiopia. Int J Ment Health Syst. 2019;13:39. \u003c/li\u003e\n\u003cli\u003eBekele M, Derseh DA. Out-of-pocket and catastrophic expenditure among chronic patients and CBHI enrollment: a hospital-based comparative study. Addis Ababa University; 2022. \u003c/li\u003e\n\u003cli\u003eZhang H, Sun Y, Zhang D, Zhang C, Chen G. Direct medical costs for patients with schizophrenia: A 4-year cohort study from health insurance claims data in Guangzhou city, Southern China. Int J Ment Health Syst. 2018;12:72. \u003c/li\u003e\n\u003cli\u003eLee IH, Chen PS, Yang YK, Liao YC, Lee YD, Yeh TL, et al. The functionality and economic costs of outpatients with schizophrenia in Taiwan. Psychiatry Res.2008;158(3):306\u0026ndash;15. \u003c/li\u003e\n\u003cli\u003eGiref AZ. Economic burden of schizophrenia and bipolar disorders in Ethiopia. Ethiop J Health Dev. 2008;22(3):1\u0026ndash;12. \u003c/li\u003e\n\u003cli\u003eCabello-Rangel H, Arredondo A, D\u0026iacute;az-Castro L, Reyes-Morales H, Medina-Mora ME. An estimate of the economic burden of schizophrenia in Mexico: a retrospective study in the psychiatric hospital setting. J Glob Health Neurol Psychiatry. 2022. https://joghnp.scholasticahq.com/article/32312. Accessed 12 Jun 2023. \u003c/li\u003e\n\u003cli\u003eReyes-Morales H, Cabello-Rangel H, Medina-Mora ME, Arredondo-L\u0026oacute;pez A. Out-of-pocket and catastrophic expenses in households of patients with schizophrenia lacking social security. Salud Publica Mex. 2021;63(4):547\u0026ndash;53. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003cp\u003e1. Exchange rate used: 1 USD = 55 ETB (Ethiopian Birr), based on the National Bank of Ethiopia\u0026apos;s 2022 average rate. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2. The human capital approach quantifies productivity loss by valuing lost workdays at the individual\u0026apos;s income level. \u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Schizophrenia, catastrophic health expenditure, out-of-pocket costs, health insurance, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-7217174/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7217174/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eIn Ethiopia, limited mental health service coverage and financial protection expose households to severe economic consequences from psychiatric disorders. One of the most common and increasing disorders being Schizophrenia, schizophrenic patients and caregivers face treatment costs, income loss, unemployment, and social stigma, highlighting the need to evaluate out-of-pocket (OOP) expenditures and the protective role of Community-Based Health Insurance (CBHI).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA hospital-based cross-sectional study was conducted at St. Amanuel Mental Specialized Hospital, Addis Ababa, including 348 schizophrenia patients (50% CBHI-enrolled) on follow-up. Data were collected via face-to-face interviews using structured questionnaires. Direct/indirect costs were measured using human capital approach, with catastrophic health expenditure (CHE) assessed at 10%, 15%, 25%, and 40% thresholds. Multivariable logistic regression analyzed CBHI's effect on CHE.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eParticipants mean age was 35 years (62.9% male). The mean annual OOP costs were: medical (2,260.83 ETB/41.23 USD), non-medical (760.12 ETB/13.87 USD), and productivity loss (3,258.29 ETB/59.29 USD). CHE incidence at 15% non-food threshold was 36.7% for CBHI members versus 48% for non-members (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eCBHI significantly reduces CHE incidence among schizophrenia patients, though indirect costs remain burdensome. Policy interventions to expand insurance coverage and address productivity losses are urgently needed.\u003c/p\u003e","manuscriptTitle":"Out-of-pocket and catastrophic expenditure among Schizophrenia patients and CBHI enrollment at St. Amanuel Mental Specialized Hospital (ST.AMSH): a hospital based comparative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-29 10:36:10","doi":"10.21203/rs.3.rs-7217174/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"06105708-8556-4319-8ebb-022f4285f605","owner":[],"postedDate":"August 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-05T07:39:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-29 10:36:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7217174","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7217174","identity":"rs-7217174","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}