Impoverishing effects of catastrophic health expenditures in Malawi

Understanding variation in catastrophic health expenditure from socio-ecological aspect: a systematic review

BACKGROUND

Out-of-pocket (OOP) payment is one of many countries' main financing options for health care. High OOP payments push them into financial catastrophe and the resultant impoverishment. The infrastructure, society, culture, economic condition, political structure, and every element of the physical and social environment influence the intensity of financial catastrophes in health expenditure. Hence, the incidence of Catastrophic Health Expenditure (CHE) must be studied more intensively, specifically from regional aspects. This systematic review aims to make a socio-ecological synthesis of the predictors of CHE.

METHOD

We retrieved data from Scopus and Web of Science. This review followed PRISMA guidelines. The interest outcomes of the included literature were the incidence and the determinants of CHE. This review analyzed the predictors in light of the socio-ecological model.

RESULTS

Out of 1436 screened documents, fifty-one met the inclusion criteria. The selected studies were quantitative. The studies analyzed the socioeconomic determinants from the demand side, primarily focused on general health care, while few were disease-specific and focused on utilized care. The included studies analyzed the interpersonal, relational, and institutional predictors more intensively. In contrast, the community and policy-level predictors are scarce. Moreover, neither of the studies analyzed the supply-side predictors. Each CHE incidence has different reasons and different outcomes. We must go with those case-specific studies. Without the supply-side response, it is difficult to find any effective solution to combat CHE.

CONCLUSION

Financial protection against CHE is one of the targets of sustainable development goal 3 and a tool to achieve universal health coverage. Each country has to formulate its policy and enact laws that consider its requirements to preserve health rights. That is why the community and policy-level predictors must be studied more intensively. Proper screening of the cause of CHE, especially from the perspective of the health care provider's perspective is required to identify the individual, organizational, community, and policy-level barriers in healthcare delivery.

Developing comprehensive woman hand-held case notes to improve quality of antenatal care in low-income settings: participatory approach with maternal health stakeholders in Malawi

BACKGROUND

In the quest for quality antenatal care (ANC) and positive pregnancy experience, the value of comprehensive woman hand-held case notes cannot be emphasised enough. However, the woman's health passport book in Malawi presents gaps which hinder provision of quality care, especially during pregnancy. We aimed to develop a compressive updated woman hand-held case notes tool (health passport book) which reflects WHO 2016 ANC guidelines in Malawi.

METHODS

From July 2022 to August 2022, we applied a co-creative participatory approach in 3 workshops with key stakeholders to compare the current ANC tool contents to the WHO 2016 ANC guidelines, decide on key elements to be changed to improve adherence and change in practice, and redesign the woman's health passport tool to reflect the changes. Within-group discussions led to whole-group discussions and consensus, guided by a modified nominal group technique. Facilitators guided the discussions while ensuring autonomy of the group members in their deliberations. Discussions were recorded and transcribed. Data was analysed through thematic analysis, and reduction and summaries in affinity diagrams. The developed tool was endorsed for implementation within Malawi's healthcare system by the national safe motherhood technical working group (TWG) in July 2023.

RESULTS

Five themes were identified in the analysis. These were (i) critical components in the current tool missed, (ii) reimagining the current ANC tool, (iii) opportunity for ultrasound scanning conduct and documentation, (iv) anticipated barriers related to implementation of the newly developed tool and (v) cultivating successful implementation. Participants further recommended strengthening of already existing policies and investments in health, strengthening public private partnerships, and continued capacity building of healthcare providers to ensure that their skill sets are up to date.

CONCLUSION

Achieving goals of quality ANC and universality of healthcare are possible if tools in practice reflect the guidelines set out. Our efforts reflect a pioneering attempt in Malawi to improve women's hand-held case notes, which we know help in enhancing quality of care and improve overall women's satisfaction with their healthcare system.

Do hospitalizations push households into poverty in India: evidence from national data

Introduction

High percentage of OOP (Out-of-Pocket) costs can lead to poverty and exacerbate existing poverty, with 21.9% of India's 1.324 billion people living below the poverty line. Factors such as increased patient cost-sharing, high-deductible health plans, and expensive medications contribute to high OOP costs. Understanding the poverty-inducing impact of healthcare payments is essential for formulating effective measures to alleviate it.

Methods

The study used data from the 75th round of the National Sample Survey Organization (Household Social Consumption in India: Health) from July 2017-June 2018, focusing on demographic-socio-economic characteristics, morbidity status, healthcare utilization, and expenditure. The analysis included 66,237 hospitalized individuals in the last 365 days. Logistic regression model was used to examine the impact of OOP expenditures on impoverishment.

Results

Logistic regression analysis shows that there is 0.2868 lower odds of experiencing poverty due to OOP expenditures in households where there is the presence of at least one child aged 5 years and less present in the household compared to households who do not have any children. There is 0.601 higher odds of experiencing poverty due to OOP expenditures in urban areas compared to households in rural areas. With an increasing duration of stay in the hospital, there is a higher odds of experiencing poverty due to OOP health expenditures. There is 1.9013 higher odds of experiencing poverty due to OOP expenditures if at least one member in the household used private healthcare facility compared to households who never used private healthcare facilities.

Conclusion

In order to transfer demand from private to public hospitals and reduce OOPHE, policymakers should restructure the current inefficient public hospitals. More crucially, there needs to be significant investment in rural areas, where more than 70% of the poorest people reside and who are more vulnerable to OOP expenditures because they lack coping skills.

The causal effect of catastrophic health expenditure on poverty in Poland

INTRODUCTION

Out-of-pocket medical expenses are a crucial source of health care financing in a number of countries. With the ongoing population aging, health care costs are likely to increase. Therefore, disentangling the relationship between health care spending and monetary poverty is becoming increasingly important. Although there is extensive literature on the impoverishment effect of out-of-pocket medical payments, it lacks empirical studies on a causal relationship between catastrophic health expenditure and poverty. In our paper, we try to fill this gap.

METHODS

We estimate recursive bivariate probit models using Polish Household Budget Survey data covering years from 2010 to 2013 and from 2016 to 2018. The model controls for a wide range of factors and endogeneity between poverty and catastrophic health expenditure.

RESULTS

We show that the causal relationship between catastrophic health expenditure and relative poverty is significant and positive across different methodological approaches. We find no empirical evidence that a one-time incidence of catastrophic health expenditure creates a poverty trap. We also show that using a poverty measure which treats out-of-pocket medical payments and luxury consumption as perfect substitutes can lead to an underestimation of poverty among the elderly.

CONCLUSION

Out-of-pocket medical payments should probably receive more attention from policymakers than the official statistics suggest. A current challenge is to correctly identify and appropriately support those who are most affected by catastrophic health expenditure. More prospectively, a complex modernization of the Polish public health system is needed.

Health, wealth, and medical expenditures among the elderly in rural Tanzania: experiences from Nzega and Igunga districts

BACKGROUND

The per capita health expenditure (HE) and share of gross domestic product (GDP) spending on elderly healthcare are expected to increase. The gap between health needs and available resources for elderly healthcare is widening in many developing countries, like Tanzania, leaving the elderly in poor health. These conditions lead to catastrophic HEs for the elderly. This study aimed to analyse the association between measures of health, wealth, and medical expenditure in rural residents aged 60 years and above in Tanzania.

METHODS

The data of this study were collected through a cross-sectional household survey to residents aged 60 years and above living in Nzega and Igunga districts using a standardised World Health Organization (WHO) Study on Global Ageing and Adult Health (SAGE) and European Quality of Life Five Dimension (EQ-5D) questionnaires. The quality of life (QoL) was estimated using EQ-5D weights. The wealth index was generated from principal component analysis (PCA). The linear regression analyses (outpatient/inpatient) were performed to analyse the association between measures of health, wealth, medical expenditure, and socio-demographic variables.

RESULTS

This study found a negative and statistically significant association between QoL and HE, whereby HE increases with the decrease of QoL. We could not find any significant relationship between HE and social gradients. In addition, age influences HE such that as age increases, the HE for both outpatient and inpatient care also increases.

CONCLUSION

The health system in these districts allocate resources mainly according to needs, and social position is not important. We thus conclude that the elderly of lower socio-economic status (SES) was subjected to similar health expenditure as those of higher socio-economic status. Health, not wealth, determines the use of medical expenditures.

Incidence of catastrophic health spending in Indonesia: insights from a Household Panel Study 2018-2019

BACKGROUND

Indonesia implemented one of the world's largest single-payer national health insurance schemes (the Jaminan Kesehatan Nasional or JKN) in 2014. This study aims to assess the incidence of catastrophic health spending (CHS) and its determinants and trends between 2018 and 2019 by which time JKN enrolment coverage exceeded 80%.

METHODS

This study analysed data collected from a two-round cross-sectional household survey conducted in ten provinces of Indonesia in February-April 2018 and August-October 2019. The incidence of CHS was defined as the proportion of households with out-of-pocket (OOP) health spending exceeding 10% of household consumption expenditure. Chi-squared tests were used to compare the incidences of CHS across subgroups for each household characteristic. Logistic regression models were used to investigate factors associated with incurring CHS and the trend over time. Sensitivity analyses assessing the incidence of CHS based on a higher threshold of 25% of total household expenditure were conducted.

RESULTS

The overall incidence of CHS at the 10% threshold fell from 7.9% to 2018 to 4.4% in 2019. The logistic regression models showed that households with JKN membership experienced significantly lower incidence of CHS compared to households without insurance coverage in both years. The poorest households were more likely to incur CHS compared to households in other wealth quintiles. Other predictors of incurring CHS included living in rural areas and visiting private health facilities.

CONCLUSIONS

This study demonstrated that the overall incidence of CHS decreased in Indonesia between 2018 and 2019. OOP payments for health care and the risk of CHS still loom high among JKN members and among the lowest income households. More needs to be done to further contain OOP payments and further research is needed to investigate whether CHS pushes households below the poverty line.

Healthcare utilization and catastrophic health expenditure in rural Tanzania: does voluntary health insurance matter?

BACKGROUND

Over 150 million people, mostly from low and middle-income countries (LMICs) suffer from catastrophic health expenditure (CHE) every year because of high out-of-pocket (OOP) payments. In Tanzania, OOP payments account for about a quarter of the total health expenditure. This paper compares healthcare utilization and the incidence of CHE among improved Community Health Fund (iCHF) members and non-members in central Tanzania.

METHODS

A survey was conducted in 722 households in Bahi and Chamwino districts in Dodoma region. CHE was defined as a household health expenditure exceeding 40% of total non-food expenditure (capacity to pay). Concentration index (CI) and logistic regression were used to assess the socioeconomic inequalities in the distribution of healthcare utilization and the association between CHE and iCHF enrollment status, respectively.

RESULTS

50% of the members and 29% of the non-members utilized outpatient care in the previous month, while 19% (members) and 15% (non-members) utilized inpatient care in the previous twelve months. The degree of inequality for utilization of inpatient care was higher (insured, CI = 0.38; noninsured CI = 0.29) than for outpatient care (insured, CI = 0.09; noninsured CI = 0.16). Overall, 15% of the households experienced CHE, however, when disaggregated by enrollment status, the incidence of CHE was 13% and 15% among members and non-members, respectively. The odds of iCHF-members incurring CHE were 0.4 times less compared to non-members (OR = 0.41, 95%CI: 0.27-0.63). The key determinants of CHE were iCHF enrollment status, health status, socioeconomic status, chronic illness, and the utilization of inpatient and outpatient care.

CONCLUSION

The utilization of healthcare services was higher while the incidence of CHE was lower among households enrolled in the iCHF insurance scheme relative to those not enrolled. More studies are needed to establish the reasons for the relatively high incidence of CHE among iCHF members and the low degree of healthcare utilization among households with low socioeconomic status.

Effects of multimorbidity patterns and socioeconomic status on catastrophic health expenditure of widowed older adults in China

Background

The high multimorbidity and lower socioeconomic status (SES) of older adults, can lead to catastrophic health expenditures (CHEs) for older adults' households. However, whether widowed older adults will bear such a financial burden has yet to be explored. The aim of this study was to investigate the influence of multimorbidity patterns and SES on CHE in Chinese widowed older adults.

Methods

Data was obtained from the 2018 China Health and Retirement Longitudinal Study (CHARLS). This is a cross-sectional study. A total of 1,721 widowed participants aged 60 years and older were enrolled in the study. Latent class analysis was performed based on 14 self-reported chronic diseases to identify multimorbidity patterns. The logistic model and Tobit model were used to analyze the influence of multimorbidity patterns and SES on the incidence and intensity of CHE, respectively.

Results

About 36.72% of widowed older adults generated CHE. The incidence and intensity of CHE were significantly higher in the cardiovascular class and multisystem class than in the minimal disease class in multimorbidity patterns (cardiovascular class, multisystem class, and minimal disease class). Among SES-related indicators (education, occupation and household per capita income), respondents with a middle school and above education level were more likely to generate CHE compared to those who were illiterate. Respondents who were in the unemployed group were more likely to generate CHE compared to agricultural workers. In addition, respondents aged 70-79 years old, geographically located in the east, having other medical insurance, or having fewer family members are more likely to generate CHE and have higher CHE intensity.

Conclusion

Widowed older adults are at high risk for CHE, especially those in the cardiovascular and multisystem disease classes, and those with low SES. Several mainstream health insurances do not provide significant relief. In addition, attention should be paid to the high-risk characteristics associated with CHE. It is necessary to carry out the popularization of chronic disease knowledge, improve the medical insurance system and medical service level, and provide more policy preferences and social support to widowed older adults.

Do national health insurance schemes guarantee financial risk protection in the drive towards Universal Health Coverage in West Africa? A systematic review of observational studies

To facilitate the drive towards Universal Health Coverage (UHC) several countries in West Africa have adopted National Health Insurance (NHI) schemes to finance health services. However, safeguarding insured populations against catastrophic health expenditure (CHE) and impoverishment due to health spending still remains a challenge. This study aims to describe the extent of financial risk protection among households enrolled under NHI schemes in West Africa and summarize potential learnings. We conducted a systematic review following the PRISMA guidelines. We searched for observational studies published in English between 2005 and 2022 on the following databases: PubMed/Medline, Web of Science, CINAHL, Embase and Google Scholar. We assessed the study quality using the Joanna Briggs Institute (JBI) critical appraisal checklist. Two independent reviewers assessed the studies for inclusion, extracted data and conducted quality assessment. We presented our findings as thematic synthesis for qualitative data and Synthesis Without Meta-analysis (SWiM) for quantitative data. We published the study protocol in PROSPERO with ID CRD42022338574. Nine articles were eligible for inclusion, comprising eight cross-sectional studies and one retrospective cohort study published between 2011 and 2021 in Ghana (n = 8) and Nigeria (n = 1). While two-thirds of the studies reported a positive (protective) effect of NHI enrollment on CHE at different thresholds, almost all of the studies (n = 8) reported some proportion of insured households still encountered CHE with one-third reporting more than 50% incurring CHE. Although insured households seemed better protected against CHE and impoverishment compared to uninsured households, gaps in the current NHI design contributed to financial burden among insured populations. To enhance financial risk protection among insured households and advance the drive towards UHC, West African governments should consider investing more in NHI research, implementing nationwide compulsory NHI programmes and establishing multinational subregional collaborations to co-design sustainable context-specific NHI systems based on solidarity, equity and fair financial contribution.

What are the factors associated with catastrophic health expenditure in Colombia? A multi-level analysis

INTRODUCTION

Target 3.8 of the Sustainable Development Goals calls for the guaranteeing of universal health service coverage without generating financial risks for households and individuals. In Colombia, there is no up-to-date information on the proportion of households that suffer catastrophic health expenditure (CHE), nor about how these expenses are associated with the place of residence. To contribute to an understanding of these issues, this study analyses the differences in the levels of CHE among Colombian households, and their association with the province and area (urban or rural) of residence.

METHODS

This is a descriptive and analytical cross-sectional study using the 2016-2017 National Household Budget Survey, the household and population Census 2018, and the Register of Health Providers 2017. We used the definition of CHE proposed by the World Health Organization, with a threshold of 20%. We estimated the percentage of households facing CHE, and its intensity, and estimated a multi-level logistic regression model, using as the dependent variable the question of whether a household experienced CHE, and the province as a second level, where explanatory variables related to the province were included.

RESULTS

We found differences in CHE levels according to the province of residence. At the national level, 1.77% of households experienced CHE, and households in the provinces of Boyacá (5.04%), Nariño (4.04%), Cauca (3.82%), and Chocó (3.78%) faced the highest CHE. For most households with CHE in these provinces, spending on medicines and medical consultations represented close to 50% of their out-of-pocket spending. The multi-level logistic regression model indicated that there are significant variations in CHE attributed to the provinces under study, where the contextual variables of hospital-bed density (AOR = 0.91; 95% CI 0.86-0.96) and incidence of multi-dimensional poverty (AOR = 1.13; 95% CI 1.01-1.30) were factors associated with CHE. For an urban household, 6.58% of the CHE variation is attributed to the province in question, while for a rural household the corresponding variation is 1.56%.

CONCLUSIONS

The geographical location of the household is a key factor when studying CHE in Colombia, where rural households present higher levels of CHE, mainly in the delivery of medicines and medical consultations. The findings reveal the need to analyse financial protection at the local level and establish policies to protect households, especially poor households, from CHE.

Perspectives of key decision makers on out-of-pocket payments for medicines in the Ethiopian healthcare system: a qualitative interview study

OBJECTIVE

This study aimed to explore the perspectives of key decision makers on out-of-pocket (OOP) payment for medicines and its implications in the Ethiopian healthcare system.

DESIGN

A qualitative design that employed audiorecorded semistructured in-depth interviews was used in this study. The framework thematic analysis approach was followed in the analysis.

SETTING

Interviewees came from five federal-level institutions engaged in policymaking (three) and tertiary referral-level healthcare service provision (two) in Ethiopia.

PARTICIPANTS

Seven pharmacists, five health officers, one medical doctor and one economist who held key decision-making positions in their respective organisations participated in the study.

RESULT

Three major themes were identified in the areas of the current context of OOP payment for medicines, its aggravating factors and a plan to reduce its burden. Under the current context, participants' overall opinions, circumstances of vulnerability and consequences on households were identified. Factors identified as aggravating the burden of OOP payment were deficiencies in the medicine supply chain and limitations in the health insurance system. Suggested mitigation strategies to be implemented by the health providers, the national medicines supplier, the insurance agency and the Ministry of Health were categorised under plans to reduce OOP payment.

CONCLUSION

The findings of this study indicate that there is widespread OOP payment for medicines in Ethiopia. System level constraints such as weaknesses in the supply system at the national and health facility levels have been identified as critical factors that undermine the protective effects of health insurance in the Ethiopian context. Ensuring steady access to essential medicines requires addressing health system and supply constraints in addition to a well-functioning financial risk protection systems.

The financial burden of out of pocket payments on medicines among households in Ethiopia: analysis of trends and contributing factors

BACKGROUND

In Ethiopia, out-of-pocket (OOP) payment is the key means of healthcare financing, and expenses on medicines are a crucial component of such payment. This study aims to investigate the financial implications of OOP payments on medicines for Ethiopian households.

METHODS

The study involved a secondary data analysis of the national household consumption and expenditure surveys of 2010/11 and 2015/16. The "capacity-to-pay" method was used to calculate catastrophic OOP medicine expenditures. The extent of economic status related to catastrophic medicine payment inequity was calculated using concentration index estimation. The impoverishment consequences of OOP payment on medicine were estimated using poverty headcount and poverty gap analysis methods. Logistic regression models were used to identify the variables that predict catastrophic medicine payments.

RESULTS

Medicines accounted for the majority of healthcare spending (> 65%) across the surveys. From 2010 to 2016, the total percentage of households facing catastrophic medicine payments decreased from 1% to 0.73%. However, the actual number of people expected to have experienced catastrophic medicine payments increased from 399,174 to 401,519 people. Payment for medicines pushed 11,132 households into poverty in 2015/16. The majority of disparities were explained by economic status, place of residence, and type of health services.

CONCLUSION

OOP payment on medicine accounted for the majority of total health expenses in Ethiopia. A high medicine OOP payment continued to push households into catastrophic payments and impoverishment. Household seeking inpatient care, those with lower economic status and urban residents were among the most affected. Hence, innovative approaches to improve the supply of medicines in public facilities especially those in urban settings and risk protection mechanisms for medicine expenditures particularly for inpatient care are recommended.

Assessing the efficiency of health systems in achieving the universal health coverage goal: evidence from Sub-Saharan Africa

OBJECTIVE

Universal health coverage (UHC) is a major pathway to save many people from catastrophic and impoverishing healthcare spending and address the inequality in health and healthcare. The objective of this paper is to assess the efficiency with which health systems in sub-Saharan Africa (SSA) are utilizing healthcare resources to progress towards achieving the UHC goal by 2030.

METHODS

The study followed the guidelines proposed by the World Health Organization (WHO) and World Bank joint UHC monitoring framework and the computational operationalization approach proposed by Wagstaff et al. (2015) to estimate the UHC index for each of the 30 selected SSA countries. The bootstrapping output-oriented data envelopment analysis (DEA) was used to estimate the bias-corrected technical efficiency scores and examine the environmental factors that influence health system efficiency.

RESULTS

The estimated UHC levels ranged from a minimum of 52% to a maximum of 81% [Formula: see text] with a median coverage of 66%. The average bias-corrected efficiency score was 0.81 [Formula: see text]. The study found that education, governance quality, public health spending, external health funding, and prepayment arrangements that pool funds for health had a positive significant effect on health system efficiency in improving UHC, while out-of-pocket payment had a negative impact.

CONCLUSION

The results show that health systems in SSA can potentially enhance UHC levels by at least 19% with existing healthcare resources if best practices are adopted. Policymakers should aim at improving education, good governance, and healthcare financing architecture to reduce out-of-pocket payments and over-reliance on donor funding for healthcare to achieve UHC.

Catastrophic health expenditures in hospitalized patients with delta variant of COVID-19: A cross-sectional study

Background: Financial protection of populations against healthcare costs is one of the fundamental responsibilities of governments. This study aimed to investigate the incidence of catastrophic health expenditures (CHE) and it's affecting factors in hospitalized patients with delta variant of COVID-19. Methods: In this cross-sectional study, we included 400 hospitalized COVID-19 patients at Kosar Hospital of Semnan in 2022, using a researcher-made checklist. Based on qualitative nature of the variables, chi-square test was used to investigate the statistical associations between the demographic/background characteristics and the incidence of CHE. Results: On average, COVID-19 imposed 1833.43 USD direct medical costs per one hospitalized patient. The ratio of direct-medical costs to household's non-food expenses was 2.35, and 61% (CI:±4.78%) of the patients were subject to CHE. Besides, residence place, basic insurance type, benefitting from supplementary insurance, suffering from underlying diseases, hospitalization in ICU, falling into a coma, facing pulmonary failure, and performing hemoperfusion had significant associations with CHE (P<0.05). Conclusion: The incidence of CHE in hospitalized COVID-19 patients was undesirable, which may be due to geographical, economical, and occupational inequalities apart from the factors related to the severity of the disease. So, health policymakers should pay attention to the provision of proper financial risk protection policies to make the health insurance system more efficient and appropriate.

Spatial disparities in impoverishing effects of out-of-pocket health payments in Malawi

BACKGROUND

Out-of-pocket health payments as a means of financing health services are a cause of concern among households in low and middle-income countries. They prevent households from accessing health care services, can disrupt households' living standards by reducing consumption of other basic needs and push households into poverty. Previous studies have reported geographical variations in impoverishing effects of out-of-pocket health payments. Yet, we know relatively little about spatial effects on impoverishing effects of health payments.

OBJECTIVE

This paper assesses the factors associated with impoverishing effects of health payments and quantifies the role of districts spatial effects on impoverishment in Malawi.

METHODS

The paper uses a cross sectional integrated household survey data collected from April 2016 to April 2017 among 12447 households in Malawi. Impoverishing effect of out-of-pocket health payments was calculated as the difference between poverty head count ratio before and after subtracting health payments from total household consumption expenditures. We assessed the factors associated with impoverishment and quantified the role of spatial effects using a spatial multilevel model.

RESULTS

About 1.6% and 1.2% of the Malawian population were pushed below the national and international poverty line of US$1.90 respectively due health payments. We found significant spatial variations in impoverishment across districts with higher spatial residual effects clustering in central region districts. Higher socio-economic status (AOR=0.34, 95% CI=0.22-0.52) decreased the risk of impoverishment whereas hospitalizations (AOR=3.63, 95% CI 2.54-5.15), chronic illness (AOR=1.56, 95% CI=1.10-1.22), residency in rural area (AOR=2.03, 95% CI=1.07-4.26) increased the risk of impoverishment.

CONCLUSIONS

Our study suggests the need to plan financial protection programs according to district specific needs and target the poor, residents of rural areas and those with chronic illnesses. Policy makers need to pay attention to the importance of spatial and neighborhood effects when designing financial protection programs and policies.

Universal health coverage and the poor: to what extent are health financing policies making a difference? Evidence from a benefit incidence analysis in Zambia

Background

Zambia has invested in several healthcare financing reforms aimed at achieving universal access to health services. Several evaluations have investigated the effects of these reforms on the utilization of health services. However, only one study has assessed the distributional incidence of health spending across different socioeconomic groups, but without differentiating between public and overall health spending and between curative and maternal health services. Our study aims to fill this gap by undertaking a quasi-longitudinal benefit incidence analysis of public and overall health spending between 2006 and 2014.

Methods

We conducted a Benefit Incidence Analysis (BIA) to measure the socioeconomic inequality of public and overall health spending on curative services and institutional delivery across different health facility typologies at three time points. We combined data from household surveys and National Health Accounts.

Results

Results showed that public (concentration index of − 0.003; SE 0.027 in 2006 and − 0.207; SE 0.011 in 2014) and overall (0.050; SE 0.033 in 2006 and − 0.169; SE 0.011 in 2014) health spending on curative services tended to benefit the poorer segments of the population while public (0.241; SE 0.018 in 2007 and 0.120; SE 0.007 in 2014) and overall health spending (0.051; SE 0.022 in 2007 and 0.116; SE 0.007 in 2014) on institutional delivery tended to benefit the least-poor. Higher inequalities were observed at higher care levels for both curative and institutional delivery services.

Conclusion

Our findings suggest that the implementation of UHC policies in Zambia led to a reduction in socioeconomic inequality in health spending, particularly at health centres and for curative care. Further action is needed to address existing barriers for the poor to benefit from health spending on curative services and at higher levels of care.

Financial risk protection from out-of-pocket health spending in low- and middle-income countries: a scoping review of the literature

Background

Financial risk protection (FRP), defined as households’ access to needed healthcare services without experiencing undue financial hardship, is a critical health systems target, particularly in low- and middle-income countries (LMICs). Given the remarkable growth in FRP literature in recent times, we conducted a scoping review of the literature on FRP from out-of-pocket (OOP) health spending in LMICs. The objective was to review current knowledge, identify evidence gaps and propose future research directions.

Methods

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines to conduct this scoping review. We systematically searched PubMed, Scopus, ProQuest and Web of Science in July 2021 for literature published since 1 January 2015. We included empirical studies that used nationally representative data from household surveys to measure the incidence of at least one of the following indicators: catastrophic health expenditure (CHE), impoverishment, adoption of strategies to cope with OOP expenses, and forgone care for financial reasons. Our review covered 155 studies and analysed the geographical focus, data sources, methods and analytical rigour of the studies. We also examined the level of FRP by disease categories (all diseases, chronic illnesses, communicable diseases) and the effect of health insurance on FRP.

Results

The extant literature primarily focused on India and China as research settings. Notably, no FRP study was available on chronic illness in any low-income country (LIC) or on communicable diseases in an upper-middle-income country (UMIC). Only one study comprehensively measured FRP by examining all four indicators. Most studies assessed (lack of) FRP as CHE incidence alone (37.4%) or as CHE and impoverishment incidence (39.4%). However, the LMIC literature did not incorporate the recent methodological advances to measure CHE and impoverishment that address the limitations of conventional methods. There were also gaps in utilizing available panel data to determine the length of the lack of FRP (e.g. duration of poverty caused by OOP expenses). The current estimates of FRP varied substantially among the LMICs, with some of the poorest countries in the world experiencing similar or even lower rates of CHE and impoverishment compared with the UMICs. Also, health insurance in LMICs did not consistently offer a higher degree of FRP.

Conclusion

The literature to date is unable to provide a reliable representation of the actual level of protection enjoyed by the LMIC population because of the lack of comprehensive measurement of FRP indicators coupled with the use of dated methodologies. Future research in LMICs should address the shortcomings identified in this review.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-022-00886-3.

The microeconomic impact of out-of-pocket medical expenditure on the households of cardiovascular disease patients in general and specialized heart hospitals in Ibadan, Nigeria

Background

Cardiovascular diseases (CVDs) present a huge threat to population health and in addition impose severe economic burden on individuals and their households. Despite this, there is no research evidence on the microeconomic impact of CVDs in Nigeria. Therefore, this study estimated the incidence and intensity of catastrophic health expenditures (CHE), poverty headcount due to out-of-pocket (OOP) medical spending and the associated factors among the households of a cohort of CVDs patients who accessed healthcare services in public and specialized heart hospitals in Ibadan, Nigeria.

Methods

This study adopts a descriptive cross-sectional study design. A standardized data collection questionnaire developed by the Initiative for Cardiovascular Health Research in Developing Countries was adapted to electronically collect data from all the 744 CVDs patients who accessed healthcare services in public and specialized heart hospitals in Ibadan between 4th November 2019 to the 31st January 2020. A sensitivity analysis, using rank-dependent thresholds of CHE which ranged from 5%-40% of household total expenditures was carried out. The international poverty line of $1.90/day recommended by the World Bank was utilized to ascertain poverty headcounts pre-and post OOP payments for healthcare services. Categorical variables like household socio-demographic and clinical characteristics, CHE and poverty headcounts, were presented using percentages and proportions. Unadjusted and adjusted logistic regression models were used to assess the factors associated with CHE and poverty. Data were analyzed using STATA version 15 and estimates were validated at 5% level of significance.

Results

Catastrophic OOP payment ranged between 3.9%-54.6% and catastrophic overshoot ranged from 1.8% to 12.6%. Health expenditures doubled poverty headcount among households, from 8.13% to 16.4%. Having tertiary education (AOR: 0.49, CI: 0.26–0.93, p = 0.03) and household size (AOR: 0.40, CI: 0.24–0.67, p = 0.001) were significantly associated with CHE. Being female (AOR: 0.41, CI: 0.18–0.92, p = 0.03), household economic status (AOR: 0.003, CI: 0.0003–0.25, p = <0.001) and having 3–4 household members (AOR: 0.30, CI: 0.15–0.61, p = 0.001) were significantly associated with household poverty status post payment for medical services.

Conclusion

OOP medical spending due to CVDs imposed enormous strain on household resources and increased the poverty rates among households. Policies and interventions that supports universal health coverage are highly recommended.

Determinants of Turkish households' out-of-pocket expenditures on three categories of health care services: A multivariate probit approach

This study identifies the driving forces that contribute to the probabilities of incidence of out-of-pocket (OOP) expenditures by households in Turkey. Factors affecting the probability of OOP expenditures on medical products/devices/supplies (MP), outpatient services (OTS), and inpatient services (ITS) are examined using the Household Budget Survey data gathered by the Turkish Statistical Institute in 2018. The study applies the multivariate probit model. The incidence of OOP spending varied with 48.9% of the households reporting OOP expenditure on MP, 22.4% on OTS, and 25.4% on ITS. The largest probability changes were associated with household disposable annual income, household type and size, age category, and having private health insurance. Gender and marital status also influenced expenditures in some categories. Lifestyle choices had small and mixed effects, with smoking and alcohol consumption lowering the probability of OOP spending. From a policy standpoint, households with the lowest incomes, large households, and those where the household head was 'others' (retiree, student, housewife, not actively working, etc.) or had a condition preventing employment seemed to report OOP expenditures less frequently and may have chosen not to receive healthcare services, leading to the need for more healthcare services later.

How equitable is health spending on curative services and institutional delivery in Malawi? Evidence from a quasi-longitudinal benefit incidence analysis

Background

Malawi is one of a handful of countries that had resisted the implementation of user fees, showing a commitment to providing free healthcare to its population even before the concept of Universal Health Coverage (UHC) acquired global popularity. Several evaluations have investigated the effects of key policies, such as the essential health package or performance-based financing, in sustaining and expanding access to quality health services in the country. Understanding the distributional impact of health spending over time due to these policies has received limited attention. Our study fills this knowledge gap by assessing the distributional incidence of public and overall health spending between 2004 and 2016.

Methods

We relied on a Benefit Incidence Analysis (BIA) to measure the socioeconomic inequality of public and overall health spending on curative services and institutional delivery across different health facility typologies. We used data from household surveys and National Health Accounts. We used a concentration index (CI) to determine the health benefits accrued by each socioeconomic group.

Results

Socioeconomic inequality in both public and overall health spending substantially decreased over time, with higher inequality observed in overall spending, non-public health facilities, curative health services, and at higher levels of care. Between 2004 and 2016, the inequality in public spending on curative services decreased from a CI of 0.037 (SE 0.013) to a CI of 0.004 (SE 0.011). Whiles, it decreased from a CI of 0.084 (SE 0.014) to a CI of 0.068 (SE 0.015) for overall spending in the same period. For institutional delivery, inequality in public and overall spending decreased between 2004 and 2016 from a CI of 0.032 (SE 0.028) to a CI of -0.057 (SE 0.014) and from a CI of 0.036 (SE 0.022) to a CI of 0.028 (SE 0.018), respectively.

Conclusions

Through its free healthcare policy, Malawi has reduced socioeconomic inequality in health spending over time, but some challenges still need to be addressed to achieve a truly egalitarian health system. Our findings indicate a need to increase public funding for the health sector to ensure access to care and financial protection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01624-5.

Decomposing socio-economic inequality in catastrophic out-of-pocket health expenditures in Malawi

Reducing health inequalities and inequities is one of the key goals that health systems aspire to achieve as it ensures improvement in health outcomes among all population groups. Addressing the factors contributing to inequality in catastrophic health expenditures is important to reducing inequality in the burden of health expenditures. However, there are limited studies to explain the factors contributing to inequalities in catastrophic health expenditures. The study aimed to measure and decompose socio-economic inequality in catastrophic health into its determinants. Data for the analysis come from the fourth integrated household survey. Data for 12447 households in Malawi were collected from April 2016 to April 2017 by the National Statistical Office. The secondary analysis was conducted from June 2021 to October 2021. Catastrophic health expenditure was estimated as a proportion of households whose out-of-pocket health expenditures as a ratio of non-food consumption expenditures exceeds 40% threshold level. We estimated the magnitude of socio-economic inequality using the Erreygers corrected concentration index and used decomposition analysis to assess the contribution of inequality in each determinant of catastrophic health expenditure to the overall socio-economic inequality. The magnitude of the Erreygers corrected concentration index of catastrophic health expenditure (CI = 0.004) is small and positive which indicates that inequality is concentrated among the better-off. Inequality in catastrophic health expenditure is largely due to inequalities in rural residency (127%), socio-economic status (-40%), household size (14%), presence of a child under five years old (10%) and region of the household (10%). The findings indicate that socio-economic inequality in catastrophic health expenditures is concentrated among the better-off in Malawi. The results imply that policies that aim to reduce inequalities in catastrophic health expenditures should simultaneously address urban-rural and income inequalities.

Factors Associated With Coverage of Health Insurance Among Women in Malawi

Introduction

Access to healthcare for the vulnerable groups including women has long been a theme encouraged worldwide from the first general assembly on health to the current sustainable development goals. Despite many countries having a free public healthcare system, there are inequalities in access to care and significant out-of-pocket spending, pushing most women into poverty against the principles of universal health coverage. Coverage of Malawian women with health insurance is poor; thus, there is limited cushioning and high risk of poverty, as women bear costs of care as primary caregivers. There is need to explore determinants of coverage of health insurance among women in Malawi to inform health policy.

Methodology

This study was quantitative in nature, using cross-sectional secondary data from the 2015 to 2016 Malawi Demographic and Health Survey involving women aged between 15 and 49 years. We assessed factors associated with insurance coverage by comparing women with and without insurance schemes using binary logistic regression. Analysis was done using STATA statistical package version 13.

Results

The analysis included a total of 24,562 women with a mean age of 28 SD (9.3). Of these cases, 1.5% had health insurance. High education attainment, occupation, and wealth were significantly associated with health insurance ownership, with all having p-values of < 0.01. On the other hand, a woman's residence, marital status, and who heads a household were not associated with ownership of health insurance significantly.

Conclusion

Education, occupation, and wealth have a key role in influencing a woman's choice in owning health insurance. This informs policymakers and health insurance providers on how best to approach women's health financing and factors to target in social security programs and health insurance products that speak to women's needs and capacity.

Assessment of equity in healthcare financing and benefits distribution in Tanzania: a cross-sectional study protocol

INTRODUCTION

Achieving universal health coverage goal by ensuring access to quality health service without financial hardship is a policy target in many countries. Thus, routine assessments of financial risk protection, and equity in financing and service delivery are required in order to track country progress towards realising this universal coverage target. This study aims to undertake a system-wide assessment of equity in health financing and benefits distribution as well as catastrophic and impoverishing health spending by using the recent national survey data in Tanzania. We aim for updated analyses and compare with previous assessments for trend analyses.

METHODS AND ANALYSIS

We will use cross-sectional data from the national Household Budget Survey 2017/2018 covering 9463 households and 45 935 individuals cross all 26 regions of mainland Tanzania. These data include information on service utilisation, healthcare payments and consumption expenditure. To assess the distribution of healthcare benefits (and in relation to healthcare need) across population subgroups, we will employ a benefit incidence analysis across public and private health providers. The distributions of healthcare benefits across population subgroups will be summarised by concentration indices. The distribution of healthcare financing burdens in relation to household ability-to-pay across population subgroups will be assessed through a financing incidence analysis. Financing incidence analysis will focus on domestic sources (tax revenues, insurance contributions and out-of-pocket payments). Kakwani indices will be used to summarise the distributions of financing burdens according to households' ability to pay. We will further estimate two measures of financial risk protection (ie, catastrophic health expenditure and impoverishing effect of healthcare payments).

ETHICS AND DISSEMINATION

We will involve secondary data analysis that does not require ethical approval. The results of this study will be disseminated through stakeholder meetings, peer-reviewed journal articles, policy briefs, local and international conferences and through social media platforms.

A spatial analysis of out-of-pocket payments for healthcare in Malawi

Out-of-pocket (OOP) expenditures on health remain high in many low- and middle-income countries despite policy efforts aiming to reduce these health costs by targeting their hotspots. Hotspot targeting remains inadequate, particularly where the OOP expenditures are related across geographic regions due to unequal demand, supply and prices of healthcare services. In this paper, we investigate the existence of geographical correlations in OOP health expenditures by employing a spatial Durbin model on data from 778 clusters obtained from the 2016 Malawi's Integrated Household Survey. Results reveal that Malawian communities face geographical spillovers of OOP health expenditures. Furthermore, we find that factors including household size, education and geographical location are important drivers of the OOP health expenditure's spatial dependency. The paper calls for policy in low-income countries to improve the quality and quantity of healthcare services in both OOP hotspots and their neighbouring communities.

"I Wish I Could Die So I Would Not Be in Pain": A Qualitative Study of Palliative Care Needs Among People With Cancer or HIV/AIDS in Vietnam and Their Caregivers

CONTEXT

Although cancer and HIV/AIDS are common causes of death in Vietnam, limited data exist on their palliative care needs. As palliative care becomes part of Universal Health Coverage, evidence is needed to scale up appropriate care.

OBJECTIVES

To elicit from people with cancer or HIV/AIDS in Vietnam, and their caregivers, the specific multidimensional symptoms and concerns that cause serious health-related suffering.

METHODS

Semistructured, qualitative, in-depth interviews were conducted with stage III or IV cancer patients, people with HIV/AIDS, and their caregivers at three cancer treatment centers and two HIV/AIDS treatment centers in northern, central, and southern Vietnam. Interviews were analyzed using thematic analysis.

RESULTS

Sixty people were interviewed (21 cancer patients, 20 people with HIV/AIDS, 19 caregivers). Pain and other physical symptoms severely impacted their daily lives. Psychological distress-including sadness, depression, worry, and a feeling of having no future-was mentioned frequently, and it was exacerbated by disease progression and by social problems such as financial difficulties and, among people with HIV/AIDS, stigma. Caregivers also suffered physically and psychosocially. Spirituality emerged as a source of strength for patients. Findings highlighted patients' and family caregivers' desire for more information about diagnosis, prognosis, and treatment, a shift toward individual decision-making.

CONCLUSION

The findings demonstrate common, multidimensional, and severe suffering among people living with cancer or HIV/AIDS and their caregivers in Vietnam. These qualitative data should guide development of optimum clinical assessment tools and palliative care services for these populations.

Socioeconomic Impact of Hospitalization Expenditure for Treatment of Noncommunicable Diseases in India: A Repeated Cross-Sectional Analysis of National Sample Survey Data, 2004 to 2018

OBJECTIVES

This article explores the consequences of hospitalization expenditure on noncommunicable diseases (NCD) and its impact on out-of-pocket expenditure (OOPE), catastrophic health expenditure, impoverishment, and hardship financing of households in India.

METHODS

Data on hospitalized cases of NCDs from the 3 rounds of National Sample Surveys (NSS) (2004, 2014, 2018) were used. Bivariate and multivariate analyses were conducted to investigate the socioeconomic differentials of the impact of OOPE on catastrophic health expenditure, impoverishment, and exposure to hardship financing.

RESULTS

Rural households had greater exposure to catastrophic health expenditure but urban households had higher risk of impoverishment due to OOPE. Older patients (aged ≥60 years) had the highest hospitalization rate per 100 000, including increase in average healthcare expenditure from 2004 to 2018. At 10% and 30% thresholds, 50% and 25% of the households, respectively, faced catastrophic health expenditure across all the 3 rounds. Due to OOPE on hospitaliation treatment for NCDs, about 3.8%, 7.4% and 4.8% of households fell below poverty line, and percentage shortfall in income for the population from the poverty line was 3%, 4.9% and 3%, in 2004, 2014 and 2018 respectively. Percentage of households facing hardship financing reduced from 49.2% in 2004 to 24.4% 2014 and 12.7% in 2018.

CONCLUSION

OOPE by households are still very high and hence the higher effects of CHE, impoverishment and exposure to hardship financing due to health expenditure in India. This study proposes that along with increase in budgetary allocations for healthcare, the government should develop suitable policies to expand the effectiveness of government-sponsored health insurance, such as developing a specific NCD service package to be included in the health insurance program.

Examining the incidence of catastrophic health expenditures and its determinants using multilevel logistic regression in Malawi

BACKGROUND

Despite a free access to public health services policy in most sub-Saharan African countries, households still contribute to total health expenditures through out-of-pocket expenditures. This reliance on out-of-pocket expenditures places households at a risk of catastrophic health expenditures and impoverishment. This study examined the incidence of catastrophic health expenditures, impoverishing effects of out-of-pocket expenditures on households and factors associated with catastrophic expenditures in Malawi.

METHODS

We conducted a secondary analysis of the most recent nationally representative integrated household survey conducted by the National Statistical Office between April 2016 to 2017 in Malawi with a sample size of 12447 households. Catastrophic health expenditures were estimated based on household annual nonfood expenditures and total household annual expenditures. We estimated incidence of catastrophic health expenditures as the proportion of households whose out-of-pocket expenditures exceed 40% threshold level of non-food expenditures and 10% of total annual expenditures. Impoverishing effect of out-of-pocket health expenditures on households was estimated as the difference between poverty head count before and after accounting for household health payments. We used a multilevel binary logistic regression model to assess factors associated with catastrophic health expenditures.

RESULTS

A total of 167 households (1.37%) incurred catastrophic health expenditures. These households on average spend over 52% of household nonfood expenditures on health care. 1.6% of Malawians are impoverished due to out-of-pocket health expenditures. Visiting a religious health facility (AOR = 2.27,95% CI:1.24-4.15), hospitalization (AOR = 6.03,95% CI:4.08-8.90), larger household size (AOR = 1.20,95% CI:1.24-1.34), higher socioeconomic status (AOR = 2.94,95% CI:1.39-6.19), living in central region (AOR = 3.54,95% CI:1.79-6.97) and rural areas (AOR = 5.13,95% CI:2.14-12.29) increased the odds of incurring catastrophic expenditures.

CONCLUSION

The risk of catastrophic health expenditures and impoverishment persists in Malawi. This calls for government to improve the challenges faced by the free public health services and design better prepayment mechanisms to protect more vulnerable groups of the population from the burden of out-of-pocket payments.

The Basic vs. Ability-to-Pay Approach: Evidence From China's Critical Illness Insurance on Whether Different Measurements of Catastrophic Health Expenditure Matter

Alleviating catastrophic health expenditure (CHE) is one of the vital objectives of health systems, as defined by the World Health Organization. However, no consensus has yet been reached on the measurement of CHE. With the aim of further relieving the adverse effects of CHE and alleviating the problem of illness-caused poverty, the Critical Illness Insurance (CII) program has been operational in China since 2012. In order to verify whether the different measurements of CHE matter under China's CII program, we compare the two-layer CII models built by using the basic approach and the ability-to-pay (ATP) approach at a range of thresholds. Exploiting the latest China family panel studies dataset, we demonstrate that the basic approach is more effective in relieving CHE for all insured households, while the ATP approach works better in reducing the severity of CHE in households facing it. These findings have meaningful implications for policymaking. The CII program should be promoted widely as a supplement to the current Social Basic Medical Insurance system. To improve the CII program's effectiveness, it should be based on the basic approach, and the threshold used to measure CHE should be determined by the goal pursued by the program.

Treatment as insurance: HIV antiretroviral therapy offers financial risk protection in Malawi

Many countries have expanded insurance programmes in an effort to achieve universal health coverage (UHC). We assess a complementary path toward financial risk protection: increased access to technologies that improve health and reduce the risk of large health expenditures. Malawi has provided free HIV treatment since 2004 with significant US Government support. We investigate the impact of treatment access on medical spending, capacity to pay and catastrophic health expenditures at the population level, exploiting the phased rollout of HIV treatment in a difference-in-differences design. We find that increased access to HIV treatment generated a 10% decline in medical spending for urban households, a 7% increase in capacity to pay for rural households and a 3-percentage point decrease in the likelihood of catastrophic health expenditure among urban households. These risk protection benefits are comparable to that found from broad-based insurance coverage in other contexts. Our findings show that targeted treatment programmes that provide free care for high burden causes of death can provide substantial financial risk protection against catastrophic health expenditure, while moving developing nations toward UHC.

Rapid Assessment of the Potential Paucity and Price Increases for Suggested Medicines and Protection Equipment for COVID-19 Across Developing Countries With a Particular Focus on Africa and the Implications

Background: Countries across Africa and Asia have introduced a variety of measures to prevent and treat COVID-19 with medicines and personal protective equipment (PPE). However, there has been considerable controversy surrounding some treatments including hydroxychloroquine where the initial hype and misinformation led to shortages, price rises and suicides. Price rises and shortages were also seen for PPE. Such activities can have catastrophic consequences especially in countries with high co-payment levels. Consequently, there is a need to investigate this further. Objective: Assess changes in utilisation, prices, and shortages of pertinent medicines and PPE among African and Asian countries since the start of pandemic. Our approach: Data gathering among community pharmacists to assess changes in patterns from the beginning of March until principally the end of May 2020. In addition, suggestions on ways to reduce misinformation. Results: One hundred and thirty one pharmacists took part building on the earlier studies across Asia. There were increases in the utilisation of principally antimalarials (hydroxychloroquine) and antibiotics (azithromycin) especially in Nigeria and Ghana. There were limited changes in Namibia and Vietnam reflecting current initiatives to reduce inappropriate prescribing and dispensing of antimicrobials. Encouragingly, there was increased use of vitamins/immune boosters and PPE across the countries where documented. In addition, generally limited change in the utilisation of herbal medicines. However, shortages have resulted in appreciable price increases in some countries although moderated in others through government initiatives. Suggestions in Namibia going forward included better planning and educating patients. Conclusion: Encouraging to see increases in the utilisation of vitamins/immune boosters and PPE. However, concerns with increased utilisation of antimicrobials needs addressing alongside misinformation, unintended consequences from the pandemic and any appreciable price rises. Community pharmacists and patient organisations can play key roles in providing evidence-based advice, helping moderate prices through improved stock management, and helping address unintended consequences of the pandemic.

Developing Malawi's Universal Health Coverage Index

The inclusion of Universal Health Coverage (UHC) in the Sustainable Development Goals (target 3.8) cemented its position as a key global health priority and highlighted the need to measure it, and to track progress over time. In this study, we aimed to develop a summary measure of UHC for Malawi which will act as a baseline for tracking UHC index between 2020 and 2030. We developed a summary index for UHC by computing the geometric mean of indicators for the two dimensions of UHC; service coverage (SC) and financial risk protection (FRP). The indicators included for both the SC and FRP were based on the Government of Malawi's essential health package (EHP) and data availability. The SC indicator was computed as the geometric mean of preventive and treatment indicators, whereas the FRP indicator was computed as a geometric mean of the incidence of catastrophic healthcare expenditure, and the impoverishing effect of healthcare payments indicators. Data were obtained from various sources including the 2015/2016 Malawi Demographic and Health Survey (MDHS); the 2016/2017 fourth integrated household survey (IHS4); 2018/2019 Malawi Harmonized Health Facility Assessment (HHFA); the MoH HIV and TB data, and the WHO. We also conducted various combinations of input indicators and weights as part of sensitivity analysis to validate the results. The overall summary measure of UHC index was 69.68% after adjusting for inequality and unadjusted measure was 75.03%. As regards the two UHC components, the inequality adjusted summary indicator for SC was estimated to be 51.59% and unadjusted measure was 57.77%, whereas the inequality adjusted summary indicator for FRP was 94.10% and unweighted 97.45%. Overall, with the UHC index of 69.68%, Malawi is doing relatively well in comparison to other low income countries, however, significant gaps and inequalities still exist in Malawi's quest to achieve UHC especially in the SC indicators. It is imperative that targeted health financing and other health sector reforms are made to achieve this goal. Such reforms should be focused on both SC and FRP rather than on only either, of the dimensions of UHC.

Factors related to excessive out-of-pocket expenditures among the ultra-poor after discontinuity of PBF: a cross-sectional study in Burkina Faso

BACKGROUND

Measuring progress towards financial risk protection for the poorest is essential within the framework of Universal Health Coverage. The study assessed the level of out-of-pocket expenditure and factors associated with excessive out-of-pocket expenditure among the ultra-poor who had been targeted and exempted within the context of the performance-based financing intervention in Burkina Faso. Ultra-poor were selected based on a community-based approach and provided with an exemption card allowing them to access healthcare services free of charge.

METHODS

We performed a descriptive analysis of the level of out-of-pocket expenditure on formal healthcare services using data from a cross-sectional study conducted in Diébougou district. Multivariate logistic regression was performed to investigate the factors related to excessive out-of-pocket expenditure among the ultra-poor. The analysis was restricted to individuals who reported formal health service utilisation for an illness-episode within the last six months. Excessive spending was defined as having expenditure greater than or equal to two times the median out-of-pocket expenditure.

RESULTS

Exemption card ownership was reported by 83.64% of the respondents. With an average of FCFA 23051.62 (USD 39.18), the ultra-poor had to supplement a significant amount of out-of-pocket expenditure to receive formal healthcare services at public health facilities which were supposed to be free. The probability of incurring excessive out-of-pocket expenditure was negatively associated with being female (β = - 2.072, p = 0.00, ME = - 0.324; p = 0.000) and having an exemption card (β = - 1.787, p = 0.025; ME = - 0.279, p = 0.014).

CONCLUSIONS

User fee exemptions are associated with reduced out-of-pocket expenditure for the ultra-poor. Our results demonstrate the importance of free care and better implementation of existing exemption policies. The ultra-poor's elevated risk due to multi-morbidities and severity of illness need to be considered when allocating resources to better address existing inequalities and improve financial risk protection.

Burden and cost of communicable, maternal, perinatal and nutrition deficiency diseases in India

BACKGROUND

Globally 36% of deaths and 42% of Disability Adjusted Life Years (DALYs) are due to communicable, maternal, perinatal and nutritional disorders (CMPND). We examined the state-wise disease burden and treatment cost for these diseases in India for 2017.

METHODS

DALYs for CMPND was obtained from National Disease Burden Estimate (NBE) Study and the expenditure was determined from the unit level records of persons who reported hospitalization for one or more CMPND in National Sample Survey (NSS)-75th Round.

RESULTS

The top conditions resulting in high DALYs for India were perinatal conditions and nutritional deficiency disorders. Odisha had the highest DALY rate, while Kerala had the lowest DALY rate for CMPNDs. The out-of-pocket expenditure (OOPE) was highest in Chattisgarh, while percentage of households pushed to CHE was highest in Uttar Pradesh for CMPND.

CONCLUSION

The public healthcare facilities need to be strengthened to facilitate patients with CMPND to undergo treatment that is timely, affordable and cost-effective. Efforts should be made for optimization of strategies aimed at primary and secondary prevention of CMPND and reduce OOPE for treatment of these diseases. In addition, advocacy spreading awareness will reduce the burden and treatment expenditure for CMPNDs in India.

Determinants of healthcare seeking and out-of-pocket expenditures in a "free" healthcare system: evidence from rural Malawi

BACKGROUND

Monitoring financial protection is a key component in achieving Universal Health Coverage, even for health systems that grant their citizens access to care free-of-charge. Our study investigated out-of-pocket expenditure (OOPE) on curative healthcare services and their determinants in rural Malawi, a country that has consistently aimed at providing free healthcare services.

METHODS

Our study used data from two consecutive rounds of a household survey conducted in 2012 and 2013 among 1639 households in three districts in rural Malawi. Given our explicit focus on OOPE for curative healthcare services, we relied on a Heckman selection model to account for the fact that relevant OOPE could only be observed for those who had sought care in the first place.

RESULTS

Our sample included a total of 2740 illness episodes. Among the 1884 (68.75%) that had made use of curative healthcare services, 494 (26.22%) had incurred a positive healthcare expenditure, whose mean amounted to 678.45 MWK (equivalent to 2.72 USD). Our analysis revealed a significant positive association between the magnitude of OOPE and age 15-39 years (p = 0.022), household head (p = 0.037), suffering from a chronic illness (p = 0.019), illness duration (p = 0.014), hospitalization (p = 0.002), number of accompanying persons (p = 0.019), wealth quartiles (p₂ = 0.018; p₃ = 0.001; p₄ = 0.002), and urban residency (p = 0.001).

CONCLUSION

Our findings indicate that a formal policy commitment to providing free healthcare services is not sufficient to guarantee widespread financial protection and that additional measures are needed to protect particularly vulnerable population groups.

Predicted effect of regionalised delivery care on neonatal mortality, utilisation, financial risk, and patient utility in Malawi: an agent-based modelling analysis

BACKGROUND

Health-care regionalisation, in which selected services are concentrated in higher-level facilities, has successfully improved the quality of complex medical care. However, the effectiveness of this strategy in routine maternal care is unknown. Malawi has established a national goal of halving its neonatal mortality by 2030. In this study, we aimed to assess the effect of obstetric service regionalisation in pregnant women and their newborn babies in Malawi.

METHODS

In this analysis, we assessed regionalisation through the use of an agent-based simulation model. We used a previously estimated utilisation function, incorporating both patient-specific and health-facility-specific characteristics, to inform patient choice. The model was validated against known utilisation patterns in Malawi. Four regionalisation scenarios were compared with the status quo: scenario 1 restricted deliveries to facilities currently capable of providing caesarean sections; scenario 2 had the same restrictions as scenario 1, but with selected facilities upgraded to provide caesarean sections; scenario 3 restricted delivery to facilities that provided five or more basic emergency obstetric and neonatal care services in the preceding 3 months; and scenario 4 had the same restrictions as scenario 3, but with selected facilities upgraded to provide at least five basic emergency obstetric and neonatal care services. We assessed neonatal mortality, utilisation, travel distance, median out-of-pocket expenditure, and proportion of women facing catastrophic expenditure. The effects of upgrading the obstetric readiness of all facilities, of removing all user fees, and of upgrading without restriction were considered in scenario analyses. Heterogeneity and parameter uncertainty were incorporated to create 95% posterior credible intervals (PCIs).

FINDINGS

Scenarios restricting women to give birth in facilities with caesarean section capabilities reduced neonatal mortality by 11·4 deaths per 1000 livebirths (scenario 1; 95% PCI 9·8-13·1) and 11·6 deaths per 1000 livebirths (scenario 2; 10·2-13·1), whereas scenarios restricting women to facilities that provided five or more basic emergency obstetric and neonatal care services did not affect neonatal mortality. Similarly, the caesarean section rate in Malawi, which is 4·6% under the status quo, was predicted to rise significantly in scenario 1 (14·7%, 95% PCI 14·5-14·9; p<0·0001) and scenario 2 (10·4%, 10·2-10·6; p<0·0001), but not in scenarios 3 and 4. Women were required to travel longer distances in scenario 1 (increase of 7·2 km, 95% PCI 4·5-9·9) and in scenario 2 (4·4 km, 1·5-7·2) than in the status quo (p<0·0001). Out-of-pocket costs tripled (p<0·0001; status quo vs scenario 1 and scenario 2), and the risk of catastrophic expenditure significantly increased from a baseline of 6·4% (95% PCI 6·1-6·6) to 14·7% (14·5-14·9) in scenario 1 and 11·3% (11·0-11·5) in scenario 2. This increase was especially pronounced among the poor (p<0·0001; status quo vs scenario 1 and scenario 2).

INTERPRETATION

Policies restricting women to give birth in facilities with caesarean section capabilities is likely to result in significant decreases in neonatal mortality and might allow Malawi to meet its goal of halving its neonatal mortality by 2030. However, this improvement comes at the cost of increased distances to care and worsening financial risks among women.

FUNDING

Bill & Melinda Gates Foundation, Damon Runyon Cancer Research Foundation.

Cost-related unmet need for healthcare services in Kenya

Background

The assessment of unmet need is one way to gauge inequities in access to healthcare services. While there are multiple reasons for unmet need, financial barriers are a major reason particularly in low- and middle-income countries where healthcare systems do not offer financial protection. Moreover, accessibility and affordability are paramount in achieving universal health coverage. This study examines the extent of unmet need in Kenya due to financial barriers, the associated determinants, and the influence of regional variations.

Methods

We use data from the 2013 Kenya household health expenditure and utilization (KHHEUS) cross sectional survey. Self-reported unmet need due to lack of money and high costs of care is used to compute the outcome of interest. A multilevel regression model is employed to assess the determinants of cost-related unmet need, confounding for the effect of variations at the regional level.

Results

Cost-related barriers are the main cause of unmet need for outpatient and inpatient services, with wide variations across the counties. A positive association between county poverty rates and cost-related unmet is noted. Results reveal a higher intraclass correlation coefficient (ICC) of 0.359(35.9%) for inpatient services relative to 0.091(9.1%) for outpatient services. Overall, differences between counties accounted for 9.4% (ICC ~ 0.094) of the total variance in cost-related unmet need. Factors that positively influence cost-related unmet need include older household heads, inpatient services, and urban residence. Education of household head, good self-rated health, larger household size, insured households, and higher wealth quintiles are negatively associated with cost-related unmet need.

Conclusion

The findings underscore the important role of cost in enabling access to healthcare services. The county level is seen to have a significant influence on cost-related unmet need. The variations noted in cost-related unmet need across the counties signify the existence of wide disparities within and between counties. Scaling up of health financing mechanisms would fundamentally require a multi-layered approach with a focus on the relatively poor counties to address the variations in access. Further segmentation of the population for better targeting of health financing policies is paramount, to address equity in access for the most vulnerable and marginalized populations.

Assessing medical impoverishment and associated factors in health care in Ethiopia

BACKGROUND

About 5% of the global population, predominantly in low- and middle-income countries, is forced into poverty because of out-of-pocket (OOP) health spending. In most countries in sub-Saharan Africa, the share of OOP health spending in current health expenditure exceeds 35%, increasing the likelihood of impoverishment. In Ethiopia, OOP payments remained high at 37% of current health expenditure in 2016. This study assesses the impoverishment resulting from OOP health spending in Ethiopia and the associated factors.

METHODS

This paper uses data from the Ethiopian Household Consumption Expenditure Survey (HCES) 2010/11. The HCES covered 10,368 rural and 17,664 urban households. OOP health spending includes spending on various outpatient and inpatient services. Impoverishing impact of OOP health spending was estimated by comparing poverty estimates before and after OOP health spending. A probit model was used to assess factors that are associated with impoverishment.

RESULTS

Using the Ethiopian national poverty line of Birr 3781 per person per year (equivalent to US$2.10 per day), OOP health spending pushed about 1.19% of the population (i.e. over 957,169 individuals) into poverty. At the regional level, impoverishment ranged between 2.35% in Harari and 0.35% in Addis Ababa. Living in rural areas (highland, moderate, or lowland) increased the likelihood of impoverishment compared to residing in an urban area. Households headed by males and adults with formal education are less likely to be impoverished by OOP health spending, compared to their counterparts.

CONCLUSION

In Ethiopia, OOP health spending impoverishes a significant number of the population. Although the country had piloted and initiated many reforms, e.g. the fee waiver system and community-based health insurance, a significant proportion of the population still lacks financial protection. The estimates of impoverishment from out-of-pocket payments reported in this paper do not consider individuals that are already poor before paying out-of-pocket for health services. It is important to note that this population may either face deepening poverty or forgo healthcare services if a need arises. More is therefore required to provide financial protection to achieve universal health coverage in Ethiopia, where the informal sector is relatively large.

Households forgoing healthcare as a measure of financial risk protection: an application to Liberia

INTRODUCTION

Access to Liberia's health system is reliant on out-of-pocket (OOP) health expenditures which may prevent people from seeking care or result in catastrophic health expenditure (CHE). CHE and impoverishment due to OOP, which are used by the World Bank and World Health Organization as the sole measures of financial risk protection, are limited: they do not consider households who, following a health shock, do not incur expenditure because they cannot access the healthcare services they need (i.e., households forgoing healthcare (HFH) services). This paper attempts to overcome this limitation and improve financial risk protection by measuring HFH incidence and comparing it with CHE standard measures using household survey data from Liberia.

METHODS

Data from the Liberia Household Income and Expenditure Survey 2014 were analysed. An OOP health expenditure is catastrophic when it exceeds a total or non-food household expenditure threshold. A CHE incidence curve, representing CHE incidence at different thresholds, was developed. To overcome CHE limitations, an HFH incidence measure was developed based on CHE, OOP and health shocks data: households incurring health shocks and having negligible OOP were considered to have forgone healthcare. HFH incidence was compared with standard CHE measures.

RESULTS

CHE incidence and intensity levels depend on the threshold used. Using a 30% non-food expenditure threshold, CHE incidence is 2.1% (95% CI: 1.7-2.5%) and CHE intensity is 37.4% (95% CI: 22.7-52.0%). CHE incidence is approximately in line with other countries, while CHE intensity is higher than in other countries. CHE pushed 1.6% of households below the food poverty line in 2014. c approximately 4 times higher than CHE (8.0, 95% CI, 7.2-8.9%).

CONCLUSION

Lack of financial risk protection is a significant problem in Liberia and it may be underestimated by CHE: this study confirms that HFH incidence can complement CHE measures in providing a complete picture of financial risk protection and demonstrates a simple method that includes measures of healthcare forgone as part of standard CHE analyses. This paper provides a new methodology to measure HFH incidence and highlights the need to consider healthcare forgone in analyses of financial risk protection, as well as the need for further development of these measures.

The Analysis of Health Index Development Factor in Aceh Province, Indonesia

BACKGROUND

Development of Health Index becomes important in measuring development. The development of the Health Index in Aceh Province is influenced by several internal and external factors.

AIM

The purpose of this study was to analyse the factors that influence the health index as well as formulate a health index development strategy for Aceh Province.

METHODS

The method used is quantitative with a survey approach. This research was conducted from January to March 2019 in Aceh Province. Participants were determined as many as 50 stakeholders using the purposive sampling method. Data was collected in the form of primary and secondary data. Primary data were obtained through questionnaires and interviews with key stakeholders such as the Aceh Provincial Government, regional authorities within the Aceh Province (Agency, Bureau, Office, Hospital, etc. Secondary data was obtained from relevant research reports, government regulations, and others. The SWOT analysis was used to identify internal and external factors, strategies for developing the health index of the Aceh Province.

RESULTS

Sixteen factors influence the development of a health index in the province of Aceh. Analysis of internal and external factors has identified five strength factors, six weakness factors, five opportunity factors, and five threat factors. The internal factors (strength) that influence the development of the health index are the increasing role of the provincial government in improving health (0.437). Internal factors (weaknesses) that influence the development of health indices in the province of Aceh are the low quality of human resources in the health sector (0.336). External factors (opportunities) that influence the development of health indices in Aceh province are support from the central government with a value (0.399). External factors that pose a threat to the development of health indices in Aceh province are the ability of the community to finance health with a value (0.437). The results of the SWOT analysis of the condition of the development of the health index are currently in squared II (Strategy Diversification). This condition shows that the development of the health index faces a big threat. Alternative strategies for the development of health indices can be done by increasing the allocation of health spending, increasing partnerships with the private sector in implementing health programs, cooperation between the central, provincial and district governments in improving policies and improving service quality.

CONCLUSION

Some factors influence the development of the Health Index in Aceh Province. Internal factors are the role of the provincial government in improving health, and the low quality of human resources in the health sector. While external factors are the existence of support from the central government, and the ability of the community to finance health.

A review of the incidence and determinants of catastrophic health expenditure in Nigeria: Implications for universal health coverage

BACKGROUND

In the Nigerian context, preconditions for financial catastrophe are operational as there is high out-of-pocket spending (OOPS) on health with low capacity to pay, presence of user fees, and poor prepayment insurance coverage. We reviewed the incidence and determinants of catastrophic health expenditure (CHE) in Nigeria.

METHODS

Databases including PubMed, OVID, EMBASE, CINAHL, and Web of Science were searched for primary research studies on the incidence and determinants of CHE in Nigeria published between 2003 and 2018. Search terms used include household, out-of-pocket expenditure, catastrophic health expenditure, and Nigeria.

RESULTS

Twenty studies that met the inclusion criteria were included in the review. At 10% of total household and nonfood expenditure, the incidence of CHE was 8.2% to 50%, while 3.2% to 100% households incurred CHE at 40% of nonfood expenditure. The incidence of CHE was higher among inpatients and studies with lower threshold definitions. Outpatient CHE was highest for type 2 diabetes and tuberculosis while human immunodeficiency virus (HIV) care incurred the most CHE among inpatients. Determinants of CHE include wealth status, age, gender, place of residence/geographical location, household size/composition, educational status, health insurance status, illness, and health provider types.

CONCLUSION

There is a high incidence of CHE across various common health conditions in Nigeria. CHE was more among the poor, elderly, rural dwellers, private facility utilization, female gender, and noninsured among others. We recommend expansion of the National Health Insurance Scheme via informal social and financing networks platforms. Increased budgetary allocation to health and intersectoral collaboration will also play a significant role in CHE reduction.

Affordable and equitable access to subsidised outpatient medicines? Analysis of co-payments under the Additional Drug Package in Kyrgyzstan

BACKGROUND

Out-of-pocket (OOP) payments can constitute a major barrier for affordable and equitable access to essential medicines. Household surveys in Kyrgyzstan pointed to a perceived growth in OOP payments for outpatient medicines, including those covered by the benefits package scheme (the Additional Drug Package, ADP). The study aimed to explore the extent of co-payments for ADP-listed medicines and to explain the reasons for developments.

METHODS

A descriptive statistical analysis was performed on prices and volumes of prescribed ADP-listed medicines dispensed in pharmacies during 2013-2015 (1,041,777 prescriptions claimed, data provided by the Mandatory Health Insurance Fund). Additionally, data on the value and volume of imported medicines in 2013-2015 (obtained from the National Medicines Regulatory Agency) were analysed.

RESULTS

In 2013-2015, co-payments for medicines dispensed under the ADP grew, on average, by 22.8%. Co-payments for ADP-listed medicines amounted to around 50% of a reimbursed baseline price, but as pharmacy retail prices were not regulated, co-payments tended to be higher in practice. The increase in co-payments coincided with a reduction in the number of prescriptions dispensed (by 14%) and an increase in average amounts reimbursed per prescription in nearly all therapeutic groups (by 22%) in the study period. While the decrease in prescriptions suggests possible underuse, as patients might forego filling prescriptions due to financial restraints, the growth in average amounts reimbursed could be an indication of inefficiencies in public funding. Variation between the regions suggests regional inequity. Devaluation of the national currency was observed, and the value of imported medicines increased by nearly 20%, whereas volumes of imports remained at around the same level in 2013-2015. Thus, patients and public procurers had to pay more for the same amount of medicines.

CONCLUSIONS

The findings suggest an increase in pharmacy retail prices as the major driver for higher co-payments. The national currency devaluation contributed to the price increases, and the absence of medicine price regulation aggravated the effects of the depreciation. It is recommended that Kyrgyzstan should introduce medicine price regulation and exemptions for low-income people from co-payments to ensure a more affordable and equitable access to medicines.

Incidence, socio-economic inequalities and determinants of catastrophic health expenditure and impoverishment for diabetes care in South Africa: a study at two public hospitals in Tshwane

BACKGROUND

Direct out of pocket (OOP) payments for healthcare may cause financial hardship. For diabetic patients who require frequent visits to health centres, this is of concern as OOP payments may limit access to healthcare. This study assesses the incidence, socio-economic inequalities and determinants of catastrophic health expenditure and impoverishment amongst diabetic patients in South Africa.

METHODS

Data were taken from a cross-sectional survey conducted in 2017 at two public hospitals in Tshwane, South Africa (N = 396). Healthcare costs and transport costs related to diabetes care were classified as catastrophic if they exceeded the 10% threshold of household's capacity to pay (WHO standard method) or if they exceeded a variable threshold of total household expenditure (Ataguba method). Erreygers concentration indices (CIs) were used to assess socio-economic inequalities. A multivariate logistic regression was applied to identify the determinants of catastrophic health expenditure and impoverishment.

RESULTS

Transport costs contributed to over 50% of total healthcare costs. The incidence of catastrophic health expenditure was 25% when measured at a 10% threshold of capacity to pay and 13% when measured at a variable threshold of total household expenditure. Depending on the method used, the incidence of impoverishment varied from 2 to 4% and the concentration index for catastrophic health expenditure varied from - 0.2299 to - 0.1026. When measured at a 10% threshold of capacity to pay factors associated with catastrophic health expenditure were being female (Odds Ratio 1.73; Standard Error 0.51), being within the 3rd (0.49; 0.20), 4th (0.31; 0.15) and 5th wealth quintile (0.30; 0.17). When measured using a variable threshold of total household expenditure factors associated with catastrophic health expenditure were not having children (3.35; 1.82) and the 4th wealth quintile (0.32; 0.21).

CONCLUSION

Financial protection of diabetic patients in public hospitals is limited. This observation suggests that health financing interventions amongst diabetic patients should target the poor and poor women in particular. There is also a need for targeted interventions to improve access to healthcare facilities for diabetic patients and to reduce the financial impact of transport costs when seeking healthcare. This is particularly important for the achievement of universal health coverage in South Africa.

Variation in health system performance for managing diabetes among states in India: a cross-sectional study of individuals aged 15 to 49 years

BACKGROUND

Understanding where adults with diabetes in India are lost in the diabetes care cascade is essential for the design of targeted health interventions and to monitor progress in health system performance for managing diabetes over time. This study aimed to determine (i) the proportion of adults with diabetes in India who have reached each step of the care cascade and (ii) the variation of these cascade indicators among states and socio-demographic groups.

METHODS

We used data from a population-based household survey carried out in 2015 and 2016 among women and men aged 15-49 years in all states of India. Diabetes was defined as a random blood glucose (RBG) ≥ 200 mg/dL or reporting to have diabetes. The care cascade-constructed among those with diabetes-consisted of the proportion who (i) reported having diabetes ("aware"), (ii) had sought treatment ("treated"), and (iii) had sought treatment and had a RBG < 200 mg/dL ("controlled"). The care cascade was disaggregated by state, rural-urban location, age, sex, household wealth quintile, education, and marital status.

RESULTS

This analysis included 729,829 participants. Among those with diabetes (19,453 participants), 52.5% (95% CI, 50.6-54.4%) were "aware", 40.5% (95% CI, 38.6-42.3%) "treated", and 24.8% (95% CI, 23.1-26.4%) "controlled". Living in a rural area, male sex, less household wealth, and lower education were associated with worse care cascade indicators. Adults with untreated diabetes constituted the highest percentage of the adult population (irrespective of diabetes status) aged 15 to 49 years in Goa (4.2%; 95% CI, 3.2-5.2%) and Tamil Nadu (3.8%; 95% CI, 3.4-4.1%). The highest absolute number of adults with untreated diabetes lived in Tamil Nadu (1,670,035; 95% CI, 1,519,130-1,812,278) and Uttar Pradesh (1,506,638; 95% CI, 1,419,466-1,589,832).

CONCLUSIONS

There are large losses to diabetes care at each step of the care cascade in India, with the greatest loss occurring at the awareness stage. While health system performance for managing diabetes varies greatly among India's states, improvements are particularly needed for rural areas, those with less household wealth and education, and men. Although such improvements will likely have the greatest benefits for population health in Goa and Tamil Nadu, large states with a low diabetes prevalence but a high absolute number of adults with untreated diabetes, such as Uttar Pradesh, should not be neglected.

An evaluation of health systems equity in Indonesia: study protocol

BACKGROUND

Many low and middle income countries are implementing reforms to support Universal Health Coverage (UHC). Perhaps one of the most ambitious examples of this is Indonesia's national health scheme known as the JKN which is designed to make health care available to its entire population of 255 million by end of 2019. If successful, the JKN will be the biggest single payer system in the world. While Indonesia has made steady progress, around a third of its population remains without cover and out of pocket payments for health are widespread even among JKN members. To help close these gaps, especially among the poor, the Indonesian government is currently implementing a set of UHC policy reforms that include the integration of remaining government insurance schemes into the JKN, expansion of provider networks, restructuring of provider payments systems, accreditation of all contracted health facilities and a range of demand side initiatives to increase insurance uptake, especially in the informal sector. This study evaluates the equity impact of this latest set of UHC reforms.

METHODS

Using a before and after design, we will evaluate the combined effects of the national UHC reforms at baseline (early 2018) and target of JKN full implementation (end 2019) on: progressivity of the health care financing system; pro-poorness of the health care delivery system; levels of catastrophic and impoverishing health expenditure; and self-reported health outcomes. In-depth interviews with stakeholders to document the context and the process of implementing these reforms, will also be undertaken.

DISCUSSION

As countries like Indonesia focus on increasing coverage, it is critically important to ensure that the poor and vulnerable - who are often the most difficult to reach - are not excluded. The results of this study will not only help track Indonesia's progress to universalism but also reveal what the UHC-reforms mean to the poor.

Understanding variations in catastrophic health expenditure, its underlying determinants and impoverishment in Sub-Saharan African countries: a scoping review

BACKGROUND

To assess the financial burden due to out of pocket (OOP) payments, two mutually exclusive approaches have been used: catastrophic health expenditure (CHE) and impoverishment. Sub-Saharan African (SSA) countries primarily rely on OOP and are thus challenged with providing financial protection to the populations. To understand the variations in CHE and impoverishment in SSA, and the underlying determinants of CHE, a scoping review of the existing evidence was conducted.

METHODS

This review is guided by Arksey and O'Malley scoping review framework. A search was conducted in several databases including PubMed, EBSCO (EconLit, PsychoInfo, CINAHL), Web of Science, Jstor and virtual libraries of the World Health Organizations (WHO) and the World Bank. The primary outcome of interest was catastrophic health expenditure/impoverishment, while the secondary outcome was the associated risk factors.

RESULTS

Thirty-four (34) studies that met the inclusion criteria were fully assessed. CHE was higher amongst West African countries and amongst patients receiving treatment for HIV/ART, TB, malaria and chronic illnesses. Risk factors associated with CHE included household economic status, type of health provider, socio-demographic characteristics of household members, type of illness, social insurance schemes, geographical location and household size/composition. The proportion of households that are impoverished has increased over time across countries and also within the countries.

CONCLUSION

This review demonstrated that CHE/impoverishment is pervasive in SSA, and the magnitude varies across and within countries and over time. Socio-economic factors are seen to drive CHE with the poor being the most affected, and they vary across countries. This calls for intensifying health policies and financing structures in SSA, to provide equitable access to all populations especially the most poor and vulnerable. There is a need to innovate and draw lessons from the 'informal' social networks/schemes as they are reported to be more effective in cushioning the financial burden.

Out-of-Pocket Payments, Catastrophic Health Expenditure and Poverty Among Households in Nigeria 2010

BACKGROUND

There is high reliance on out-of-pocket (OOP) health payments as a means of financing health system in Nigeria. OOP health payments can make households face catastrophe and become impoverished. The study aims to examine the financial burden of OOP health payments among households in Nigeria.

METHODS

Secondary data from the Harmonized Nigeria Living Standard Survey (HNLSS) of 2009/2010 was utilized to assess the catastrophic and impoverishing effects of OOP health payments on households in Nigeria. Data analysis was carried out using ADePT 6.0 and STATA 12.

RESULTS

We found that a total of 16.4% of households incurred catastrophic health payments at 10% threshold of total consumption expenditure while 13.7% of households incurred catastrophic health payments at 40% threshold of nonfood expenditure. Using the $1.25 a day poverty line, poverty headcount was 97.9% gross of health payments. OOP health payments led to a 0.8% rise in poverty headcount and this means that about 1.3 million Nigerians are being pushed below the poverty line. Better-off households were more likely to incur catastrophic health payments than poor households.

CONCLUSION

Our study shows the urgency with which policy makers need to increase public healthcare funding and provide social health protection plan against informal OOP health payments in order to provide financial risk protection which is currently absent among high percentage of households in Nigeria.

Improvement of the reduction in catastrophic health expenditure in China's public health insurance

This study aimed to locate the contributing factors of Catastrophic Health Expenditure (CHE), evaluate their impacts, and try to propose strategies for reducing the possibilities of CHE in the context of China’s current public health insurance system. The financial data of all hospitalization cases from a sample hospital in 2013 were gathered and used to determine the pattern of household medical costs. A simulation model was constructed based on China’s current public health insurance system to evaluate the financial burden for medical service on Chinese patients, as well as to calculate the possibilities of CHE. Then, by adjusting several parameters, suggestions were made for China’s health insurance system in order to reduce CHE. It’s found with China’s current public health insurance system, the financial aid that a patient may receive depends on whether he is from an urban or rural area and whether he is employed. Due to the different insurance policies and the wide income gap between urban and rural areas, rural residents are much more financially vulnerable during health crisis. The possibility of CHE can be more than 50% for low-income rural families. The CHE ratio can be dramatically lowered by applying different policies for different household income groups. It’s concluded the financial burden for medical services of Chinese patients is quite large currently, especially for those from rural areas. By referencing different healthcare policies in the world, applying different health insurance policies for different income groups can dramatically reduce the possibility of CHE in China.

Decomposing inequality in financial protection situation in Iran after implementing the health reform plan: What does the evidence show based on national survey of households' budget?

BACKGROUND

Lack of well-designed healthcare financing mechanisms and high level of out-of-pocket payments in Iran over the last decades led to implementing Health Transformation Plan, in 2014. This study aims to decompose inequality in financial protection of Iranian households after the implementation of the Health Transformation Plan.

METHODS

The data of Statistical Center of Iran (SCI) Survey on Rural and Urban Households Income-Expenditure in 2015 to 2016 were used. The headcount ratio of catastrophic health expenditures was calculated. The corrected concentration index was estimated. The role of contributors on inequality in the exposure to catastrophic health expenditures among poor and nonpoor households was calculated using Farelie's model.

RESULTS

The headcount ratio of the exposure to catastrophic health expenditures in urban and rural households was 2.5% (2.43% - 2.64%) and 3.6% (3.48% - 3.76%), respectively. The difference in households' income levels was the main contributor in explaining the inequality in facing catastrophic health expenditures between poor and nonpoor households. [Correction added on 02 June 2018, after first online publication: The "Results" section of the Abstract of the published article has been correctly updated on this version.] CONCLUSION: Even after implementing the HTP, the headcount ratios of catastrophic health expenditure are still considerable. The results show that income is the greatest determinant of inequality in facing catastrophic health expenditure and in urban households.

Association of socioeconomic status with financial burden of disease among elderly patients with cardiovascular disease: evidence from the China Health and Retirement Longitudinal Survey

OBJECTIVES

The prevalence of cardiovascular diseases (CVD) within low-income and middle-income countries has reached epidemic proportions. However, the association between out-of-pocket (OOP) payment and socioeconomic status (SES) of patients with CVD is not well studied. We aimed to understand the financial burden among Chinese middle-aged and older patients with CVD, and whether there was an association with SES.

SETTINGS

A nationally representative survey-The China Health and Retirement Longitudinal Survey (CHARLS)-was conducted in 28 provinces of mainland China in 2011 and 2013.

PARTICIPANTS

Of the over 18 000 CHARLS respondents, eligible participants were those aged 45 years and over who had been previously diagnosed with CVD.

OUTCOME MEASURES

Financial burden was measured by individual OOP payment and household catastrophic health expenditure (CHE) occurrence (ie, the annual household health expenditure was 40% or more of the total non-food household expenditure). Multilevel regression models were used to explore the association between financial burden and SES.

RESULTS

Among CHARLS respondents, CVD prevalence increased from 14.7% in 2011 to 16.6% in 2013. Average annual CVD OOP payment increased from 5000 RMB (770 USD) to 6120 RMB (970 USD). Furthermore, CHE occurrence increased from 44.2% to 48.1%. Patients spent almost twice on outpatient as on inpatient services. Two of the three SES indicators (total household expenditure, occupation type) were found to be associated with CVD OOP payment amount, and the likelihood of CHE. Unemployed patients had a higher likelihood of CHE compared with agricultural workers. Rural-urban difference was associated with the likelihood of CHE in 2011 alone.

CONCLUSION

The Chinese health system should use this health expenditure pattern among patients with CVD to create more equitable health insurance schemes that financially balance between outpatient and inpatient care, and provide better financial risk protection to patients with low SES.