Health-related financial catastrophe, inequality and chronic illness in Bangladesh

Factors affecting out-of-pocket expenditures for chronic and acute illnesses in Bangladesh

BACKGROUND

In the absence of universal healthcare protection, out-of-pocket (OOP) expenditures are the main source of healthcare financing in Bangladesh. This study assesses the disparities in the overall and the components of OOP expenditures among households with both chronic and acute illnesses compared to those having acute illnesses only. It also identifies factors influencing OOP expenditures over time and examines patterns related to various illness conditions.

MATERIALS AND METHODS

Data from the Household Income and Expenditure Surveys (HIES) of 2016-17 and 2022 were used. A Log-linear Multiple Regression Model was employed to identify factors influencing OOP expenditures in households with different disease profiles.

RESULTS

The average OOP expenditures increased significantly from 2016 to 2022, even after inflation adjustments. Higher expenditures were observed in urban households BDT 939.34 in 2016 and BDT 1605.36 in 2022, and in households having both chronic and acute illness conditions with OOP expenditure of BDT 2290.43 and BDT 3525.32 in 2016 and 2022 respectively. Wealthier households spent more on healthcare, with the cost of medicines being the largest component with over 50% of total OOP expenditures. The regression analysis suggests that area of residence (urban vs rural), household size, level of education of the household head, the presence of elderly members (≥60 years), the number of employed members and sick household members, and hospitalisation of household members were mainly responsible for higher OOP expenditure.

CONCLUSION

Our study provides valuable insights on the determinants of OOP expenditures over time, with a notable increase among households managing both chronic and acute illnesses, and in urban areas. Key contributors to increased expenditures include medicines, medical tests and surgery costs, with cancer causing higher expenses. This study recommends improving treatment protocols help reduce unnecessary prescriptions of medicine and investigations, and alleviate financial burdens of the vulnerable population.

Assessing the determinants of out-of-pocket health expenditures among Cambodian households in informal employment using survey data

BACKGROUND

As the deadline for the Sustainable Development Goals approaches, financial protection in Cambodia remains inadequate, especially for nonpoor informal workers lacking formal social health protection coverage or access to other prepayment schemes. This exposes them to high out-of-pocket health expenditures (OOPE) and related financial hardship. To better understand the drivers behind these expenditures, our study aims to model their healthcare, health, and social determinants and to assess their relative importance.

METHODS

In 2023, we conducted a cross-sectional multistage clustered sampling survey across seven Cambodian provinces, surveying 3,254 households engaged in informal employment and not covered by any formal social health protection scheme. The survey gathered information on households' use of outpatient and inpatient care and associated OOPE. We employed generalized linear models (GLMs) to analyse the healthcare, health, and social determinants of OOPE and the OOPE budget share (the proportion of total annual household consumption expenditure spent on OOPE) and applied Shapley decomposition analysis to quantify the relative contributions of these determinants to the explained variance in our outcomes.

RESULTS

Healthcare variables were the dominant contributors to the explained variance in all outcomes (41.36-50.73%), followed by health factors. While several social variables were significant, only the wealth quintile made notable contributions to explaining variance in our outcomes. The key healthcare contributors included the sector type and level of care, and the number of outpatient medications. Important health contributors included illness severity and the presence of chronic illnesses or noncommunicable diseases.

CONCLUSIONS

Our findings emphasize the necessity of integrating nonpoor informal workers and their dependents into formal prepayment schemes to reduce OOPE and enhance financial protection on Cambodia's path toward universal health coverage. Strategically engaging with private providers and pharmacies to improve access to essential services and medicines, coupled with the implementation of an effective referral system are important policy considerations to this end. Further research is needed on how health determinants are modifiable with policy interventions. Our findings can assist the Cambodian government in advancing its universal health coverage goals and offer insights for other countries aiming to extend coverage to similar population groups.

Determinants of out-of-pocket expenditure on medicines among adults in Saudi Arabia: a cross-sectional study

Introduction

To achieve universal health coverage consistent with World Health Organization recommendations, monitoring financial protection is vital, even in the context of free medical care. Toward this end, this study investigated out-of-pocket (OOP) expenditure on medicines and their determinants among adults in Saudi Arabia.

Methods

This analysis was based on cross-sectional data derived from the Family Health Survey conducted by the General Authority for Statistics in 2018. Data analyses for this study were based on the total sample of 10,785 respondents. Descriptive statistics were used to identify the sample distribution for all variables included in the study. Tobit regression analysis was used to examine the determinants of OOP expenditure on medicines.

Results

The average OOP expenditure on medicines was estimated to be 279.69 Saudi Riyal in the sampled population. Tobit regression analysis showed that age, average household monthly income, education level, and suffering a chronic condition were the main determinants of OOP expenditure on medicines. Conversely, being married and employed were associated with a lower probability of OOP expenditure on medicines.

Conclusion

This study could assist policy makers to provide additional insurance funding and benefits to reduce the possibility of catastrophic OOP expenditure on medicines, especially for the most vulnerable demographic.

Monitoring financial healthcare protection in Brazil: evolution, inequalities, and associated factors

OBJECTIVES

Although catastrophic health spending is the main measure for assessing financial healthcare protection, it varies considerably in methodological and empirical terms, which hinders comparison between studies. The aim of this study was to measure the prevalence of catastrophic health spending in Brazil in 2003, 2009, and 2018, its associated factors, and disparities in prevalence distribution according to socioeconomic status.

STUDY DESIGN

This was a time series study.

METHODS

Data from the Household Budget Surveys were used. Prevalence of catastrophic health spending was measured as a percentage of the budget and ability to pay, considering thresholds of 10, 25, and 40%. It was determined whether household, family, and household head characteristics influence the likelihood of incurring catastrophic health spending. Households were stratified by income deciles, consumption, and wealth score.

RESULTS

There was an increase in prevalence of catastrophic health spending between 2003 and 2009 in Brazil and a slight reduction in 2018. The wealth score showed more pronounced distributional effects between the poor and the rich, with the former being the most affected by catastrophic health spending. Consumption showed greater percentage variations in the prevalence of catastrophic health spending. The prevalence of catastrophic health spending was positively associated with the presence of older adults, age and female household head, rural area, receipt of government benefits, and some degree of food insecurity.

CONCLUSIONS

The poorest families are most affected by catastrophic health spending in Brazil, requiring more effective and equitable policies to mitigate financial risk.

A geographic perspective of the association between physical activity and cardiovascular health: A need for community-level intervention

Cardiovascular diseases (CVDs) are a major cause of death globally, and minority communities are at higher risk of chronic health outcomes. A combination of lifestyle, including physical activity (PA), good nutrition, and reduced stress, can improve life expectancy. This study aimed to analyze the association between CVDs and PA among the adult population (N = 3,956) based on the World Health Organization (WHO) STEPwise Approach to Surveillance (STEPS) survey in Afghanistan. Descriptive statistics, logistic regression, and spatial analytical techniques were used to analyze the data. Based on the WHO STEPS data, the computed prevalence of CVDs, obesity, hypertension, diabetes, and high cholesterol were 7.41%, 45.57%, 34.06%, 9.51%, and 12.16%, respectively. Multivariate logistic analysis indicated that moderate work-related PA was associated with higher odds of CVDs and high cholesterol while inversely associated with obesity. Moderate leisure-related PA was positively associated with obesity. Vigorous leisure-related PA was associated with lower risks of CVDs, obesity, and high cholesterol but had a positive association with hypertension. Spatial analysis revealed a CVD hotspot in the southern region and the risk factors clustered in the northern region. These findings offer valuable insights for community and public health practitioners to design targeted interventions for reducing the burden of CVDs and risk factors in communities in developing countries.

Catastrophic out-of-pocket payments related to non-communicable disease multimorbidity and associated factors, evidence from a public referral hospital in Addis Ababa Ethiopia

BACKGROUND

In low and middle-income countries (LMICs), non-communicable diseases (NCDs) are on the rise and have become a significant cause of mortality. Unfortunately, accessing affordable healthcare services can prove to be challenging for individuals who are unable to bear the expenses out of their pockets. For NCDs, the treatment costs are already high, and being multimorbid further amplifies the economic burden on patients and their families. The present study seeks to bridge the gap in knowledge regarding the financial risks that come with NCD multimorbidity. It accomplishes this by examining the catastrophic out-of-pocket (OOP) expenditure levels and the factors that contribute to it at Tikur Anbesa Specialized Hospital, Addis Ababa, Ethiopia.

METHODS

A facility-based cross-sectional study was conducted at Tikur Anbesa Specialized Hospital between May 18 and July 22, 2020 and 392 multimorbid patients participated. The study participants were selected from the hospital's four NCD clinics using systematic random sampling. Patients' direct medical and non-medical out-of-pocket (OOP) expenditures were recorded, and the catastrophic OOP health expenditure for NCD care was estimated using various thresholds as cutoff points (5%, 10%, 15%, 20%, 25%, and 40% of both total household consumption expenditure and non-food expenditure). The collected data was entered into Epi Data version 3.1 and analyzed using STATA V 14. Descriptive statistics were utilized to present the study's findings, while logistic regression was used to examine the associations between variables.

RESULTS

A study was conducted on a sample of 392 patients who exhibited a range of socio-demographic and economic backgrounds. The annual out-of-pocket spending for the treatment of non-communicable disease multimorbidity was found to be $499.7 (95% CI: $440.9, $558.6) per patient. The majority of these expenses were allocated towards medical costs such as medication, diagnosis, and hospital beds. It was found that as the threshold for spending increased from 5 to 40% of total household consumption expenditure, the percentage of households facing catastrophic health expenditures (CHE) decreased from 77.55 to 10.46%. Similarly, the proportion of CHE as a percentage of non-food household expenditure decreased from 91.84 to 28.32% as the threshold increased from 5 to 40%. The study also revealed that patients who traveled to Addis Ababa for healthcare services (AOR = 7.45, 95% CI: 3.41-16.27), who were not enrolled in an insurance scheme (AOR = 4.97, 95% CI: 2.37, 10.4), who had more non-communicable diseases (AOR = 2.05, 95% CI: 1.40, 3.01), or who had more outpatient visits (AOR = 1.46, 95%CI: 1.31, 1.63) had a higher likelihood of incurring catastrophic out-of-pocket health expenditures at the 40% threshold.

CONCLUSION AND RECOMMENDATION

This study has revealed that patients with multiple non-communicable diseases (NCDs) frequently face substantial out-of-pocket health expenditures (CHE) due to both medical and non-medical costs. Various factors, including absence from an insurance scheme, medical follow-ups necessitating travel to Addis Ababa, multiple NCDs and outpatient visits, and utilization of both public and private facilities, increase the likelihood of incurring CHE. To mitigate the incidence of CHE for individuals with NCD multimorbidity, an integrated NCD care service delivery approach, access to affordable medications and diagnostic services in public facilities, expanded insurance coverage, and fee waiver or service exemption systems should be explored.

Challenges to establishing and maintaining kidney transplantation programs in developing countries: What are the coping strategies?

Kidney transplantation (KT) is the optimal form of renal replacement therapy for patients with end-stage renal diseases. However, this health service is not available to all patients, especially in developing countries. The deceased donor KT programs are mostly absent, and the living donor KT centers are scarce. Single-center studies presenting experiences from developing countries usually report a variety of challenges. This review addresses these challenges and the opposing strategies by reviewing the single-center experiences of developing countries. The financial challenges hamper the infrastructural and material availability, coverage of transplant costs, and qualification of medical personnel. The sociocultural challenges influence organ donation, equity of beneficence, and regular follow-up work. Low interests and motives for transplantation may result from high medicolegal responsibilities in KT practice, intense potential psychosocial burdens, complex qualification protocols, and low productivity or compensation for KT practice. Low medical literacy about KT advantages is prevalent among clinicians, patients, and the public. The inefficient organizational and regulatory oversight is translated into inefficient healthcare systems, absent national KT programs and registries, uncoordinated job descriptions and qualification protocols, uncoordinated on-site investigations with regulatory constraints, and the prevalence of commercial KT practices. These challenges resulted in noticeable differences between KT services in developed and developing countries. The coping strategies can be summarized in two main mechanisms: The first mechanism is maximizing the available resources by increasing the rates of living kidney donation, promoting the expertise of medical personnel, reducing material consumption, and supporting the establishment and maintenance of KT programs. The latter warrants the expansion of the public sector and the elimination of non-ethical KT practices. The second mechanism is recruiting external resources, including financial, experience, and training agreements.

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.

From the local disparities to national realities: Mapping and multilevel modeling of catastrophic health expenditure in Bangladesh using HIES 2016

In developing nations, catastrophic health expenditures have become an all-too-common occurrence, threatening to push households into impoverishment and poverty. By analyzing the Household Income and Expenditure Survey 2016, which features a sample of 46,080 households, this study provides a comprehensive district-by-district analysis of the variation in household catastrophic health expenditures and related factors. The study utilizes a multilevel logistic regression model, which considers both fixed and random effects to identify factors associated with catastrophic health expenditure. The findings of the study indicate that districts located in the eastern and southern regions are at a significantly higher risk of experiencing catastrophic health expenditures. A potential explanation for this trend may be attributed to the high prevalence of chronic diseases in these districts, as well as their economic conditions. The presence of chronic diseases (AOR 5.45 with 95% CI: 5.14, 5.77), presence of old age person (AOR 1.50 with 95% CI: 1.39, 1.61), place of residence (AOR 1.40 with 95% CI: 1.14, 1.73) are found to be highly associated factors. Additionally, the study reveals that the thresholds used to define catastrophic health expenditures exhibit substantial variation across different regions, and differ remarkably from the threshold established by the WHO. On average, the thresholds are 23.12% of nonfood expenditure and 12.14% of total expenditure. In light of these findings, this study offers important insights for policymakers and stakeholders working towards achieving universal health coverage and sustainable development goals in Bangladesh.

The role of the private sector in noncommunicable disease prevention and management in low- and middle-income countries: a series of systematic reviews and thematic syntheses

PURPOSE

Conduct six systematic reviews investigating for-profit private sector roles in NCD prevention and management in low- and middle-income countries (LMICs) through our a priori framework's pillars.

METHODS

Six systematic reviews and thematic syntheses were performed between March-August 2021, Six databases, websites of relevant organizations, and references lists of included studies were comprehensively searched. Studies published in English from 2000 onwards involving the pillar of interest, for-profit private sector, NCD prevention/management, and LMIC context were included. Results were synthesized using an inductive thematic synthesis approach.

RESULTS

Ultimately, 25 articles were included in the PPP review, 33 in Governance and Policy, 22 in Healthcare Provision, 15 in Innovation, 14 in Knowledge Educator, and 42 in Investment and Finance. The following themes emerged: PPPs (coordination; financial resources; provision; health promotion; capacity building; innovation; policy); Governance/Policy (lobbying; industry perception; regulation); Healthcare Provision (diagnosis/treatment; infrastructure; availability/accessibility/affordability); Innovation (product innovation; process innovation; marketing innovation; research; innovation dissemination); Knowledge Educator (training; health promotion; industry framework/guideline formation); Investment and Finance (treatment cost; regulation; private insurance; subsidization; direct investment; collaborative financing; innovative financing; research).

CONCLUSION

These findings will be instrumental for LMICs considering private sector engagement. Potential conflicts of interest must be considered when implementing private sector involvement.

Laos' Social Health Insurance (SHI) program's impact on older people's accessibility and financial security against catastrophic health expense

Laos has introduced various SHI schemes for multiple groups of the population, such as government officials and other population groups under the NHI schemes. There is no specific health insurance policy for this group of people who need special health services and may have a higher possibility of entering financial catastrophe. This study aims to assess the impact of SHI schemes on accessibility and financial catastrophe against catastrophic health expenditures for older people in Laos. A structured questionnaire has been used to retrieve information from 400 older people across 39 villages in Kaysone Phomvihane District, Savannakhet province, the largest province in Laos. In the analytical process, this study used a cross-sectional study design and binary logistic regression models to predict the likelihood of accessing health facilities and experiencing financial catastrophe. The study outcome shows that the increase in age, occupation, number of older people within a household, and presence of chronic conditions increase the likelihood of using health services. Despite the existence of various SHI schemes, this study found that 74 out of 165 households reported using health services experienced catastrophic health expenditure. Several characteristics are associated with catastrophic health expenditure: age, income level, and gender are prone to suffer from catastrophic health expenditure. The difficult problems stem from the absence of comprehensive legislation regarding the older population. Recommendations for policymakers in various timeframes have been made, which cover short- and long-term policy proposals, including providing a specialized lane or fast-track for an older population, building health facilities exclusively for older people, and providing transportation services for older individuals living alone.

Out-of-pocket health expenditure and associated factors among patients with hypertension in Debre-Tabor Comphrensive Specialized Hospital, South Gondar zone, Northwest Ethiopia, 2020

Introduction

Hypertension is a non-communicable chronic disease that has a wide financial effect at the individual and household levels especially in developing countries due to its complexity and chronicity. Nevertheless, there are limited studies in Ethiopia. Therefore the aim of this study was to assess out-of pocket health expenditure and associated factors among adult patients with hypertension in Debre-Tabor Comphrensive Specialized Hospital.

Methods

A facility-based cross-sectional study was conducted in total of 357 adult hypertensive patients from March to April 2020 using a systematic random sampling technique. Descriptive stastics were used to estimate the magnitude of out-of-pocket health expenditure, while after checking the assumptions linear regression model was fitted for identifying the factors associated with the outcome variable at a significance level of value of p < 0.05 and 95% confidence interval.

Result

A total of 346 study participants interviewed with a response rate of 96.92%. Annual mean out of pocket health expenditure of the participant was $113.40 ± $10.18 with 95% CI = (102.63, 124.16) per patient. The direct medical mean out of pocket health expenditure of the participant was $68.86 per patient per year and the median of non-medical components of the out of pocket health expenditure of the participant was $3.53. Sex, wealth status, distance from hospital, comorbidity, health insurance and number of visit are factors significantly associated to out-of-pocket expenditure.

Conclusion

This study revealed that out of pocket health expenditure among adult patients with hypertension was found high compared to the national per capita health expenditure. Sex, wealth index, distance away from hospital, frequency of visit, comorbidities, and health insurance coverage were factors significantly associated with high out-of-pocket health expenditure. Ministry of health together with regional health bureaus and other concerned stakeholders work on strengthening early detection and prevention strategies of chronic comorbidities of hypertensive patients,promote health insurance coverage and better to subsidize medication costs for the poors.

The economics of healthcare access: a scoping review on the economic impact of healthcare access for vulnerable urban populations in low- and middle-income countries

BACKGROUND

The growing urban population imposes additional challenges for health systems in low- and middle-income countries (LMICs). We explored the economic burden and inequities in healthcare utilisation across slum, non-slum and levels of wealth among urban residents in LMICs.

METHODS

This scoping review presents a narrative synthesis and descriptive analysis of studies conducted in urban areas of LMICs. We categorised studies as conducted only in slums, city-wide studies with measures of wealth and conducted in both slums and non-slums settlements. We estimated the mean costs of accessing healthcare, the incidence of catastrophic health expenditures (CHE) and the progressiveness and equity of health expenditures. The definitions of slums used in the studies were mapped against the 2018 UN-Habitat definition. We developed an evidence map to identify research gaps on the economics of healthcare access in LMICs.

RESULTS

We identified 64 studies for inclusion, the majority of which were from South-East Asia (59%) and classified as city-wide (58%). We found severe economic burden across health conditions, wealth quintiles and study types. Compared with city-wide studies, slum studies reported higher direct costs of accessing health care for acute conditions and lower costs for chronic and unspecified health conditions. Healthcare expenditures for chronic conditions were highest amongst the richest wealth quintiles for slum studies and more equally distributed across all wealth quintiles for city-wide studies. The incidence of CHE was similar across all wealth quintiles in slum studies and concentrated among the poorest residents in city-wide studies. None of the definitions of slums used covered all characteristics proposed by UN-Habitat. The evidence map showed that city-wide studies, studies conducted in India and studies on unspecified health conditions dominated the current evidence on the economics of healthcare access. Most of the evidence was classified as poor quality.

CONCLUSIONS

Our findings indicated that city-wide and slums residents have different expenditure patterns when accessing healthcare. Financial protection schemes must consider the complexity of healthcare provision in the urban context. Further research is needed to understand the causes of inequities in healthcare expenditure in rapidly expanding and evolving cities in LMICs.

The burden of chronic diseases and patients' preference for healthcare services among adult patients suffering from chronic diseases in Bangladesh

BACKGROUND

Low- and middle-income countries (LMICs) have a disproportionately high burden of chronic diseases, with inequalities in health care access and quality services. This study aimed to assess patients' preferences for healthcare services for chronic disease management among adult patients in Bangladesh.

METHODS

The present analysis was conducted among 10,385 patients suffering from chronic diseases, drawn from the latest Household Income and Expenditure Survey 2016-2017. We used the multinomial logistic regression to investigate the association of chronic comorbid conditions and healthcare service-related factors with patients' preferences for healthcare services.

RESULTS

The top four dimensions of patient preference for healthcare services in order of magnitude were quality of treatment (30.3%), short distance to health facility (27.6%), affordability of health care (21.7%) and availability of doctors (11.0%). Patients with heart disease had a 29% significantly lower preference for healthcare affordability than the quality of healthcare services (relative risk ratio [RRR] = 0.71; 0.56-0.90). Patients who received healthcare services from pharmacies or dispensaries were more likely to prefer a short distance to a health facility (RRR = 6.99; 4.80-9.86) or affordability of healthcare services (RRR = 3.13; 2.25-4.36). Patients with comorbid conditions were more likely to prefer healthcare affordability (RRR = 1.39; 1.15-1.68). In addition, patients who received health care from a public facility had 2.93 times higher preference for the availability of medical doctors (RRR = 2.93; 1.70-5.04) than the quality of treatment in the health facility, when compared with private service providers.

CONCLUSIONS

Patient preferences for healthcare services in chronic disease management were significantly associated with the type of disease and its magnitude and characteristics of healthcare providers. Therefore, to enhance service provision and equitable distribution and uptake of health services, policymakers and public health practitioners should consider patient preferences in designing national strategic frameworks for chronic disease management.

PATIENT OR PUBLIC CONTRIBUTION

Our research team includes four researchers (co-authors) with chronic diseases who have experience of living or working with people suffering from chronic conditions or diseases.

The role of artificial intelligence based systems for cost optimization in colorectal cancer prevention programs

Colorectal Cancer (CRC) has seen a dramatic increase in incidence globally. In 2019, colorectal cancer accounted for 1.15 million deaths and 24.28 million disability-adjusted life-years (DALYs) worldwide. In India, the annual incidence rates (AARs) for colon cancer was 4.4 per 100,000. There has been a steady rise in the prevalence of CRC in India which may be attributed to urbanization, mass migration of population, westernization of diet and lifestyle practices and a rise of obesity and metabolic risk factors that place the population at a higher risk of CRC. Moreoever, CRC in India differs from that described in the Western countries, with a higher proportion of young patients and more patients presenting with an advanced stage. This may be due to poor access to specialized healthcare and socio-economic factors. Early identification of adenomatous colonic polyps, which are well-recognized pre-cancerous lesions, at the time of screening colonoscopy has been shown to be the most effective measure used for CRC prevention. However, colonic polyps are frequently missed during colonoscopy and moreover, these screening programs necessitate man-power, time and resources for processing resected polyps, that may hamper penetration and efficacy in mid- to low-income countries. In the last decade, there has been significant progress made in the automatic detection of colonic polyps by multiple AI-based systems. With the advent of better AI methodology, the focus has shifted from mere detection to accurate discrimination and diagnosis of colonic polyps. These systems, once validated, could usher in a new era in Colorectal Cancer (CRC) prevention programs which would center around "Leave in-situ" and "Resect and discard" strategies. These new strategies hinge around the specificity and accuracy of AI based systems in correctly identifying the pathological diagnosis of the polyps, thereby providing the endoscopist with real-time information in order to make a clinical decision of either leaving the lesion in-situ (mucosal polyps) or resecting and discarding the polyp (hyperplastic polyps). The major advantage of employing these strategies would be in cost optimization of CRC prevention programs while ensuring good clinical outcomes. The adoption of these AI-based systems in the national cancer prevention program of India in accordance with the mandate to increase technology integration could prove to be cost-effective and enable implementation of CRC prevention programs at the population level. This level of penetration could potentially reduce the incidence of CRC and improve patient survival by enabling early diagnosis and treatment. In this review, we will highlight key advancements made in the field of AI in the identification of polyps during colonoscopy and explore the role of AI based systems in cost optimization during the universal implementation of CRC prevention programs in the context of mid-income countries like India.

Effect of Socioeconomic Factors on the Choice of Health care Institutions for Delivery Care

During the past two decades, Pakistan witnessed a significant progress in maternal health outcomes. However, there exist persistent urban-rural and socio-economic inequalities in access and utilization of maternal healthcare services across the country. The overall objective of this research was to identify the significant socio-economic factors determining the choice of healthcare institutions for delivery care. This was a cross-sectional study conducted in Rajan Pur, a predominantly rural district in Punjab province. Using a multi-stage random sampling technique, 368 mothers who had childbirths from 1st October to 31st December 2020 in different healthcare institutions were interviewed. Data for the study was collected through a validated study instrument used by earlier studies on maternal healthcare utilization. The results of logistic regression analysis showed that use of public healthcare facilities for delivery care increases with increasing maternal education, monthly household income, and distance to healthcare facilities. The findings and recommendations drawn from the research would provide some insights to health policymakers and planners in developing an integrated and viable maternal healthcare program in Pakistan.

Disease-specific distress healthcare financing and catastrophic out-of-pocket expenditure for hospitalization in Bangladesh

Background

Financial risk protection and equity are two fundamental components of the global commitment to achieve Universal Health Coverage (UHC), which mandates health system reform based on population needs, disease incidence, and economic burden to ensure that everyone has access to health services without any financial hardship. We estimated disease-specific incidences of catastrophic out-of-pocket health expenditure and distress financing to investigate progress toward UHC financial risk indicators and investigated inequalities in financial risk protection indicators by wealth quintiles. In addition, we explored the determinants of financial hardship indicators as a result of hospitalization costs.

Methods

In order to conduct this research, data were extracted from the latest Bangladesh Household Income and Expenditure Survey (HIES), conducted by the Bangladesh Bureau of Statistics in 2016–2017. Financial hardship indicators in UHC were measured by catastrophic health expenditure and distress financing (sale/mortgage, borrowing, and family support). Concentration curves (CC) and indices (CI) were estimated to measure the pattern and severity of inequalities across socio-economic classes. Binary logistic regression models were used to assess the determinants of catastrophic health expenditure and distress financing.

Results

We found that about 26% of households incurred catastrophic health expenditure (CHE) and 58% faced distress financing on hospitalization in Bangladesh. The highest incidence of CHE was for cancer (50%), followed by liver diseases (49.2%), and paralysis (43.6%). The financial hardship indicators in terms of CHE (CI = -0.109) and distress financing (CI = -0.087) were more concentrated among low-income households. Hospital admission to private health facilities, non-communicable diseases, and the presence of chronic patients in households significantly increases the likelihood of higher UHC financial hardship indicators.

Conclusions

The study findings strongly suggest the need for national-level social health security schemes with a particular focus on low-income households, since we identified greater inequalities between low- and high-income households in UHC financial hardship indicators. Regulating the private sector and implementing subsidized healthcare programmes for diseases with high treatment costs, such as cancer, heart disease, liver disease, and kidney disease are also expected to be effective to protect households from financial hardship. Finally, in order to reduce reliance on OOPE, the government should consider increasing its allocations to the health sector.

Effects of Out-of-Pocket Medicine's Spending on Catastrophic Expenditure and Impoverishment in Tunisia

OBJECTIVES

This study aimed to estimate and analyze the effects of out-of-pocket expenditure attributed to medicine on catastrophic health expenditure (CHE) and impoverishment. Our study also explored the determinants of CHE for Tunisian households.

METHODS

CHE and impoverishment were estimated using the representative sample of 25 087 households' survey of Budget, Consumption, and Living Standards in 2015. Logistic regression was applied to determine factors associated with the CHE.

RESULTS

The occurrence of catastrophic expenditure on health and medicine from the total population was, respectively, estimated to be 18.4% and 8.0%, whereas the impoverishment was 2.8% and 1.8%. The catastrophic expenditure was high in households having a chronic disease, disability, elderly, and children younger than 5 years and those living in a rural area. The rich and insured households are also experiencing financial hardship.

CONCLUSIONS

Out-of-pocket expenditure for medicine generates high levels of catastrophic and impoverishment in Tunisia. To achieve universal and affordable access to medicine, policy makers should remove fees at public facilities for patients with chronic diseases and disabilities, consolidate public procurement and distribution, and ensure effective reimbursement of health insurance.

The comparison of catastrophic health expenditure and its inequality between urban and rural households in China

BACKGROUND

In recent years, the goal of universal coverage of the basic medical insurance schemes has been basically achieved in China, but the heavy economic burden of diseases is still the main cause of poverty in many households. Exploring catastrophic health expenditure (CHE) and its inequality are highly important for forward-looking policymaking. This study aims to compare the incidence, intensity and inequality of CHE between urban and rural households in China.

METHODS

This study was based on a national representative household survey-the China Family Panel Studies (CFPS)-that was conducted from 2012 to 2018. Concentration index (CI) was employed to measure the inequality of CHE incidence and overshoot, while the decomposition method of the CI was used to estimate the main influencing factors affecting inequality of CHE incidence.

RESULTS

From 2012 to 2018, the CHE incidence of urban households increased from 11.01 to 11.88%, while the CHE incidence of rural households decreased from 18.42 to 18.31%. During the same period, the CI of CHE incidence for urban households decreased from - 0.1480 to - 0.1693, while that for rural households declined from - 0.1062 to - 0.1501. The major contribution to the pro-poor inequality in CHE incidence was associated with socioeconomic status, lagged CHE, receiving inpatient services, having elderly members, education of household head, and self-assessed health status of household head.

CONCLUSIONS

Rural households had higher risk of incurring CHE than urban households. The strong pro-poor inequality for CHE incidence and overshoot could be found in both two groups. The problem of poverty due to illness was more severe among low-income groups in rural areas than in urban areas. The relevant policy interventions should further focus on encouraging the development of supplementary medical insurance and increasing the reimbursement rate for hospitalization expenses in the medical assistance system.

Universal Health Insurance Coverage and the Economic Burden of Disease in Eastern China: A Pooled Cross-Sectional Analysis From the National Health Service Survey in Jiangsu Province

China has achieved universal social health insurance coverage, but it is unclear whether this has alleviated the economic burden of disease for individuals. This was investigated in the present study by analyzing National Health Service Survey (2008-2018) data from Jiangsu province. Ordinary least squares and binary multivariate logistic regression of pooled cross-sectional data were carried out to evaluate the effect of universal health insurance coverage and other socioeconomic factors on the economic burden of disease. Total health expenses (THE) first increased and then decreased during the survey period while out-of-pocket health expenses (OOP) decreased except for urban residents, for whom OOP increased after 2013. Household catastrophic health expenditure (HCHE) was stable between 2008 and 2013 but increased after 2013. Social health insurance had a significant positive effect on the annual THE and OOP and a negative effect on HCHE, however, universal health insurance coverage could alleviated THE and the economic burden of disease on individuals (OOP) while it was insufficient to protect against the economic risk of diseases (HCHE), with greater benefits for urban as compared to rural residents. Other socioeconomic factors including age, marital status, education, income, and health status also influenced the economic burden of disease.

A STUDY OF CATASTROPHIC HEALTH EXPENDITURES IN INDIA - EVIDENCE FROM NATIONALLY REPRESENTATIVE SURVEY DATA: 2014-2018

Abstract

Background: India is taking steps to provide Universal Health Coverage (UHC). Out-of-pocket (OOP) health care payment is the most important mechanism for health care payment in India. This study aims to investigate the effect of OOP health care payments on catastrophic health expenditures (CHE).

Methods: Data from the National Sample Survey Organization, Social Consumption in Health 2014 and 2018 are used to investigate the effect of OOP health expenditure on household welfare in India. Three aspects of catastrophic expenditure were analyzed in this paper: (i) incidence and intensity of ‘catastrophic’ health expenditure, (ii) socioeconomic inequality in catastrophic health expenditures, and (iii) factors affecting catastrophic health expenditures.

Results: The odds of incidence and intensity of CHE were higher for the poorer households. Using the logistic regression model, it was observed that the odds of incidence of CHE was higher among the households with at least one child aged less than 5 years, one elderly person, one secondary educated female member, and if at least one member in the household used a private healthcare facility for treatment. The multiple regression model showed that the intensity of CHE was higher among households with members having chronic illness, and if members had higher duration of stay in the hospital. Subsidizing healthcare to the households having elderly members and children is necessary to reduce CHE.

Conclusion: Expanding health insurance coverage, increasing coverage limits, and inclusion of coverage for outpatient and preventive services are vital to protect households. Strengthening public primary health infrastructure and setting up a regulatory organization to establish policies and conduct regular audits to ensure that private hospitals do not increase hospitalizations and the duration of stay is necessary.

Forgone healthcare and financial burden due to out-of-pocket payments in Bangladesh: a multilevel analysis

BACKGROUND

Ensuring access to health services for all is the main goal of universal health coverage (UHC) plan. Out-of-pocket (OOP) payment still remains the main source of funding for healthcare in Bangladesh. The association between barriers to accessing healthcare and over-reliance on OOP payments has not been explored in Bangladesh using nationally representative household survey data. This study is a novel attempt to examine the burden of OOP payment and forgone healthcare in Bangladesh, and further explores the inequalities in catastrophic health expenditures (CHE) and forgone healthcare at the national and sub-national levels.

METHODS

This study used data from the most recent nationally representative cross-sectional survey, Bangladesh Household Income and Expenditure Survey, conducted in 2016-17 (N = 39,124). In order to identify potential determinants of CHE and forgone healthcare, multilevel Poisson regression was used. Inequalities in CHE and forgone healthcare were measured using the slope index of inequality.

RESULTS

Around 25% of individuals incurred CHE and 14% of the population had forgone healthcare for any reasons. The most common reasons for forgone healthcare were treatment cost (17%), followed by none to accompany or need for permission (5%), and distance to health facility (3%). Multilevel analysis indicated that financial burden and forgone care was higher among households with older populations or chronic illness, and those who utilize either public or private health facilities. Household consumption quintile had a linear negative association with forgone care and positive association with CHE.

CONCLUSION

This study calls for incorporation of social safety net in health financing system, increase health facility, and gives priority to the disadvantaged population to ensure access to health services for all.

Catastrophic health expenditure in patients with Guillain Barre syndrome: Retrospective study

INTRODUCTION

Catastrophic health expenditure (CHE) is a reliable measure of the financial unpreparedness of the studied population to meet unexpected health issues. The alarming proportion of patients who incur CHE in the wake of an acute neurological illness like Guillain Barre Syndrome (GBS) is of serious concern in a country like India where a large majority of households are uninsured.

METHODOLOGY

Medical records of patients diagnosed with at a tertiary care centre in Delhi were analysed retrospectively to determine the rate of CHE. Clinical details and other contributory variables were also recorded.

RESULTS

53 patients with a median age of 29 years (10.5-46.5) were included in the study. Tow- third of patients were less than 40 years of age and 58.5% were male. 90.6% of patients incurred CHE with a median amount INR 273 300 spent out of pocket.

CONCLUSION

The enormous magnitude of financial distress and crisis emerging out of an acute neurological illness needs to be addressed with urgency to prevent impoverishment of already weakened households.

Strategies for reducing out of pocket payments in the health system: a scoping review

BACKGROUND

Direct out-of-pocket payments (OOP) are among the most important financing mechanisms in many health systems, especially in developing countries, adversely affecting equality and leading vulnerable groups to poverty. Therefore, this scoping review study was conducted to identify the strategies involving OOP reduction in health systems.

METHODS

Articles published in English on strategies related to out-of-pocket payments were Searched and retrieved in the Web of Science, Scopus, PubMed, and Embase databases between January 2000 and November 2020, following PRISMA guidelines. As a result, 3710 papers were retrieved initially, and 40 were selected for full-text assessment.

RESULTS

Out of 40 papers included, 22 (55%) and 18 (45%) of the study were conducted in developing and developed countries, respectively. The strategies were divided into four categories based on health system functions: health system stewardship, creating resources, health financing mechanisms, and delivering health services.As well, developing and developed countries applied different types of strategies to reduce OOP.

CONCLUSION

The present review identified some strategies that affect the OOP payments According to the health system functions framework. Considering the importance of stewardship, creating resources, the health financing mechanisms, and delivering health services in reducing OOP, this study could help policymakers make better decisions for reducing OOP expenditures.

Impoverishment impact of out-of-pocket payments for healthcare in rural Bangladesh: Do the regions facing different climate change risks matter?

INTRODUCTION

Out-of-pocket (OOP) payments for healthcare severely affect the current consumption, future health and earnings capacity of poor/underprivileged households and hence it is crucial for priority setting. This study assesses the variation in overall as well as disease-specific impoverishment impact of OOP payments between the regions experiencing different climate change risks, defined as high disaster-prone (HDP) areas and low-disaster-prone (LDP) areas, in Bangladesh.

MATERIALS AND METHODS

This paper estimated three poverty measures, such as poverty headcount, poverty intensity and normalized poverty gap for all ailments, catastrophic events, diseases types (communicable, non-communicable (NCDs), and accident and injury), illness conditions (acute and chronic) and hospitalization using 3,791 randomly selected rural households (1,203 from HDP and 2,588 from LDP areas) across the regions. Cost of basic need approach was used for estimating poverty line expenditure.

RESULTS

About 13 percent households annually fall into poverty due to OOP outlays for healthcare. Despite having significantly (p-value≤0.01) less OOP payments (HDP areas: BDT 5,117; LDP areas: BDT5,811) the impoverishment impact of OOP payments for healthcare in HDP areas (16.5%) has substantially higher than LDP areas (11.3%). Population in HDP areas, especially char (river island; 19.55 percent) and haor (water submerged; 16.80 percent) are more susceptible to any level of OOP payments due to low level of earnings. Catastrophic healthcare expenditure (61.79%) and NCDs (14.29 percent) are exacerbating the poverty level in Bangladesh. Both absolute and relative average poverty gap are more widen in HDP than LDP areas due to catastrophic OOP outlays for healthcare.

CONCLUSION

The impoverishment effect due to OOP payments for healthcare in both HDP and LDP areas are high, especially for NCDs and catastrophic healthcare expenditure. However, the situation is bit worse in HDP areas. Preventing the escalation of NCDs as well as catastrophic expenditure and hence reducing the level of impoverishment thereof call for restricting tobacco use, increasing physical activity, encouraging to intake healthy diets, ensuring food safety, controlling air pollution, and improving mental health. Moreover, government should give more emphasis, especially in the HDP areas, on making community clinics more functional through providing screening equipment and training to the Community Health Care Providers for early detection of NCDs, and ensuring availability of medicine all the time. Note that other than community clinics, there is little option for providing healthcare in HDP areas due to poor functionality of public facilities as well as lack of private facilities in HDP areas.

The impacts of health insurance on financial strain for people with chronic diseases

Background

Due to ongoing expenses for both short-term and long-term needs for health services, people with chronic diseases tend to struggle with financial hardship. Health insurance is employed as a useful tool in aiding people to solve such financial strain. This study aims to examine and compare the impacts of public and private health insurance on solving financial barriers for people with chronic diseases.

Methods

This research obtained an outpatient sample consisted of 1739 individuals and an inpatient sample consisted of 1034 individuals. We employed a Chi-square test and a two-sample T-test to explore differences in financial strain and insurance status between people with chronic diseases and those without. Then we adopted binary logistic regression technique to assess the impacts of different types of health insurance on outpatient and inpatient financial strain for people with chronic diseases.

Results

Our research has five key findings: first, people with chronic diseases were more likely to experience both the outpatient and inpatient financial strain (P < 0.01); second, public health insurance was found to reduce the outpatient financial strain; third, private health insurance was found to positively associate with inpatient financial barriers; fourth, Urban Employment Insurance (UEI) was expected to reduce both the outpatient and inpatient financial barriers, while self-paid private insurance (SPI) was positively associated with inpatient financial barriers; and fifth, income was identified as a positive predictor of having outpatient and inpatient financial strain.

Conclusions

Public health insurance has the potential to reduce the outpatient financial strain for people with chronic diseases. Private health insurance was identified as a positive predictor of inpatient financial strain for people with chronic diseases. Policy should be proposed to promote the capacity of public health insurance and explore the potential effects of private health insurance on solving the inpatient financial barriers faced by people with chronic diseases in China.

Trends and determinants of catastrophic health expenditure in China 2010-2018: a national panel data analysis

BACKGROUND

Catastrophic health expenditures (CHE) are out-of-pocket payments (OOP) that exceed a predefined percentage or threshold of a household's resources, usually 40 %, that can push households into poverty in China. We analyzed the trends in the incidence and intensity, and explored the determinants, of CHE, and proposed policy recommendation to address CHE.

METHODS

A unique 5-year national urban-rural panel database was constructed from the China Family Panel Studies (CFPS) surveys. CHE incidence was measured by calculating headcount (percentage of households incurring CHE to the total household sample) and intensity was measured by overshoot (degree by which an average out of pocket health expenditure exceeds the threshold of the total sample). A linear probability model was employed to assess the trend in the net effect of the determinants of CHE incidence and a random effect logit model was used to analyse the role of the characteristics of the household head, the household and household health utilization on CHE incidence.

RESULTS

CHE determinants vary across time and geographical location. From 2010 to 2018, the total, urban and rural CHE incidence all showed a decreasing tend, falling from 14.7 to 8.7 % for total households, 12.5-6.6 % in urban and 16.8-10.9 % in rural areas. CHE intensity decreased in rural (24.50-20.51 %) and urban (22.31-19.57 %) areas and for all households (23.61-20.15 %). Inpatient services were the most important determinant of the incidence of CHE. For urban households, the random effect logit model identified household head (age, education, self-rated health); household characteristics (members 65 + years, chronic diseases, family size and income status); and healthcare utilization (inpatient and outpatient usage) as determinants of CHE. For rural areas, the same variables were significant with the addition of household head's sex and health insurance.

CONCLUSIONS

The incidence and intensity of CHE in China displayed a downward trend, but was higher in rural than urban areas. Costs of inpatient service usage should be a key intervention strategy to address CHE. The policy implications include improving the economic level of poor households, reforming health insurance and reinforcing pre-payment hospital insurance methods.

Assessing the household economic burden of non-communicable diseases in India: evidence from repeated cross-sectional surveys

BACKGROUND

Financing for NCDs is encumbered by out-of-pocket expenditure (OOPE) assuming catastrophic proportions. Therefore, it is imperative to investigate the extent of catastrophic health expenditure (CHE) on NCDs, which are burgeoning in India. Thus, our paper aims to examine the extent of CHE and impoverishment in India, in conjunction with socio-economic determinants impacting the CHE.

METHODS

We used cross-sectional data from nationwide healthcare surveys conducted in 2014 and 2017-18. OOPE on both outpatient and inpatient treatment was coalesced to estimate CHE on NCDs. Incidence of CHE was defined as proportion of households with OOPE exceeding 10% of household expenditure. Intensity of catastrophe was ascertained by the measure of Overshoot and Mean Positive Overshoot Indices. Further, impoverishing effects of OOPE were assessed by computing Poverty Headcount Ratio and Poverty Gap Index using India's official poverty line. Concomitantly, we estimated the inequality in incidence and intensity of catastrophic payments using Concentration Indices. Additionally, we delineated the factors associated with catastrophic expenditure using Multinomial Logistic Regression.

RESULTS

Results indicated enormous incidence of CHE with around two-third households with NCDs facing CHE. Incidence of CHE was concentrated amongst poor that further extended from 2014(CI = - 0.027) to 2017-18(CI = - 0.065). Intensity of CHE was colossal as households spent 42.8 and 34.9% beyond threshold in 2014 and 2017-18 respectively with poor enduring greater overshoot vis-à-vis rich (CI = - 0.18 in 2014 and CI = - 0.23 in 2017-18). Significant immiserating impact of NCDs was unraveled as one-twelfth in 2014 and one-eighth households in 2017-18 with NCD burden were pushed to poverty with poverty deepening effect to the magnitude of 27.7 and 30.1% among those already below poverty on account of NCDs in 2014 and 2017-18 respectively. Further, large inter-state heterogeneities in extent of CHE and impoverishment were found and multivariate analysis indicated absence of insurance cover, visiting private providers, residing in rural areas and belonging to poorest expenditure quintile were associated with increased likelihood of incurring CHE.

CONCLUSION

Substantial proportion of households face CHE and subsequent impoverishment due to NCD related expenses. Concerted efforts are required to augment the financial risk protection to the households, especially in regions with higher burden of NCDs.

Assessing the incidence of catastrophic health expenditure and impoverishment from out-of-pocket payments and their determinants in Bangladesh: evidence from the nationwide Household Income and Expenditure Survey 2016

Background

Out-of-pocket (OOP) payments for healthcare have been increasing steadily in Bangladesh, which deteriorates the financial risk protection of many households.

Methods

We aimed to investigate the incidence of catastrophic health expenditure (CHE) and impoverishment from OOP payments and their determinants. We employed nationally representative Household Income and Expenditure Survey 2016 data with a sample of 46 076 households. A household that made OOP payments of >10% of its total or 40% of its non-food expenditure was considered to be facing CHE. We estimated the impoverishment using both national and international poverty lines. Multiple logistic models were employed to identify the determinants of CHE and impoverishment.

Results

The incidence of CHE was estimated as 24.6% and 10.9% using 10% of the total and 40% of non-food expenditure as thresholds, respectively, and these were concentrated among the poor. About 4.5% of the population (8.61 million) fell into poverty during 2016. Utilization of private facilities, the presence of older people, chronic illness and geographical location were the main determinants of both CHE and impoverishment.

Conclusion

The financial hardship due to OOP payments was high and it should be reduced by regulating the private health sector and covering the care of older people and chronic illness by prepayment-financing mechanisms.

The effect of a community-based health insurance on the out-of-pocket payments for utilizing medically trained providers in Bangladesh

BACKGROUND

We aimed to estimate the effect of the community-based health insurance (CBHI) scheme on the magnitude of out-of-pocket (OOP) payments for the healthcare of the informal workers and their dependents. The CBHI scheme was piloted through a cooperative of informal workers, which covered seven unions in Chandpur Sadar Upazila, Bangladesh.

METHODS

A quasi-experimental study was conducted using a case-comparison design. In total 1292 (646 insured and 646 uninsured) households were surveyed. Propensity score matching was done to minimize the observed baseline differences in the characteristics between the insured and uninsured groups. A two-part regression model was applied using both the probability of OOP spending and magnitude of such spending for healthcare in assessing the association with enrolment status in the CBHI scheme while controlling for other covariates.

RESULTS

The OOP payment was 6.4% (p < 0.001) lower for medically trained provider (MTP) utilization among the insured compared with the uninsured. However, no significant difference was found in the OOP payments for healthcare utilization from all kind of providers, including the non-trained ones.

CONCLUSIONS

The CBHI scheme could reduce OOP payments while providing better quality healthcare through the increased use of MTPs, which consequently could push the country towards universal health coverage.

Out of pocket expenditures of patients with a chronic condition consulting a primary care provider in Tajikistan: a cross-sectional household survey

BACKGROUND

Within its reform efforts, the Government of Tajikistan is embracing the essential role of primary health care (PHC) in decreasing out of pocket (OOP) expenditures and increasing equity in access to health services. In the light of the increasing burden of disease relating to chronic conditions, we investigated OOP expenditures of patients with chronic conditions within a PHC setting; and if and how those expenditures are impacted by several interventions currently being implemented within Tajikistan.

METHODS

A cross-sectional survey among 1600 adult patients who had visited a PHC facility was conducted. The data obtained through interviews were descriptively analysed, and logistic regressions and gamma generalized linear models were performed.

RESULTS

The total OOP expenditures related to a patient's last visit to the PHC facility were 17.2 USD for those with chronic conditions and 13.9 USD for those visiting due to an acute condition. Adjustment for potential confounders reduced the discrepancy from 3.3 USD to 0.5 USD. This convergence of costs was only observed in districts covered by the Basic Benefit Package (BBP), a governmental pilot project, aiming to standardise exemptions for payment and formal co-payments for health care services. Hence, we found the BBP to have a protective impact for patients with chronic conditions. However, considering the demographics of these patients (older in age, with greater dependency on pensions and social aid, and lower socio-economic status) in combination with the 40% higher utilisation rate of PHC and the high rate of onward referrals to specialists; it is clear that patients with chronic conditions continue to face substantial long-term costs and disadvantages.

CONCLUSIONS

After accounting for confounders, patients with chronic and acute conditions faced similar costs related to a single visit to a PHC facility in districts covered by the BBP. However, greater efforts are required to ensure that citizens are well informed about their rights to health care, the BBP and the services that should be provided at no cost at the point of delivery. Moreover, the needs of patients with chronic conditions warrant a more integrative approach that takes long-term expenditures and services beyond the level of PHC into account.

Healthcare seeking for chronic illness among adult slum dwellers in Bangladesh: A descriptive cross-sectional study in two urban settings

Introduction

Accompanying rapid urbanization in Bangladesh are inequities in health and healthcare which are most visibly manifested in slums or low-income settlements. This study examines socioeconomic, demographic and geographic patterns of self-reported chronic illness and healthcare seeking among adult slum dwellers in Bangladesh. Understanding these patterns is critical in designing more equitable urban health systems and in enabling the country’s goal of Universal Health Coverage by 2030.

Methods

This descriptive cross-sectional study compares survey data from slum settlements located in two urban sites in Bangladesh, Tongi and Sylhet. Reported chronic illness symptoms and associated healthcare-seeking strategies are compared, and the catastrophic impact of household healthcare expenditures are assessed.

Results

Significant differences in healthcare-seeking for chronic illness were apparent both within and between slum settlements related to sex, wealth score (PPI), and location. Women were more likely to use private clinics than men. Compared to poorer residents, those from wealthier households sought care to a greater extent in private clinics, while poorer households relied more on drug shops and public hospitals. Chronic symptoms also differed. A greater prevalence of musculoskeletal, respiratory, digestive and neurological symptoms was reported among those with lower PPIs. In both slum sites, reliance on the private healthcare market was widespread, but greater in industrialized Tongi. Tongi also experienced a higher probability of catastrophic expenditure than Sylhet.

Conclusions

Study results point to the value of understanding context-specific health-seeking patterns for chronic illness when designing delivery strategies to address the growing burden of NCDs in slum environments. Slums are complex social and geographic entities and cannot be generalized. Priority attention should be focused on developing chronic care services that meet the needs of the working poor in terms of proximity, opening hours, quality, and cost.

Mediators of the association between low socioeconomic status and poor glycemic control among type 2 diabetics in Bangladesh

Although low socioeconomic status (SES) is related to poor glycemic control, the underlying mechanisms remain unclear. We examined potentially modifiable factors involved in the association between low SES and poor glycemic control using data from the baseline survey of a multicenter, prospective cohort study. Five hundred adult type 2 diabetes patients were recruited from three diabetes centers. Glycemic control was poorer in diabetic individuals with low SES than in those with higher SES. Adverse health-related behaviors, such as non-adherence to medication (adjusted odds ratio [AOR] = 1.07, 95% confidence interval [CI] 1.04–1.13) and diet (AOR = 1.04, 95% CI 1.02–1.06); existing comorbidities, such as depressive symptoms (AOR = 1.05, 95% CI 1.04–1.09); and non-adherence to essential health service-related practices concerning diabetes care, such as irregular scheduled clinic visits (AOR = 1.04, 95% CI 1.03–1.06) and not practicing self-monitoring of blood glucose (AOR = 1.05, 95% CI 1.03–1.07), mediated the relationship between social adversity and poor glycemic control specially in urban areas of Bangladesh. Those identified factors provide useful information for developing interventions to mitigate socioeconomic disparities in glycemic control.

Do employer-sponsored health insurance schemes affect the utilisation of medically trained providers and out-of-pocket payments among ready-made garment workers? A case-control study in Bangladesh

OBJECTIVE

We estimated the effect of an employer-sponsored health insurance (ESHI) scheme on healthcare utilisation of medically trained providers and reduction of out-of-pocket (OOP) expenditure among ready-made garment (RMG) workers.

DESIGN

We used a case-control study design with cross-sectional preintervention and postintervention surveys.

SETTINGS

The study was conducted among workers of seven purposively selected RMG factories in Shafipur, Gazipur in Bangladesh.

PARTICIPANTS

In total, 1924 RMG workers (480 from the insured and 482 from the uninsured, in each period) were surveyed from insured and uninsured RMG factories, respectively, in the preintervention (October 2013) and postintervention (April 2015) period.

INTERVENTIONS

We tested the effect of a pilot ESHI scheme which was implemented for 1 year.

OUTCOME MEASURES

The outcome measures were utilisation of medically trained providers and reduction of OOP expenditure among RMG workers. We estimated difference-in-difference (DiD) and applied two-part regression model to measure the association between healthcare utilisation, OOP payments and ESHI scheme membership while controlling for the socioeconomic characteristics of workers.

RESULTS

The ESHI scheme increased healthcare utilisation of medically trained providers by 26.1% (DiD=26.1; p<0.01) among insured workers compared with uninsured workers. While accounting for covariates, the effect on utilisation significantly reduced to 18.4% (p<0.05). The DiD estimate showed that OOP expenditure among insured workers decreased by -3700 Bangladeshi taka and -1100 Bangladeshi taka compared with uninsured workers when using healthcare services from medically trained providers or all provider respectively, although not significant. The multiple two-part models also reported similar results.

CONCLUSION

The ESHI scheme significantly increased utilisation of medically trained providers among RMG workers. However, it has no significant effect on OOP expenditure. It can be recommended that an educational intervention be provided to RMG workers to improve their healthcare-seeking behaviours and increase their utilisation of ESHI-designated healthcare providers while keeping OOP payments low.

Disease-specific out-of-pocket healthcare expenditure in urban Bangladesh: A Bayesian analysis

BACKGROUND

Because of the rapid increase of non-communicable diseases (NCDs) and high burden of healthcare-related financial issues in Bangladesh, there is a concern that out-of-pocket (OOP) payments related to illnesses may become a major burden on household. It is crucial to understand what are the major illnesses responsible for high OPP at the household level to help policymakers prioritize key areas of actions to protect the household from 100% financial hardship for seeking health care as part of universal health coverage.

OBJECTIVES

We first estimated the costs of illnesses among a population in urban Bangladesh, and then assessed the household financial burden associated with these illnesses.

METHOD

A cross-sectional survey of 1593 randomly selected households was carried out in Bangladesh (urban area of Rajshahi city), in 2011. Catastrophic expenditure was estimated at 40% threshold of household capacity to pay. We employed the Bayesian two-stage hurdle model and Bayesian logistic regression model to estimate age-adjusted average cost and the incidence of household financial catastrophe for each illness, respectively.

RESULTS

Overall, approximately 45% of the population of Bangladesh had at least one episode of illness. The age-sex-adjusted average medical expenses and catastrophic health care expenditure among the households were TK 621 and 8%, respectively. Households spent the highest amount of money 7676.9 on paralysis followed by liver disease (TK 2695.4), injury (TK 2440.0), mental disease (TK 2258.0), and tumor (TK 2231.2). These diseases were also responsible for higher incidence of financial catastrophe. Our study showed that 24% of individuals who suffered typhoid incurred catastrophic expenditure followed by liver disease (12.3%), tumor (12.1%), heart disease (8.4%), injury (7.9%), mental disease (7.9%), cataract (7.1%), and paralysis (6.5%).

CONCLUSION

The study findings suggest that chronic illnesses were responsible for high costs and high catastrophic expenditures in Bangladesh. Effective risk pooling mechanism might reduce household financial burden related to illnesses. Chronic illness related to NCDs is the major cause of OOP. It is also important to consider prioritizing vulnerable population by subsidizing the high health care cost for some of the chronic illnesses.

Catastrophic health expenditure and health-related quality of life among older adults in China

Older adults have more health-care needs and higher financial burdens but fewer income resources compared to other age groups in China. Meanwhile, substantial inequalities exist between rural and urban older adults in terms of welfare benefits level, access to health care, quality of care and financial resources to pay for health-care services. Using 2011–2013 panel data from the China Health and Retirement Longitudinal Study and a difference-in-differences methodology, this study examined the association between the incidence of catastrophic health expenditure (CHE) and health-related quality of life among older adults in China. To distinguish the dynamic of CHE and generate rigorous estimates, we categorised the older adults into four groups: CHE entry group, non-CHE group, CHE exit group and CHE persistent group. Overall, we found that entry into CHE was associated with poorer physical and mental health for both rural and urban older adults, but this association was more consistent and robust for physical than for mental health. Exiting CHE was found to have a weak and sporadic positive association with physical and mental health across rural and urban areas. The results suggest that financial resources and social services are needed in China to support older adults who experience CHE persistently or periodically to help improve their health outcomes.

Health shocks, care-seeking behaviour and coping strategies of extreme poor households in Bangladesh's Chittagong Hill tracts

Background

How and whether health shocks, care-seeking behaviour and coping strategies are interlinked and influence households resilience to ill-health remains an under-researched subject in the context of Bangladesh. This study investigates whether and how health shocks, care-seeking processes and coping strategies interplay and impact the resilience of extremely poor adivasi (ethnic minority) households in the Chittagong Hill Tracts (CHT), Bangladesh.

Methods

Our analysis draws from qualitative data collected through a range of methods (see Additional file 1). We conducted 25 in-depth interviews (IDIs) of two adivasi communities targeted by an extreme-poverty alleviation programme, 11 key informant interviews (KIIs) with project personnel (community workers, field officers, project managers), community leaders, and healthcare providers, and 9 focus group discussions (FGDs) with community members. Data triangulation was performed to further validate the data, and a thematic analysis approach was used to analyze the data.

Results

Health shocks were a defining characteristic of households’ experiences of extreme poverty in the studied region. Care-seeking behaviours are influenced by an array of cultural and economic factors. Households adopt a range of coping strategies during the treatment or care-seeking process, which are often insufficient to allow households to maintain a stable economic status. This is largely due to the fact that healthcare costs are borne by the household, primarily through out-of-pocket payments. Households meet healthcare cost by selling their means of livelihoods, borrowing cash, and marketing livestock. This process erodes their wellbeing and hinders they attempt at achieving resilience, despite their involvement in an extreme poverty-alleviation programme.

Conclusions

Livelihood supports or asset-transfers alone are insufficient to improve household resilience in this context. Therefore, we argue that extreme poor households’ healthcare needs should be central to the design of poverty-alleviating intervention for them to contribute to foster resilience.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7335-7) contains supplementary material, which is available to authorized users.

Exploratory qualitative study to understand the underlying motivations and strategies of the private for-profit healthcare sector in urban Bangladesh

OBJECTIVES

This paper explores the underlying motivations and strategies of formal small and medium-sized formal private for-profit sector hospitals and clinics in urban Bangladesh and their implications for quality and access.

METHODS

This exploratory qualitative study was conducted in Dhaka, Sylhet and Khulna City Corporations. Data collection methods included key informant interviews (20) with government and private sector leaders, in-depth interviews (30) with clinic owners, managers and providers and exit interviews (30) with healthcare clients.

RESULTS

Profit generation is a driving force behind entry into the private healthcare business and the provision of services. However, non-financial motivations are also emphasised such as aspirations to serve the disadvantaged, personal ambition, desire for greater social status, obligations to continue family business and adverse family events.The discussion of private sector motivations and strategies is framed using the Business Policy Model. This model is comprised of three components: products and services, and efforts to make these attractive including patient-friendly discounts and service-packages, and building 'good' doctor-patient relationships; the market environment, cultivated using medical brokers and referral fees to bring in fresh clientele, and receipt of pharmaceutical incentives; and finally, organisational capabilities, in this case overcoming human resource shortages by relying on medical staff from the public sector, consultant specialists, on-call and less experienced doctors in training, unqualified nursing staff and referring complicated cases to public facilities.

CONCLUSIONS

In the context of low public sector capacity and growing healthcare demands in urban Bangladesh, private for-profit engagement is critical to achieving universal health coverage (UHC). Given the informality of the sector, the nascent state of healthcare financing, and a weak regulatory framework, the process of engagement must be gradual. Further research is needed to explore how engagement in UHC can be enabled while maintaining profitability. Incentives that support private sector efforts to improve quality, affordability and accountability are a first step in building this relationship.

Household out-of-pocket expenditure on health care - A cross-sectional study among urban and rural households, Puducherry

CONTEXT

A major proportion of health expenditure is by households as out-of-pocket expenditure (OOPE) in India. Recent estimates at district level are required for planning implementation of Universal Health Coverage.

AIMS

To estimate the proportion of households incurring OOPE and the average amount spent by the household for healthcare.

SETTINGS AND DESIGN

A cross-sectional study was conducted during August 2016 in the field practice areas of a medical college in Puducherry. A random sample of 240 households (120 rural and 120 urban) with 1,029 participants (531 rural and 498 urban) were surveyed.

SUBJECTS AND METHODS

A pretested questionnaire was used to collect information on sociodemographic details, morbidity, healthcare services utilized, and expenses incurred. Recall period of 1 month was fixed for OP/Pharmacy Services and 6 months for IP services.

RESULTS

In total, 120 rural and 120 urban households were surveyed; out of which, majority of the households were below poverty line [rural (83.3%, n = 100), urban (69.2%, n = 83)] and belonged to other backward classes [rural (60.8%, n = 73), urban (83.3%, n = 100)]. The proportion (95% CI) of households which incurred OOPE was 68.3% (59.5%-76%) in rural and 65.8% (57%-73.7%) in urban areas. The median (inter quartile range) proportion of OOPE out of the household budget was 3.31% (0.4%-10.96%) in rural and 5.15% (0.83%-16.3%) in urban areas.

CONCLUSIONS

Even in a resource rich setting as the selected areas of Puducherry, majority of the households (67%) reported OOPE. The study estimates are lesser than the national estimates, but the availability and accessibility of resources are higher in Puducherry compared with the other parts of country.

Catastrophic out-of-pocket payments for households of people with severe mental disorder: a comparative study in rural Ethiopia

BACKGROUND

There are limited data on healthcare spending by households containing a person with severe mental disorder (SMD) in low- and middle-income countries (LMIC). This study aimed to estimate the incidence and intensity of catastrophic out-of-pocket (OOP) payments and coping strategies implemented by households with and without a person with SMD in a rural district of Ethiopia.

METHODS

A comparative cross-sectional community household survey was carried out from January to November 2015 as part of the Emerald programme (emerging mental health systems in low- and middle-income countries). A sample of 290 households including a person with SMD and 289 comparison households without a person with SMD participated in the study. An adapted and abbreviated version of the World Health Organization SAGE (Study on global Ageing and adult health) survey instrument was used. Households were considered to have incurred catastrophic health expenditure if their annual OOP health expenditures exceeded 40% of their annual non-food expenditure. Multiple logistic regression was used to explore factors associated with catastrophic expenditure and types of coping strategies employed.

RESULTS

The incidence of catastrophic OOP payments in the preceding 12 months was 32.2% for households of a person with SMD and 18.2% for comparison households (p = 0.006). In households containing a person with SMD, there was a significant increase in the odds of hardship financial coping strategies (p < 0.001): reducing medical visits, cutting down food consumption, and withdrawing children from school. Households of a person with SMD were also less satisfied with their financial status and perceived their household income to be insufficient to meet their livelihood needs (p < 0.001).

CONCLUSIONS

Catastrophic OOP health expenditures in households of a person with SMD are high and associated with hardship financial coping strategies which may lead to poorer health outcomes, entrenchment of poverty and intergenerational disadvantage. Policy interventions aimed at financial risk pooling mechanisms are crucial to reduce the intensity and impact of OOP payments among vulnerable households living with SMD and support the goal of universal health coverage.

Inequalities in the prevalence of undiagnosed hypertension among Bangladeshi adults: evidence from a nationwide survey

BACKGROUND

In recent years, developing countries like Bangladesh are facing a higher burden of non-communicable diseases such as hypertension as a result of demographic transition. Prevalence of hypertension is often studied in this setting. However, evidence on undiagnosed hypertension is not widely available in the existing literature. Therefore, the current study focuses on inequalities in the prevalence of undiagnosed hypertension in Bangladesh.

METHODS

A total of 8835 participants aged 35+ years were included in this study using nationally representative Bangladesh Demographic and Health Survey 2011 (BDHS). In the survey, systolic blood pressure (SBP) and diastolic blood pressure (DBP) of these participants were measured three times with approximately 10 minutes of an interval between each measurement. Any respondent with either SBP ≥ 140 mmHg or DBP ≥ 90 mmHg was considered as patient with hypertension as per the guidelines from American Heart Association. Among the participants, undiagnosed hypertension was defined as having SBP > =140 mmHg or DBP > =90 mmHg and never taking prescribed medicine or being told by health professionals to lower/control blood pressure. Multiple logistic regression analysis was applied for identifying factors associated with undiagnosed hypertension. Further, socioeconomic inequalities in the prevalence of undiagnosed hypertension were estimated using Concentration Index (C).

RESULTS

We found 978 (59.9% of the total) were undiagnosed among 1685 hypertensive patients studied. Regression analysis showed individuals with being underweight, having poor socioeconomic conditions, and lower educational qualifications were more likely to have undiagnosed hypertension. A similar association between undiagnosed hypertension and socioeconomic quintiles was observed using concentration index (C = - 0.07). On the other hand, individuals from higher age group (50-64 or above), female sex, and Sylhet region were at lower risk of undiagnosed hypertension.

CONCLUSIONS

This study showed that a large proportion of the cases with hypertension are remained undiagnosed in Bangladesh, especially among the poor and low educated population. Screening and awareness building initiatives on hypertension should be taken for this group of population to reduce the burden of undiagnosed hypertension.

Distribution of out of pocket health expenditures in a sub-Saharan Africa country: evidence from the national survey of household standard of living, Côte d'Ivoire

OBJECTIVE

The purpose and objective of our research is to identify the determinants of the out of pocket (OOP) health expenditures in the population of Ivory Coast and the ratios across three different area; Abidjan, the rural and urban area. We used data from the 2015 standard households living survey conducted by the National Institute of Statistic.

RESULTS

About 6315 (13.3%) of the participants had experienced OOP health expenditure. There was significant differences in the self-reported OOP between these three areas (p < 0.001). The overall mean of OOP expenditure among all participants was 16,034.33 XOF (29 USD). People in Abidjan spent an average of 1.6 and 1.5 times more than those in the rural and urban areas respectively (p < 0.001). Hospitalization is the highest expenditure item in terms of money spent, while drugs are the most common item of expenditure in terms of frequency, regardless of the place of residence. Female gender, high social economic status and large household size increase OOP health expenditure significantly in all areas of residence when insurance reduce it. To reduce the impact of the direct payments there is a need to take into account social demographic factors in addition to economic factor in health policy development.

Financing health care in Bangladesh: Policy responses and challenges towards achieving universal health coverage

Bangladesh has attained notable progress in most of the health indicators, but still, health system of the country is suffering badly from poor funding. Issues like burden of out-of-pocket expenditure, low per capita share in health, inadequate service facilities, and financial barriers in reducing malnutrition are being overlooked due to inadequacy and inappropriate utilization of allocated funds. We aimed to review the current status of health care spending in Bangladesh in response to national health policy (NHP) and determine the future challenges towards achieving universal health coverage (UHC). National health policy suggested a substantial increase in budgetary allocation for health care, although government health care expenditures in proportion to total public spending plummeted down from 6.2% to 4.04% in the past 8 years. Overall, 67% of the health care cost is being paid by people, whereas global standard is below 32%. Only one hospital bed is allocated per 1667 people, and 34% of total posts in health sector are vacant due to scarcity of funds. The country is experiencing demographic dividend with a concurrent rise of aged people, but there seems no financial protection schemes for the aged and working age populations. Such situation results in multiple obstacles in achieving financial risk protection as well as UHC. Policy makers must think effectively to develop and adapt systems in order to achieve UHC and ensure health for all.

Determinants of Household Catastrophic Health Expenditure: A Systematic Review

The World Health Organization estimates that annually 150 million people experience severe (catastrophic) financial difficulties as a result of healthcare payments. Therefore, a systematic review was carried out to identify the determinants of household catastrophic health expenditure (CHE) in low-to high-income countries around the world. Both electronic and manual searches were conducted. The main outcome of interest was the determinants of CHE due to healthcare payments. Thirty eight studies met the inclusion criteria for review. The analysis revealed that household economic status, incidence of hospitalisation, presence of an elderly or disabled household member in the family, and presence of a family member with a chronic illness were the common significant factors associated with household CHE. The crucial finding of the current study is that socioeconomic inequality plays an important role in the incidence of CHE all over the world, where low-income households are at high risk of financial hardship from healthcare payments. This suggests that healthcare financing policies should be revised in order to narrow the gap in socioeconomic inequality and social safety nets should be implemented and strengthened for people who have a high need for health care.

Noncommunicable disease-attributable medical expenditures, household financial stress and impoverishment in Bangladesh

BACKGROUND

Treatment of noncommunicable diseases (NCDs) in low-income countries can entail large out-of-pocket (OOP) medical expenditures, which can increase the likelihood of household impoverishment and perpetuate the poverty cycle. This paper studies the implications of NCDs on household medical expenditure, household financial stress (e.g. selling assets or borrowing for treatment financing), catastrophic OOP expenditure, and impoverishment in Bangladesh.

METHODS

We used self-reported health status and household expenditure survey data from 12,240 households in Bangladesh. NCD-afflicted households were defined by presence of at least one of the following conditions within the household - heart disease, hypertension, asthma, diabetes, cancer, or kidney disease. Using linear regression models, we examined whether NCD households incur more medical expenditures, allocate a larger budget share on medical expenditures, and have greater probability of experiencing catastrophic medical expenditure or financial stress from OOP spending than non-NCD households. Finally, using survey weights, we extrapolated how NCD-attributable medical expenditure can result in impoverishment and downward movement in net consumption status at the population level.

RESULTS

NCD-afflicted households allocate a greater share of household expenditures for medical care than households without NCDs, and their probability of incurring catastrophic medical expenditure is higher by 6.7 percentage points compared to the households with no reported conditions. NCD households are 85% more likely to sell assets or borrow from informal sources to finance treatment cost. Household spending on NCD care is estimated to account for the impoverishment of 0.66 million persons in Bangladesh in 2010, and for reducing the net consumption status of 7.63 million persons on both sides of the poverty line after accounting for NCD-related OOP expenditures.

CONCLUSION

NCD-related household medical expenditure is associated with experiencing financial distress and aggravating poverty in Bangladesh.

A comparative study of catastrophic health expenditure in Zhejiang and Qinghai province, China

Background

China has made great achievements in health insurance coverage and healthcare financing; however, the rate of catastrophic health expenditure (CHE) was 13.0% in China in 2008, which is higher than that in some other countries. There remain some differences in life-style, national customs, medical conditions, and health consciousness in different provinces in China. This study aimed to compare the rates of households with CHE, further to explore the different performance of factors influencing CHE between Zhejiang and Qinghai province, China.

Methods

Data were derived from the household surveys conducted in Zhejiang and Qinghai. Sampling on multi-stage stratified cluster random method was adopted. Household with CHE occurs when the out-of-pocket payment for health care equals to or exceeds 40% of a household’s income. Univariate and multivariate logistic regression analyses were used to identify the performance of factors of CHE.

Results

A total of 1598 households were included in this study, including 995 in Zhejiang and 603 in Qinghai. The average rates of CHE in Zhejiang and Qinghai were 9.6 and 30.5%, respectively. We found that economic status of households and households headed by an employed person are the protective factors for CHE; and number of members with chronic diseases and number of inpatients in household are the risk factors for CHE in the two provinces. Besides, poor/low-insured households in Zhejiang; and households having outpatients and households headed by a minority person in Qinghai are more likely to experience the risk of CHE.

Conclusions

This study highlights the importance of improving economic development, expanding employment, and adjusting policies to make greater efforts to protect chronic diseases patients, outpatients, and inpatients, further to reduce the risk of CHE. The Chinese government should pay more attention to the actual conditions in different provinces, further to make policy decisions according to the local knowledge.

Gasto de bolsillo y gasto catastrófico en salud en los hogares de Cartagena, Colombia

Objetivo Estimar el gasto de bolsillo y la probabilidad de gasto catastrófico de los hogares y sus determinantes socioeconómicos en Cartagena, Colombia.Materiales y Métodos Estudio transversal en una muestra poblacional estratificada aleatoria de hogares de Cartagena. Se estimaron dos modelos de regresión cuyas variables dependientes fueron gasto de bolsillo y probabilidad de gasto catastrófico en salud de los hogares.Resultados El gasto de bolsillo promedio anual en hogares pobres fue 1 566 036 COP (US$783) (IC95% 1 117 597–2 014 475); en hogares de estrato medio 2 492 928 COP (US$1246) (IC95% 1 695 845-3 290 011) y en hogares ricos 4 577 172 COP (US$2 288) (IC95% 1 838 222-7 316 122). Como proporción del ingreso, el gasto de bolsillo en salud fue de 14,6% en los hogares pobres, de 8,2% en los hogares de estrato medio y de 7,0% en los hogares ricos. La probabilidad de gasto catastrófico en salud de los hogares pobres fue 30,6% (IC95% 25,6-35,5%), de los de estrato medio del 10,2% (IC95% 4,5-15,9%) y de los hogares de estrato alto del 8,6% (IC95% 1,8-23,0%). El estrato socioeconómico, la educación y la ocupación fueron los principales determinantes del gasto de bolsillo en salud y de la probabilidad de incurrir en gasto catastrófico en salud.Conclusiones En el sistema de salud persisten desigualdades en la protección financiera de los hogares contra el gasto de bolsillo y la probabilidad de gasto catastrófico. El presente estudio genera evidencia para revisar la política de protección social de los hogares socioeconómicamente más vulnerables.