Analysis of the Health Expenditure’s Weight in the Household Economy in Kourtheye (Niger)

Farm households in Niger face health expenses each year. This study on Analysis of the health expenditure’s weight in the household economy was conducted in the rural commune of Kourtheye, in the department of Tillaberi located in the Tillaberi region (NIGER). The adopted methodology is based on a documentary research and a collection of primary data at the level of the households in 6 villages. The extensive Household economic approach (HEA) methodological approach, combined with the amplitude class discretization method was used. A total of 125 farm households were surveyed. the study shown that the share of health spending by farm households increases from very poor households to wealthy households. In relative value among the very poor (VP), the share of health expenditure is 13.4% against 15.4% among the poor (P), 19.2% among the middle (M) and 21% among the wealthy (W). Thus, according to the World Health Organization, these households incur catastrophic expenses. The main pathologies in the area are chronic diseases, malaria, bilharzia and work accidents. Spending by households on self-medication is higher among VP (63%) and P (57%), and low among the middle (15%) and wealthy (19%). This is explained by the fact that the poor do not have enough financial resources to care for their sick in health centers, unlike the middle and wealthy farm households.


Introduction
Health is an important component of the household's standard of living and is therefore one of the major concerns of public authorities (INS, 2011). The composition of household spending, measured by the share of spending in the budget for consumption needs, is an indicator of living standards.This is a reality, whether it is a matter of basic needs (e.g. food, shelter, transport, clothing) or any other need that can be satisfied by the market consumption of goods and services (e.g. leisure). (Stéphane Crespo1 2018). Spending on health has steadily increased in OECD countries (Jos Schoonbroodt, 1997). They include health services (preventive and curative), family planning activities, activities relating to nutrition and emergency aid reserved for health. However, they exclude the provision of water and sanitation services. The share of total health expenditure in global gross domestic product (GDP) increased from 3% in 1948 to more than 8% in 2004.In 2016, it is estimated that health spending averaged 9.0% of GDP in OECD countries, (OECD, 2017). In 2018, consumption of healthcare and medical goods (CSBM) is provisionally estimated at 203.5 billion euros. It progressed more slowly in 2018 than in 2017 (+1.5% after +1.7%), due to the marked slowdown in hospital care (DREES, 2019). The inequality of access to public health expenditure is particularly high in Africa, compared to other developing regions (Davoodi et al. 2003). Niger, in particular, achieved 7.2% of GDP in current expenditure on health in 2015 (WHO, 2018).There is, at the microeconomic level as at the macroeconomic level, a poverty trap associated with health: a family struck by the illness of one of its members can find itself permanently impoverished due to the loss of income associated with the illness and the cost of access to the care (Jean-Claude Berthélemy and Juliette Seban, 2009).In addition, at the microeconomic level, catastrophic proportions of health expenditure are observed, thus reflecting the level of poverty and vulnerability of households.
Nigerien households, especially those living in rural areas and those in the river valley in particular face a much more critical situation. The Tillabéry region is one of the regions where the majority of its households live and carry out activities in the Niger river valley. Many households face a recurring health problem, which forces them to make often some catastrophic expenditure. This is why, this study focuses on an analysis of analysis of the health expenditure's weight in the household economy of the municipality of Kourthey in the department of Tillabéry. Thus, the overall objective of this study aims to contribute to the understanding of the importance of health expenditure for agricultural households in the commune of Kourthey in the department of Tillabéry. More specifically it is about to:  Evaluate the weight of health expenditure according to the socioeconomic characteristics of households  Estimate health costs by morbidity according to socioeconomic categories of households  Appreciate the types of health expenditure by socio-economic category

Materials and Methods of Analysis
The main materials used in this study are: Aging of the population and growth in health expenditure, adopted a descriptive analysis, as well as a modelization.This method of analysis, adopted in this study, allowed to know the shares of household health expenditure and to make an estimation of this expenditure in the overall household budget. The main variables considered for this study are the level of health expenditure and the socioeconomic characteristics of households (Jean-Claude B and Juliette S, 2009). In order to complete the analysis on the effects of health care spending, two variables designed to capture other factors that can influence access to the care are introduced. It is about the individual wealth of households, and their level of education.The first variable is defined as the wealth aggregate and the second is associated with the education of mothers, who may reasonably be expected to play an essential role in child health. First, each of these variables of access to health services by quintile is linked to, on the one hand, total health expenditure per person, and on the other hand, the wealth and education variables mothers by quintile. The second variable was taken into account in the qualitative characteristic of households. The following ratings and formulas are used in the calculation of the various expenses: For food, the monthly expenditure is given by the following formula: N= ∑ ix30 . Ni: daily expenditure of household i for food; Di: monthly household expenditure i for other items. This result is then multiplied by 12 for annual expenditure. Other expenses outside of health are given by the following equation: Dp = Y Dpi/m where Dpi denotes the expenditure made by household i for item p, and m denotes the total number of households considered in the study. Health expenditure by households is calculated per individual and then per household using the following formula. C = ∑xi / n where C denotes the average monthly cost per individual, x represents the costs of treatment by disease and n corresponds to the total number of diseases in the area. With regard to the method allowing socio-economic categorization of agricultural households, the following procedure is adopted: A first step is to perform classes of the same extent. For this, the following approach has been adopted as illustrated by the following diagram (Didier P., 2007 ): The

Type of study, target population, inclusion and exclusion criteria
It is a transversal study. The Study Population is made up of heads of farming households located in the villages of the river valley in the department of Tillabéry. The study concerned heads of households located in villages in the farming area.

Presentation of the study area
Located in the far west of Niger, the Tillabéri region is the youngest of the eight regions of the country due to its creation, which took place by Ordinance No. 8888-20 of April 7, 1988. It is limited to the northwest by the region of Tahoua, in the East by the Dosso region, in the West by Burkina Faso and in the South by Benin. The Tillabéri Region is subdivided into six (6) departments Filingué, Kollo, Say, Ouallam, Téra, Tillabéri (Fig. 1). It covers an area of 92,908 km². The study was carried out in the commune of Kourtheye, particularly in its riparian part composed essentially of villages along the river, those of the flood plain and those of the alluvial terraces.

Assessment of levels of health expenditure according to international standards
The World Health Organization has set a critical threshold for health spending at a coefficient of 0.01 or 10% of total spending. Exceeding this threshold leads the household to a situation of catastrophic expenditure. Figure 3 illustrates this observation.
Share of expenditure     This increase may be due not only to the different costs of taking charge of the illnesses recorded in households (the degree of complication, treatment, prevention and other expenses linked to the indirect treatment process) but also to the total number of sick people whose the deleterious consequences heavily affect other expenses, such as food.Food, being an essential component for survival, it constitutes the main expenditure of households in the area, this corroborates with the results of the study carried out in Morocco (DHS, 1995) and confirmed as being the first WINTER G expenditure. (1967). The share of spending among the categories of middle and wealthy households is close to that obtained by Harouna T, (2012). To produce more, we will have to invest more in factors of production.This allows households to classify investments in agriculture as the second main expenditure. They also contribute to households in creating wealth, jobs and ensuring many functions, food production (Joseph G, and Martine, 2014 ). The weight of health expenditure according to socioeconomic characteristics represents the third main household expenditure as demonstrated by DHS in 1995. The rural environment constitutes one of the common characteristics of these two studies. On the other hand, in terms of relative share of health, the results are clearly superior to those obtained by the same author who reveals 6% as part devoted to health. Indeed, in this study, this share of health expenditure is catastrophic for all socio-economic categories.It is close to the health expenditure of Belgian households (Jos S, 1997), and that of the Harouna T study (2012) at MBODA, in Senegal, but is lower than that of average and wealthy agricultural households. The large shares of household health expenditure can be explained by the fact that the areas concerned by this study are characterized by several factors which favor the development of morbidities throughout the year.They can be climatic factors or geographic location of agricultural households in the area. The large share of expenditure on self-medication costs is found among the poor. This may be explained by the fact that the latter do not have enough financial resources to care for their patients in health centers. Self-medication practices based on the existence of a "family" medicine cabinet could also explain this phenomenon (Mireille E, 2002), while among the middle and better-off, it is the cost of care that represents a part significant expense. In terms of patient transport costs, the results are significantly higher than those obtained by Myriam M, Raphael T, and Alexis M in 2017 in France, where consumption of patient transport is 2.4%.

Conclusion
According to the results, health represents the third main household expenditure after food and investments in agriculture. It is clear that the situation is precarious among agricultural households, who face catastrophic expenses in the care of their patients. This is not without consequences for other basic necessities.The main morbidities causing these catastrophic expenses are malaria, chronic diseases, bilharziasis and accidents at work in all socioeconomic categories. However, special emphasis must be placed on malaria, which is the first pathology that affects the physical capacity of farmers. The study reveals a significant weight in the shares of health expenditure, through self-medication among the categories of the very poor and poor. Furthermore, given the income available to the means and the wealthy; the share of expenditure for care costs is significant. To reduce catastrophic spending among farmers, actors need to be more involved in facilitating access to health centers for all socioeconomic groups, especially the very poor and poor.