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Tsega Y, Endawkie A, Kebede SD, Kebede N, Mihiretu MM, Bekele E, Ayele K, Asmare L, Bayou FD, Arefaynie M. The burden of health expenditure on household impoverishment in Ethiopia: a systematic review and meta-analysis. Cost Eff Resour Alloc 2024; 22:36. [PMID: 38704568 PMCID: PMC11069253 DOI: 10.1186/s12962-024-00543-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 04/16/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Ethiopia, like many low-income countries, faces significant challenges in providing accessible and affordable healthcare to its population. Health expenditure is a critical factor in determining the quality and accessibility of healthcare. However, high health expenditure can also have detrimental effects on households, potentially leading to impoverishment. To the best knowledge of investigators, no similar study has been conducted in Ethiopia. Therefore, this systematic review and meta-analysis aimed to determine the pooled burden of health expenditure on household impoverishment in Ethiopia. METHODS This systematic review and meta-analysis used the updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. PubMed, Cochrane Library, HINARI, Google Scholar and Epistemonikos electronic databases were searched systematically. Moreover, direct manual searching through google was conducted. The analysis was performed using STATA version 17 software. Heterogeneity and publication bias were assessed using I2 statistics and Egger's test, respectively. The trim and fill method was also performed to adjust the pooled estimate. Forest plots were used to present the pooled incidence with a 95% confidence interval of meta-analysis using the random effect model. RESULTS This systematic review and meta-analysis included a total of 12 studies with a sample size of 66344 participants. The pooled incidence of impoverishment, among households, attributed to health expenditure in Ethiopia was 5.20% (95% CI: 4.30%, 6.20%). Moreover, there was significant heterogeneity between the studies (I2 = 98.25%, P = 0.000). As a result, a random effect model was employed. CONCLUSION The pooled incidence of impoverishment of households attributed to their health expenditure in Ethiopia was higher than the incidence of impoverishment reported by the world health organization in 2023.
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Affiliation(s)
- Yawkal Tsega
- Department of Health System and Management, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia.
| | - Abel Endawkie
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Shimels Derso Kebede
- Department of Health Informatics, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Natnael Kebede
- Department of Health Promotion, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Mengistu Mera Mihiretu
- Department of Health System and Management, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Ermias Bekele
- Department of Health Informatics, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Kokeb Ayele
- Department of Health Promotion, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Lakew Asmare
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Fekade Demeke Bayou
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Mastewal Arefaynie
- Department of Reproductive and Family Health, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
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Hussein N, Ng CW, Ramli R, Liew SM, Hanafi NS, Lee PY, Cheong AT, Ghazali SS, Pinnock H, Stoddart A, Schwarze J, Khoo EM. Assessing catastrophic health expenditure and impoverishment in adult asthma care: a cross-sectional study of patients attending six public health clinics in Klang District, Malaysia. BMC Health Serv Res 2024; 24:327. [PMID: 38475801 DOI: 10.1186/s12913-024-10731-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 02/15/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND In Malaysia, asthma is a common chronic respiratory illness. Poor asthma control may increase out-of-pocket payment for asthma care, leading to financial hardships Malaysia provides Universal Health Coverage for the population with low user fees in the public health system to reduce financial hardship. We aimed to determine out-of-pocket expenditure on outpatient care for adult patients with asthma visiting government-funded public health clinics. We examined the catastrophic impact and medical impoverishment of these expenses on patients and households in Klang District, Malaysia. METHODS This is a cross-sectional face-to-face questionnaire survey carried out in six government-funded public health clinics in Klang District, Malaysia. We collected demographic, socio-economic profile, and outpatient asthma-related out-of-pocket payments from 1003 adult patients between July 2019 and January 2020. Incidence of catastrophic health expenditure was estimated as the proportion of patients whose monthly out-of-pocket payments exceeded 10% of their monthly household income. Incidence of poverty was calculated as the proportion of patients whose monthly household income fell below the poverty line stratified for the population of the Klang District. The incidence of medical impoverishment was estimated by the change in the incidence of poverty after out-of-pocket payments were deducted from household income. Predictors of catastrophic health expenditure were determined using multivariate regression analysis. RESULTS We found the majority (80%) of the public health clinic attendees were from low-income groups, with 41.6% of households living below the poverty line. About two-thirds of the attendees reported personal savings as the main source of health payment. The cost of transportation and complementary-alternative medicine for asthma were the main costs incurred. The incidences of catastrophic expenditure and impoverishment were 1.69% and 0.34% respectively. The only significant predictor of catastrophic health expenditure was household income. Patients in the higher income quintiles (Q2, Q3, Q4) had lower odds of catastrophic risk than the lowest quintile (Q1). Age, gender, ethnicity, and poor asthma control were not significant predictors. CONCLUSION The public health system in Malaysia provides financial risk protection for adult patients with asthma. Although patients benefited from the heavily subsidised public health services, this study highlighted those in the lowest income quintile still experienced financial catastrophe and impoverishment, and the risk of financial catastrophe was significantly greater in this group. It is crucial to ensure health equity and protect patients of low socio-economic groups from financial hardship.
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Affiliation(s)
- Norita Hussein
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia.
| | - Chiu Wan Ng
- Department of Social and Preventive Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Rizawati Ramli
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Su May Liew
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Nik Sherina Hanafi
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Ping Yein Lee
- UM eHealth Unit, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Ai Theng Cheong
- Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, 43400, Malaysia
| | - Sazlina Shariff Ghazali
- Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, 43400, Malaysia
| | - Hilary Pinnock
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, UK
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Andrew Stoddart
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Jürgen Schwarze
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, Usher Institute, The University of Edinburgh, Edinburgh, UK
- Child Life and Health, Centre for Inflammation Research, The University of Edinburgh, Edinburgh, EH8 9AG, UK
| | - Ee Ming Khoo
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
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Krishnamoorthy Y, Rajaa S, Sinha I, Krishnan M, Samuel G, Kanth K. Equity and extent of financial risk protection indicators during COVID-19 pandemic in rural part of Tamil Nadu, India. Heliyon 2023; 9:e18902. [PMID: 37593630 PMCID: PMC10428029 DOI: 10.1016/j.heliyon.2023.e18902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 07/30/2023] [Accepted: 08/02/2023] [Indexed: 08/19/2023] Open
Abstract
Catastrophic health expenditure [CHE] in India is on a rise. This situation would worsen even further when resources are disproportionately distributed across various socioeconomic classes. Hence, we conducted this study to determine the equity and extent of out-of-pocket [OOP] payments, Catastrophic health expenditure and impoverishment among rural households during COVID-19 pandemic in Tamil Nadu, India. A cross-sectional survey covering 2409 households was conducted during November 2021 across six districts in rural part of Tamil Nadu. Information on out-of-pocket payments, Catastrophic health expenditure (based on 40% capacity-to-pay [CTP] method) and impoverishment was obtained through World Health Organization standard criteria. Point estimates were reported as proportions with 95% Confidence Interval [CI]. Our results showed that the proportion of households with out-of-pocket payments on health and Catastrophic health expenditure in the month preceding the survey was 82.8% (95%CI: 81.2%-84.3%) and 26.9% (95%CI: 25.1%-28.7%) respectively. Nuclear (couple with dependent children only) and joint family type (extended family), presence of under-five children and lower socioeconomic status were significant determinants of Catastrophic health expenditure. The prevalence of impoverishment was 6.4% (95%CI: 5.4%-7.5%). To conclude, more than three fourth of the rural households in Tamil Nadu has out-of-pocket payments for health with one-fourth having Catastrophic health expenditure. Almost one in fourteen non-poor households faced impoverishment during the COVID-19 pandemic. This shows the disproportionate distribution of health expenses especially in the rural areas. Hence, appropriate financial risk protection measures should be taken in order to progress towards universal healthcare in our country.
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Affiliation(s)
- Yuvaraj Krishnamoorthy
- Department of Community Medicine, ESIC Medical College and PGIMSR, K.K. Nagar, Chennai, India
| | - Sathish Rajaa
- Department of Community Medicine, ESIC Medical College and PGIMSR, K.K. Nagar, Chennai, India
| | - Isha Sinha
- Department of Community Medicine, ESIC Medical College and PGIMSR, K.K. Nagar, Chennai, India
| | - Murali Krishnan
- Department of Community Medicine, ESIC Medical College and PGIMSR, K.K. Nagar, Chennai, India
| | - Gerald Samuel
- Department of Community Medicine, ESIC Medical College and PGIMSR, K.K. Nagar, Chennai, India
| | - Krishna Kanth
- Department of Community Medicine, ESIC Medical College and PGIMSR, K.K. Nagar, Chennai, India
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Hedayati M, Masoudi Asl I, Maleki M, Fazaeli AA, Goharinezhad S. Policy analysis of the protection of Iranian households against catastrophic health expenditures: a qualitative analysis. BMC Health Serv Res 2023; 23:445. [PMID: 37147681 PMCID: PMC10161991 DOI: 10.1186/s12913-023-09275-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 03/11/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND Despite the adoption of various policies and strategies in recent decades, the Iranian health system has not succeeded in protecting households against catastrophic health expenditures (CHE) and impoverishment. Accordingly, this qualitative study aimed to critically analyze current policies for reducing CHE. METHODS This qualitative study was conducted as a retrospective policy analysis based on a document review and semi-structured interviews with key informants between July to October 2022. Two theoretical frameworks were used, including the Analysis of Determinants of Policy Impact (ADEPT) model and Walt and Gilson's "Policy Triangle framework." The country's related documents were searched through databases. In total, 35 participants were interviewed. Interviews and documents were analyzed using directed content analysis in MAXQDA v12 software. Interobserver reliability, peer check, and member check were done to confirm the trustworthiness of the data. RESULTS Twelve main themes and 42 sub-themes emerged from the data. The findings revealed that policy accessibility, policy background, and a clear statement of goals influenced the policy process. However, resources, monitoring and evaluation, opportunities, and obligations negatively affected the implementation process. In addition, a policy analysis based on the policy triangle framework demonstrated that the main factors affecting the policy on reducing CHE in Iran were "conflicts of interest," "contextual factors," "monitoring and evaluation," and "intersectoral relationship" factors. CONCLUSION The present study reflected the multifaceted nature of the barriers to reducing CHE in Iran. The implementation of the policy on reducing CHE requires the political will to improve intersectoral collaboration, strengthen the stewardship role of the Ministry of Health, design monitoring and evaluation mechanisms, and prevent personal and organizational conflicts of interest.
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Affiliation(s)
- Maryam Hedayati
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Iravan Masoudi Asl
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
| | - Mohammadreza Maleki
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Akbar Fazaeli
- Department of Health Management, Policy and Economics, Tehran university of medical sciences, Tehran, Iran
| | - Salime Goharinezhad
- Preventive Medicine and Public Health Research Center, Psychosocial Research Institute, Iran University of Medical Sciences, Tehran, Iran
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Hedayati M, Masoudi Asl I, Maleki M, Fazaeli AA, Goharinezhad S. The Variations in Catastrophic and Impoverishing Health Expenditures, and Its Determinants in Iran: A Scoping Review. Med J Islam Repub Iran 2023; 37:44. [PMID: 37426477 PMCID: PMC10329513 DOI: 10.47176/mjiri.37.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Indexed: 07/11/2023] Open
Abstract
Background The high reliance on out-of-pocket (OOP) payments for health financing in Iran have been led to different inequity problems such as catastrophic health expenditure (CHE) and impoverishment. This scoping review has been conducted to understand the variations in CHE and impoverishment, the underlying determinants of CHE, and its inequality in the past 20 years. Methods This scoping review is guided by Arksey and O'Malley's scoping review framework. systematically PubMed, Scopus, Web of Science, ProQuest, Scientific Information Database, IranMedex, IranDoc, Magiran Science, Google Scholar, and grey literature were searched systematically from 1 January 2000 to August 2021. We included studies that reported the rate of CHE, impoverishment, inequality, and its influencing factors. Simple descriptive statistics and narrative synthesis were used to present the review findings. Results From 112 included articles, the average incidence of CHE was 3.19% at the 40% threshold, and about 3.21% of the households had impoverished. We found an unfavorable status of health inequality indices, including the average of fair financial contribution (0.833), concentration (-0.01), Gini coefficient (0.42), and Kakwani (-0.149). The most widely applied key drivers influencing the rate of CHE in these studies were household economic status, place of residence, health insurance status, household size, head of the household's gender, education level and employment status, having a household member under 5/ above 60 years old, with chronic diseases (in particular cancer and dialysis), disability, using inpatient and outpatient and dentistry services, medicines and equipment, and low insurance coverage. Conclusion The result of this review calls for intensifying health policies and financing structures in Iran to provide more equitable access to all populations, especially the poorest and vulnerable. Moreover, the government is expected to adopt effective measures in inpatient and outpatient care, dental services, medicines, and equipment.
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Affiliation(s)
- Maryam Hedayati
- Department of Health Service Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Iravan Masoudi Asl
- Department of Health Service Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - MohammadReza Maleki
- Department of Health Service Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Akbar Fazaeli
- Department of Health Management, Policy and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Salime Goharinezhad
- Preventive Medicine and Public Health Research Center, Psychosocial Research Institute, Iran University of Medical Sciences, Tehran, Iran
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Getachew N, Shigut H, Jeldu Edessa G, Yesuf EA. Catastrophic health expenditure and associated factors among households of non community based health insurance districts, Ilubabor zone, Oromia regional state, southwest Ethiopia. Int J Equity Health 2023; 22:40. [PMID: 36894937 PMCID: PMC9996994 DOI: 10.1186/s12939-023-01847-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/18/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Out-of-pocket health expenditure is the proportion of total health expenditure that is paid by individuals and households at the time of health service. Hence, the objective of this study is to assess the incidence and intensity of catastrophic health expenditure and associated factors among households in non-community-based health insurance districts in the Ilubabor zone, Oromia National Regional State, Ethiopia. METHOD A community-based cross-sectional study design was employed in the Ilubabor zone on non-community-based health insurance scheme districts from August 13 to September 2, 2020, and 633 households participated in the study. A multistage one cluster sampling method was used to select three districts out of seven districts. Data was collected by using a structured mix of open and close-ended pre -tested questionnaires by face-to-face interviewing. A micro-costing/bottom up approach was used for all household expenditure. After checking its completeness, all household consumption expenditure was done by mathematical analysis using Microsoft Excel. Binary and multiple logistic were done using 95%CI and significance was declared at P < 0.05. RESULTS The number of households that participated in the study was 633, with a response rate of 99.7%. Out of 633 households surveyed, 110 (17.4%) were in catastrophe, which exceeds 10% of total household expenditure. After medical care expenses, about 5% of the households moved downward from the middle poverty line to extreme poverty. Out-of-pocket payment AOR: 31.201: 95% CI (12.965-49.673), daily income less than 1.90 USD AOR: 2.081: 95% CI (1.010-3.670), living a medium distance from a health facility AOR: 6.219: 95% CI (1.632-15.418), and chronic disease AOR: 5.647: 95% CI (1.764-18.075. CONCLUSION In this study, family size, average daily income, out of pocket payment and chronic diseases were statistically significant and independent predictors for household catastrophic health expenditure. Therefore, to overcome financial risk, the Federal Ministry of Health should develop different guidelines and modalities by considering household per capita and income to improve the enrolment of community-based health insurance. Also, the regional health bureau should improve their budget share of 10% to increase the coverage of poor households. Strengthening financial risk protection mechanisms, such as community-based health insurance, could help to improve healthcare equity and quality.
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Affiliation(s)
- Nigusu Getachew
- Department of Health Policy and Management, Faculty of Public Health, Institute of Health, Jimma University, P.O. Box 378, Jimma, Ethiopia.
| | - Hailu Shigut
- Department of Health Policy and Management, Faculty of Public Health, Institute of Health, Jimma University, P.O. Box 378, Jimma, Ethiopia
| | - Gebeyehu Jeldu Edessa
- Department of Health Policy and Management, Faculty of Public Health, Institute of Health, Jimma University, P.O. Box 378, Jimma, Ethiopia
| | - Elias Ali Yesuf
- Department of Health Policy and Management, Faculty of Public Health, Institute of Health, Jimma University, P.O. Box 378, Jimma, Ethiopia
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Chen S, Dong D. Improving Insurance Protection for Rare Diseases: Economic Burden and Policy Effects - Simulation of People With Pompe Disease in China. Int J Health Policy Manag 2022; 12:6282. [PMID: 36404504 PMCID: PMC10125180 DOI: 10.34172/ijhpm.2022.6282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 09/28/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The economic burden of Pompe disease (PD) is under-researched. This study aimed to fill this gap and provide evidence-based suggestions for policy improvement based on policy simulation. METHODS Data were derived from a nationally based cross-sectional survey on rare diseases in early 2018. Answers from 92 PD patients were used for data analysis and simulation. Catastrophic health expenditure (CHE) and impoverishment due to illness (IDI) were adopted to measure PD patients' economic burden. Two typical reimbursement patterns, a dosage-based model and a cost-based model, in China were simulated. RESULTS Twenty-four pediatric and 68 adult PD patients were investigated. Families with pediatric PD patients on average had lower annual household incomes than families with adult PD patients (RMB 37 890 vs. RMB 66 120). The direct medical expense and out-of-pocket expenses were almost double for pediatric patients compared with adult patients (RMB 120 050 vs. RMB 66 350; RMB 112 710 vs. RMB 57 940, respectively). The direct non-medical expense for patients was almost six times the expense of adult patients (RMB 73 790 vs. RMB 13 080, respectively). About 88.24% of families with pediatric PD patients and 67.21% of families with adult PD patients suffered from CHE. Around 84.21% of families with pediatric PD patients and 45.90% of families with adult PD patients were forced to live in poverty due to illness. The simulation indicated that, although the two current reimbursement schemes helped reduce CHE, they almost had no effect on reducing IDI; the dosage-based model was more sensitive to changes in policy parameters. CONCLUSION Our study highlighted the alarmingly high disease burden faced by PD patients with first-hand patient-reported evidence. Our series of simulations could be a good reference for China and other countries to improve their reimbursement policy regarding PD.
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Affiliation(s)
- Shanquan Chen
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Dong Dong
- Jockey Club School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
- Shenzhen Research Institute, The Chinese University of Hong Kong, Shenzhen, China
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Rahman T, Gasbarro D, Alam K. Financial risk protection against noncommunicable diseases: trends and patterns in Bangladesh. BMC Public Health 2022; 22:1835. [PMID: 36175951 PMCID: PMC9524135 DOI: 10.1186/s12889-022-14243-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 09/26/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Demographic and epidemiological transitions are changing the disease burden from infectious to noncommunicable diseases (NCDs) in low- and middle-income countries, including Bangladesh. Given the rising NCD-related health burdens and growing share of household out-of-pocket (OOP) spending in total health expenditure in Bangladesh, we compared the country's trends and socioeconomic disparities in financial risk protection (FRP) among households with and without NCDs. METHODS We used data from three recent waves of the Bangladesh Household Income and Expenditure Survey (2005, 2010, and 2016) and employed the normative food, housing (rent), and utilities method to measure the levels and distributions of catastrophic health expenditure (CHE) and impoverishing effects of OOP health expenditure among households without NCDs (i.e. non-NCDs only) and with NCDs (i.e. NCDs only, and both NCDs and non-NCDs). Additionally, we examined the incidence of forgone care for financial reasons at the household and individual levels. RESULTS Between 2005 and 2016, OOP expenses increased by more than 50% across all households (NCD-only: USD 95.6 to 149.3; NCD-and-non-NCD: USD 89.5 to 167.7; non-NCD-only: USD 45.3 to 73.0), with NCD-affected families consistently spending over double that of non-affected households. Concurrently, CHE incidence grew among NCD-only families (13.5% to 14.4%) while declining (with fluctuations) among non-NCD-only (14.4% to 11.6%) and NCD-and-non-NCD households (12.9% to 12.2%). Additionally, OOP-induced impoverishment increased among NCD-only and non-NCD-only households from 1.4 to 2.0% and 1.1 to 1.5%, respectively, affecting the former more. Also, despite falling over time, NCD-affected individuals more frequently mentioned prohibiting treatment costs as the reason for forgoing care than the non-affected (37.9% vs. 13.0% in 2016). The lowest quintile households, particularly those with NCDs, consistently experienced many-fold higher CHE and impoverishment than the highest quintile. Notably, CHE and impoverishment effects were more pronounced among NCD-affected families if NCD-afflicted household members were female rather than male, older people, or children instead of working-age adults. CONCLUSIONS The lack of FRP is more pronounced among households with NCDs than those without NCDs. Concerted efforts are required to ensure FRP for all families, particularly those with NCDs.
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Affiliation(s)
- Taslima Rahman
- Murdoch Business School, Murdoch University, Perth, WA 6150 Australia
- Institute of Health Economics, University of Dhaka, Dhaka, 1000 Bangladesh
| | - Dominic Gasbarro
- Murdoch Business School, Murdoch University, Perth, WA 6150 Australia
| | - Khurshid Alam
- Murdoch Business School, Murdoch University, Perth, WA 6150 Australia
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Rahman MM, Jung J, Islam MR, Rahman MM, Nakamura R, Akter S, Sato M. Global, regional, and national progress in financial risk protection towards universal health coverage, 2000-2030. Soc Sci Med 2022; 312:115367. [PMID: 36167025 DOI: 10.1016/j.socscimed.2022.115367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 08/18/2022] [Accepted: 09/08/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Complete (100%) protection against catastrophic health expenditure (CHE) and impoverishment is the main target of universal health coverage (UHC). Evidence-based estimates must be at the heart of policy development for UHC, further research using updated data is essential to monitor, track, and compare country progress up to 2030. We estimate global, regional, and country-level CHE and impoverishment during 2000-2030. METHODS We aggregated 636 data points from 140 countries that were conducted between 2000 and 2021. We used Bayesian hierarchical model for trend and projection analysis. Furthermore, we constructed scenario-based projections of CHE and impoverishment based on 5% GDP spending on health and per capita health expenditure (PCHE) of $86. RESULTS Most countries fail to achieve financial protection targets by 2030, with the global incidence of CHE predicted to persist around 7% at 10% threshold. CHE is predicted to increase in most of Asia (Southern: 8.1% in 2000 to 13.4% in 2030; Central: 3.6%-23.2%; Eastern: 8.3%-14.4%; and Western: 7.3%-20.2%), Northern Africa (12.4%-27.2%), Eastern (7.1%-14.9%) and Northern Europe (6.6%-13.2%). In contrast, a decrease is predicted in Oceania, Latin America and the Caribbean, and Northern America. By 2030, incidence of impoverishment is predicted to be 0% worldwide at $3.10 poverty line, however in several African and Soth Asian countries is predicted to be high impoverishment. The scenario-based analysis indicated that CHE and impoverishment is expected to decrease in 41 and 42 countries for GDP increase and 43 and 62 for PCHE increase respectively compared to current spending on health. CONCLUSION To accelerate progress towards reducing financial protection, governments should carefully assess the country context to determine how health can be prioritised through government spending to reduce out-of-pocket payments.
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Affiliation(s)
- Md Mizanur Rahman
- Hitotsubashi Institute for Advanced Study, Hitotsubashi University, Tokyo, Japan.
| | - Jenny Jung
- Maternal and Child Health Program, Burnet Institute, Melbourne, Australia; Global Public Health Research Foundation, Dhaka, Bangladesh
| | - Md Rashedul Islam
- Hitotsubashi Institute for Advanced Study, Hitotsubashi University, Tokyo, Japan; Department of Global Health Policy, School of International Health, The University of Tokyo, Tokyo, Japan
| | | | - Ryota Nakamura
- Hitotsubashi Institute for Advanced Study, Hitotsubashi University, Tokyo, Japan
| | - Shamima Akter
- Hitotsubashi Institute for Advanced Study, Hitotsubashi University, Tokyo, Japan
| | - Motohiro Sato
- Hitotsubashi Institute for Advanced Study, Hitotsubashi University, Tokyo, Japan
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Kitole FA, Lihawa RM, Mkuna E. Comparative Analysis on Communicable and Non-Communicable Diseases on Catastrophic Spending and Impoverishment in Tanzania. Glob Soc Welf 2022:1-12. [PMID: 36043157 PMCID: PMC9412805 DOI: 10.1007/s40609-022-00241-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/11/2022] [Indexed: 05/23/2023]
Abstract
The question of whether communicable or non-communicable diseases have higher economic effects on households is rarely explored from the global to local level despite of their significant contribution in increasing household catastrophic spending and impoverishment. To shed light into this, therefore, this paper comparatively examines the economic effects of communicable and non-communicable diseases in Tanzania by the use of Tanzania Panel Survey data of 2019/2020 which has been used to analyze different parameters to provide needful information. The empirical analysis employed probit, two-stage residual inclusion (2SRI), and control function approachf (CFA) helpful in controlling endogeneity issues. Findings showed that, comparatively, non-communicable diseases have higher economic effects in endangering households into catastrophic spending and impoverishment comparing to communicable diseases. Conclusively, neglecting developing countries to fights against multiplicative effects of these diseases alone will result in killing their economies since most of these countries depend on donors and household as a means of healthcare financing. However, this paper recommends for global initiatives in reducing the burden of disease by funding on palliative care costs and enhancing the availability of affordable health insurance schemes to reduce household economic burden.
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Affiliation(s)
| | | | - Eliaza Mkuna
- Department of Economics, Mzumbe University, P.O. Box 5, Morogoro, Tanzania
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11
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Rahman T, Gasbarro D, Alam K. Financial risk protection from out-of-pocket health spending in low- and middle-income countries: a scoping review of the literature. Health Res Policy Syst 2022; 20:83. [PMID: 35906591 PMCID: PMC9336110 DOI: 10.1186/s12961-022-00886-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 07/05/2022] [Indexed: 11/26/2022] Open
Abstract
Background Financial risk protection (FRP), defined as households’ access to needed healthcare services without experiencing undue financial hardship, is a critical health systems target, particularly in low- and middle-income countries (LMICs). Given the remarkable growth in FRP literature in recent times, we conducted a scoping review of the literature on FRP from out-of-pocket (OOP) health spending in LMICs. The objective was to review current knowledge, identify evidence gaps and propose future research directions. Methods We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines to conduct this scoping review. We systematically searched PubMed, Scopus, ProQuest and Web of Science in July 2021 for literature published since 1 January 2015. We included empirical studies that used nationally representative data from household surveys to measure the incidence of at least one of the following indicators: catastrophic health expenditure (CHE), impoverishment, adoption of strategies to cope with OOP expenses, and forgone care for financial reasons. Our review covered 155 studies and analysed the geographical focus, data sources, methods and analytical rigour of the studies. We also examined the level of FRP by disease categories (all diseases, chronic illnesses, communicable diseases) and the effect of health insurance on FRP. Results The extant literature primarily focused on India and China as research settings. Notably, no FRP study was available on chronic illness in any low-income country (LIC) or on communicable diseases in an upper-middle-income country (UMIC). Only one study comprehensively measured FRP by examining all four indicators. Most studies assessed (lack of) FRP as CHE incidence alone (37.4%) or as CHE and impoverishment incidence (39.4%). However, the LMIC literature did not incorporate the recent methodological advances to measure CHE and impoverishment that address the limitations of conventional methods. There were also gaps in utilizing available panel data to determine the length of the lack of FRP (e.g. duration of poverty caused by OOP expenses). The current estimates of FRP varied substantially among the LMICs, with some of the poorest countries in the world experiencing similar or even lower rates of CHE and impoverishment compared with the UMICs. Also, health insurance in LMICs did not consistently offer a higher degree of FRP. Conclusion The literature to date is unable to provide a reliable representation of the actual level of protection enjoyed by the LMIC population because of the lack of comprehensive measurement of FRP indicators coupled with the use of dated methodologies. Future research in LMICs should address the shortcomings identified in this review. Supplementary Information The online version contains supplementary material available at 10.1186/s12961-022-00886-3.
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Affiliation(s)
- Taslima Rahman
- Murdoch Business School, Murdoch University, Perth, WA, 6150, Australia. .,Institute of Health Economics, University of Dhaka, Dhaka, 1000, Bangladesh.
| | - Dominic Gasbarro
- Murdoch Business School, Murdoch University, Perth, WA, 6150, Australia
| | - Khurshid Alam
- Murdoch Business School, Murdoch University, Perth, WA, 6150, Australia
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Klingelhöfer D, Braun M, Brüggmann D, Groneberg DA. Does health-related poverty publication landscape reflect global needs in the light of the current poverty rebound? Global Health 2022; 18:35. [PMID: 35313907 PMCID: PMC8935118 DOI: 10.1186/s12992-022-00828-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/07/2022] [Indexed: 11/21/2022] Open
Abstract
Background After nearly a quarter-century of declining poverty, the numbers are rising again significantly. This is due not only to effects of climate change but also to the COVID-19 pandemics and armed conflict. Combined with the enormous health impacts, that will cause misery and health care costs worldwide. Therefore, this study provides background information on the global research landscape on poverty and health to help researchers, stakeholders, and policymakers determine the best way to address this threat. Results The USA is the key player, dealing mainly with domestic issues. European countries are also involved but tend to be more internationally oriented. Developing countries are underrepresented, with Nigeria standing out. A positive correlation was found between publication numbers and economic strength, while the relationship between article numbers and multidimensional poverty was negatively correlated. Conclusions These findings highlight the need for advanced networking and the benefits of cross-disciplinary research to mitigate the coming impacts.
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Affiliation(s)
- Doris Klingelhöfer
- Institute of Occupational, Social and Environmental Medicine, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany.
| | - Markus Braun
- Institute of Occupational, Social and Environmental Medicine, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Dörthe Brüggmann
- Institute of Occupational, Social and Environmental Medicine, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - David A Groneberg
- Institute of Occupational, Social and Environmental Medicine, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
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Bashir S, Kishwar S, Salman. Incidence and determinants of catastrophic health expenditures and impoverishment in Pakistan. Public Health 2021; 197:42-47. [PMID: 34311430 DOI: 10.1016/j.puhe.2021.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 05/20/2021] [Accepted: 06/08/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Out-of-pocket (OOP) payment is a major health financing mechanisms across developing nations such as Pakistan. Private health expenditures are estimated to be 64.4%, of which 89% are OOP made by the households (National Health Accounts, 2015-16). These high health care expenditures cause households to face financial burden resulting in poverty. This study aims to estimate the incidence and determinants of catastrophic health expenditures and impoverishment for Pakistan. STUDY DESIGN Household-based cross-section study. METHODS We used the data from the Household Integrated Economic Survey (2015-16 and 2018-19), carried out by the Pakistan Bureau of Statistics. The well known methodology developed by Wagstaff and Doorslaer was used in this study for estimating the incidence and impoverishment effect of catastrophic health spending. RESULTS It is found that at 10% threshold (out of total consumption expenditures), catastrophic health payments are incurred by 4.51% and 13.15% of households for 2015-16 and 2018-19, respectively. Moreover, following the 40% threshold (out of non-food expenditures), this incidence is 0.45% and 4.57%. Poverty headcount was 23.28% and 18.43% gross of health payments in both the considered years, respectively, whereas it turns out to be 24.68% and 22.02% net of healthcare payments for the respective years, representing an increase in poverty headcounts of 1.4% and 3.59%. CONCLUSION OOP health payments exert pressure on household's capacity to pay and push them into poverty. This article recommends that the burden of OOP expenditures borne by households should be reduced to prevent them from falling into poverty by initiating some strategies (health financing policy reforms in terms of financial protection) with political support.
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Affiliation(s)
- S Bashir
- Clinical Tropical Medicine, University Hospital Heidelberg, Germany.
| | - S Kishwar
- Pakistan Institute of Development Economics, Quaid-i-Azam University Campus, Islamabad, Pakistan.
| | - Salman
- Pakistan Institute of Development Economics, Pakistan.
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14
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Fu XZ. Financial protection effects of private health insurance: experimental evidence from Chinese households with resident basic medical insurance. Int J Equity Health 2021; 20:122. [PMID: 34001149 PMCID: PMC8130397 DOI: 10.1186/s12939-021-01468-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 05/04/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND After achieving universal basic medical insurance coverage, Chinese government put the development of private health insurance (PHI) on its agenda to further strengthen financial risk protection. This paper aims to assess the level of financial protection that PHI provides for its insured households on the basis of resident basic medical insurance (RBMI). METHODS We employed balanced panel data collected between 2015 and 2017 from the China Household Finance Survey (CHFS). Catastrophic health expenditure (CHE) and impoverishment due to health spending were applied to measure the financial protection effects. Random effects panel logistic regression model was performed to identify the factors associated with CHE and impoverishment among households covered by RBMI. In the robustness test, the method of propensity score matching (PSM) was employed to solve the problem of endogeneity. RESULTS From 2015 to 2017, the CHE incidence increased from 12.96 to 14.68 % for all sampled households, while the impoverishment rate decreased slightly from 5.43 to 5.32 % for all sampled households. In 2015, the CHE incidence and impoverishment rate under RBMI + PHI were 4.53 and 0.72 %, respectively, which were lower than those under RBMI alone. A similar phenomenon was observed in 2017. Regression analysis also showed that the households with RBMI + PHI were significantly less likely to experience CHE (marginal effect: -0.054, 95 %CI: -0.075 to -0.034) and impoverishment (marginal effect: -0.049, 95 %CI: -0.069 to -0.028) compared to those with RBMI alone. The results were still robust after using PSM method to eliminate the effects of self-selection on the estimation results. CONCLUSIONS In the context of universal basic medical insurance coverage, the CHE incidence and impoverishment rate of Chinese households with RBMI were still considerably high in 2015 and 2017. PHI played a positive role in decreasing household financial risk on the basis of RBMI.
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Affiliation(s)
- Xian-Zhi Fu
- School of Political Science and Public Administration, Wuhan University, Wuhan, Hubei, 430072, China.
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15
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Verma VR, Kumar P, Dash U. Assessing the household economic burden of non-communicable diseases in India: evidence from repeated cross-sectional surveys. BMC Public Health 2021; 21:881. [PMID: 33962625 PMCID: PMC8106177 DOI: 10.1186/s12889-021-10828-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 04/09/2021] [Indexed: 01/07/2023] Open
Abstract
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.
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Affiliation(s)
- Veenapani Rajeev Verma
- Department of Humanities and Social Sciences, Indian Institute of Technology Madras, Chennai, India
| | - Piyush Kumar
- Department of Humanities and Social Sciences, Indian Institute of Technology Madras, Chennai, India
| | - Umakant Dash
- Department of Humanities and Social Sciences, Indian Institute of Technology Madras, Chennai, India
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Mohanty SK, Dwivedi LK. Addressing data and methodological limitations in estimating catastrophic health spending and impoverishment in India, 2004-18. Int J Equity Health 2021; 20:85. [PMID: 33743735 PMCID: PMC7981828 DOI: 10.1186/s12939-021-01421-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/04/2021] [Indexed: 11/12/2022] Open
Abstract
Background Estimates of catastrophic health expenditure (CHE) are counterintuitive to researchers, policy makers, and developmental partners due to data and methodological limitation. While inferences drawn from use of capacity-to-pay (CTP) and budget share (BS) approaches are inconsistent, the non-availability of data on food expenditure in the health survey in India is an added limitation. Methods Using data from the health and consumption surveys of National Sample Surveys over 14 years, we have overcome these limitations and estimated the incidence and intensity of CHE and impoverishment using the CTP approach. Results The incidence of CHE for health services in India was 12.5% in 2004, 13.4% in 2014 and 9.1% by 2018. Among those households incurring CHE, they spent 1.25 times of their capacity to pay in 2004 (intensity of CHE), 1.71 times in 2014 and 1.31 times by 2018. The impoverishment due to health spending was 4.8% in 2004, 5.1% in 2014 and 3.3% in 2018. The state variations in incidence and intensity of CHE and incidence of impoverishment is large. The concentration index (CI) of CHE was − 0.16 in 2004, − 0.18 in 2014 and − 0.22 in 2018 suggesting increasing inequality over time. The concentration curves based on CTP approach suggests that the CHE was concentrated among poor. The odds of incurring CHE were lowest among the richest households [OR 0.22; 95% CI: 0.21, 0.24], households with elderly members [OR 1.20; 95% CI:1.12, 1.18] and households using both inpatient and outpatient services [OR 2.80, 95% CI 2.66, 2.95]. Access to health insurance reduced the chance of CHE and impoverishment among the richest households. The pattern of impoverishment was similar to that of CHE. Conclusion In the last 14 years, the CHE and impoverishment in India has declined while inequality in CHE has increased. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-021-01421-6.
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Affiliation(s)
- Sanjay K Mohanty
- Department of Fertility Studies, International Institute for Population Sciences, Mumbai, India.
| | - Laxmi Kant Dwivedi
- Department of Mathematical Demography and Statistics, International Institute for Population Sciences, Mumbai, India
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Taniguchi H, Rahman MM, Swe KT, Hussain A, Shibuya K, Hashizume M. Trends and projections of universal health coverage indicators in Iraq, 2000-2030: A national and subnational study. Soc Sci Med 2020; 270:113630. [PMID: 33360536 DOI: 10.1016/j.socscimed.2020.113630] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 10/06/2020] [Accepted: 12/16/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Iraq has had limited access to healthcare services due to successive conflicts and political turmoil. Since 2018, Iraq has embarked on a new reconstruction process which includes a goal of 100% immunisation against certain diseases in 2030. We aimed to undertake a comprehensive assessment of Iraq's progress towards universal health coverage (UHC) targets that could contribute to Iraq's policy and strategies. METHODS We estimated the coverage of UHC indicators from six nationally representative population-based household surveys in Iraq during 2000-2018. We employed 14 health service indicators and two financial risk protection indicators in our UHC progress assessment. We used a Bayesian hierarchical regression model to estimate the trend and projection of health service indicators. RESULTS Improved water sources, adequate sanitation, institutional delivery, skilled birth attendants, and BCG reached the 80% targets in 2018, and are projected to maintain their status in 2030 at national and subnational levels. Family planning needs satisfied, acute respiratory infection treatment for pneumonia, and oral rehydration therapy will be much less than 80% in 2030. 12% of Iraqi households incurred catastrophic health expenditures in 2012, which was a fourfold increase from 2007. Some governorates faced ten- to twentyfold increases in catastrophic health expenditures, for example, from 0.8% to 15.9% in Diala. Approximately 3% of non-poor households became poor due to out-of-pocket (OOP) payments in 2012. CONCLUSION Without proactive strengthening of the healthcare systems, achieving UHC in Iraq by 2030 would be a challenge. Worsened trends were observed in both conflict-affected and underdeveloped areas in health service coverage and financial risk protection. Recovery of GDP spending on health and pre-pooled financing mechanisms should be introduced for OOP payment reduction. Prioritising nationwide primary healthcare services and regulating public-private role-allotment in the health sector are crucial in improving low coverage indicators and decreasing disparities among governorates.
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Affiliation(s)
- Hiroko Taniguchi
- Department of Global Health Policy, School of International Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
| | - Md Mizanur Rahman
- Department of Global Health Policy, School of International Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Khin Thet Swe
- Department of Global Health Policy, School of International Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan; Hitotsubashi Institute for Advanced Study (HIAS), Hitotsubashi University, 2-1, Naka, Kunitachi, Tokyo, 186-8601, Japan
| | - Ashraf Hussain
- Department of Family and Community Medicine, College of Medicine, University of Babylon, PO Box: 4, Hilla, Babil, Iraq
| | - Kenji Shibuya
- University Institute of Population Health, King's College London, Strand, London, WC2R 2LS, United Kingdom
| | - Masahiro Hashizume
- Department of Global Health Policy, School of International Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
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Kwesiga B, Aliti T, Nabukhonzo P, Najuko S, Byawaka P, Hsu J, Ataguba JE, Kabaniha G. What has been the progress in addressing financial risk in Uganda? Analysis of catastrophe and impoverishment due to health payments. BMC Health Serv Res 2020; 20:741. [PMID: 32787844 PMCID: PMC7425531 DOI: 10.1186/s12913-020-05500-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 07/02/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Monitoring progress towards Universal Health Coverage (UHC) requires an assessment of progress in coverage of health services and protection of households from the impact of direct out-of-pocket payments (i.e. financial risk protection). Although Uganda has expressed aspirations for attaining UHC, out-of-pocket payments remain a major contributor to total health expenditure. The aim of this study is to monitor progress in financial risk protection in Uganda. METHODS This study uses data from the Uganda National Household Surveys for 2005/06, 2009/10, 2012/13 and 2016/17. We measure financial risk protection using catastrophic health care payments and impoverishment indicators. Health care payments are catastrophic if they exceed a set threshold (i.e. 10 and 25%) of the total household consumption expenditure. Health payments are impoverishing if they push the household below the poverty line (the US$1.90/day and Uganda's national poverty lines). A logistic regression model is used to assess the factors associated with household financial risk. RESULTS The results show that while progress has been made in reducing financial risk, this progress remains minimal, and there is still a risk of a reversal of this trend. We find that although catastrophic health payments at the 10% threshold decreased from 22.4% in 2005/06 to 13.8% in 2012/13, it increased to 14.2% in 2016/17. The percentage of Ugandans pushed below the national poverty line (US$1.90/day) has decreased from 5.2% in 2005/06 to 2.7% in 2016/17. The distribution of both catastrophic health payments and impoverishment varies across socio-economic status, location and residence. In addition, certain household characteristics (poverty, having a child below 5 years and an adult above 60 years) are more associated with the lack of financial risk protection. CONCLUSION There is need for targeted interventions to reduce OOP, especially among those affected so as to increase financial risk protection. In the short-term, it is important to ensure that public health services are funded adequately to enable effective coverage with quality health care. In the medium-term, increased reliance on mandatory prepayment will reduce the burden of OOP health spending further.
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Affiliation(s)
- Brendan Kwesiga
- World Health Organization, Health Systems Cluster, Nairobi, Kenya
| | - Tom Aliti
- Ministry of Health, Planning Department, Kampala, Uganda
| | | | - Susan Najuko
- Ministry of Health, Planning Department, Kampala, Uganda
| | | | - Justine Hsu
- World Health Organization, Economic Analysis Cluster, Geneva, Switzerland
| | - John E. Ataguba
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Grace Kabaniha
- World Health Organization, Health Systems Cluster India Country Office, New Delhi, India
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Bhargava A, Shewade HD. The potential impact of the COVID-19 response related lockdown on TB incidence and mortality in India. Indian J Tuberc 2020; 67:S139-S146. [PMID: 33308660 PMCID: PMC7348601 DOI: 10.1016/j.ijtb.2020.07.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 06/25/2020] [Accepted: 07/03/2020] [Indexed: 11/24/2022]
Abstract
India has the highest burden of incident tuberculosis (TB) cases and deaths globally. TB is strongly associated with poverty and this risk is largely mediated by undernutrition in India. COVID-19 response related lockdown has resulted in an economic crisis which may double levels of poverty, has exacerbated food insecurity, and disrupted TB services. These developments may have serious implications for TB progression and transmission in India. The nutritional status of a population is a strong determinant of the TB incidence, and undernutrition in adults alone accounts for 32-44% of TB incidence in India. A systematic review has shown that a 14% increase in TB incidence can occur per one unit decrease in body mass index (BMI), across the BMI range of 18.5-30 kg/m2. We believe that one unit decrease in BMI (corresponding to a 2-3 kg weight loss) may result in the poor in India as a result of the lockdown and its aftermath. This may result in an increase in estimated (uncertainty interval) incident TB by 185 610 (180 230, 190 990) cases. A 59% reduction in TB case detection between end March and May 2020, may result in an estimated (uncertainty interval) additional 87 711 (59 998, 120 630) TB deaths [19.5% increase (14.5, 24.7)] in 2020. Disadvantaged social groups and those living in states with higher levels of poverty, under-nutrition,and migrant workers are at particular risk. We suggest enhanced rations including pulses through the public distribution system and direct cash transfers to the poor pending restoration of livelihoods. TB services should be resumed immediately with enhanced efforts at case detection including active case finding. To prevent deaths among TB detected within the national TB programme, systemic identification, referral and management of severe disease at notification should be considered.
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Affiliation(s)
- Anurag Bhargava
- Department of Medicine, Yenepoya Medical College, Yenepoya (Deemed to Be University), Mangaluru, 575018, India; Department of Medicine, McGill University, Montreal, H4A 3J1, Canada; Center for Nutrition Studies, Yenepoya (Deemed to Be University), Mangaluru, 575018, India
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Liu Y, Xu CH, Wang XM, Wang ZY, Wang YH, Zhang H, Wang L. Out-of-pocket payments and economic consequences from tuberculosis care in eastern China: income inequality. Infect Dis Poverty 2020; 9:14. [PMID: 32019611 PMCID: PMC7001258 DOI: 10.1186/s40249-020-0623-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 01/09/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite the availability of free tuberculosis (TB) diagnosis and treatment, TB care still generates substantial costs that push people into poverty. We investigated out-of-pocket (OOP) payments for TB care and assessed the resulting economic burden and economic consequences for those with varying levels of household income in eastern China. METHODS A cross-sectional study was conducted among TB patients in the national TB programme networks in eastern China. TB-related direct OOP costs, time loss, and coping strategies were investigated across households in different economic strata. Analysis of Variance was used to examine the differences in various costs, and Kruskal-Wallis tests were used to compare the difference in total costs as a percentage of annual household income. RESULTS Among 435 patients, the mean OOP total costs of TB care were USD 2389.5. In the lower-income quartile, OOP payments were lower, but costs as a percentage of reported annual household income were higher. Medical costs and costs prior to treatment accounted for 66.4 and 48.9% of the total costs, respectively. The lower the household income was, the higher the proportion of medical costs to total costs before TB treatment, but the lower the proportion of medical costs patients spent in the intensive phase. TB care caused 25.8% of TB-affected households to fall below the poverty line and caused the poverty gap (PG) to increase by United States Dollar (USD) 145.6. Patients in the poorest households had the highest poverty headcount ratio (70.2%) and PG (USD 236.1), but those in moderately poor households had the largest increase in the poverty headcount ratio (36.2%) and PG (USD 177.8) due to TB care. Patients from poor households were more likely to borrow money to cope with the costs of TB care; however, there were fewer social consequences, except for food insecurity, in poor households. CONCLUSIONS Medical and pretreatment costs lead to high costs of TB care, especially among patients from the poorest households. It is necessary to train health system staff in general hospitals to promptly identify and refer TB patients. Pro-poor programmes are also needed to protect TB patients from the medical poverty trap.
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Affiliation(s)
- Yan Liu
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, 100005, China.,Department of Critical Care Medicine, The Second People's Hospital of Shenzhen & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen, 518035, China
| | - Cai-Hong Xu
- National Center for Tuberculosis Control and Prevention, China Center for Disease Control, Beijing, 100226, China
| | - Xiao-Mo Wang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, 100005, China
| | - Zhen-Yu Wang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, 100005, China
| | - Yan-Hong Wang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, 100005, China
| | - Hui Zhang
- National Center for Tuberculosis Control and Prevention, China Center for Disease Control, Beijing, 100226, China.
| | - Li Wang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, 100005, China.
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Gabani J, Guinness L. Households forgoing healthcare as a measure of financial risk protection: an application to Liberia. Int J Equity Health 2019; 18:193. [PMID: 31823823 PMCID: PMC6902593 DOI: 10.1186/s12939-019-1095-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 11/18/2019] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Access to Liberia's health system is reliant on out-of-pocket (OOP) health expenditures which may prevent people from seeking care or result in catastrophic health expenditure (CHE). CHE and impoverishment due to OOP, which are used by the World Bank and World Health Organization as the sole measures of financial risk protection, are limited: they do not consider households who, following a health shock, do not incur expenditure because they cannot access the healthcare services they need (i.e., households forgoing healthcare (HFH) services). This paper attempts to overcome this limitation and improve financial risk protection by measuring HFH incidence and comparing it with CHE standard measures using household survey data from Liberia. METHODS Data from the Liberia Household Income and Expenditure Survey 2014 were analysed. An OOP health expenditure is catastrophic when it exceeds a total or non-food household expenditure threshold. A CHE incidence curve, representing CHE incidence at different thresholds, was developed. To overcome CHE limitations, an HFH incidence measure was developed based on CHE, OOP and health shocks data: households incurring health shocks and having negligible OOP were considered to have forgone healthcare. HFH incidence was compared with standard CHE measures. RESULTS CHE incidence and intensity levels depend on the threshold used. Using a 30% non-food expenditure threshold, CHE incidence is 2.1% (95% CI: 1.7-2.5%) and CHE intensity is 37.4% (95% CI: 22.7-52.0%). CHE incidence is approximately in line with other countries, while CHE intensity is higher than in other countries. CHE pushed 1.6% of households below the food poverty line in 2014. c approximately 4 times higher than CHE (8.0, 95% CI, 7.2-8.9%). CONCLUSION Lack of financial risk protection is a significant problem in Liberia and it may be underestimated by CHE: this study confirms that HFH incidence can complement CHE measures in providing a complete picture of financial risk protection and demonstrates a simple method that includes measures of healthcare forgone as part of standard CHE analyses. This paper provides a new methodology to measure HFH incidence and highlights the need to consider healthcare forgone in analyses of financial risk protection, as well as the need for further development of these measures.
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Affiliation(s)
- Jacopo Gabani
- Centre for Health Economics, University of York, York, UK. .,London School of Hygiene & Tropical Medicine, London, UK.
| | - Lorna Guinness
- London School of Hygiene & Tropical Medicine, London, UK
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Amiresmaili M, Emrani Z. Studying the impoverishing effects of procuring medicines: a national study. BMC Int Health Hum Rights 2019; 19:23. [PMID: 31366400 PMCID: PMC6670235 DOI: 10.1186/s12914-019-0210-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 07/24/2019] [Indexed: 11/17/2022]
Abstract
Background One of the main treatment procedures is through medicine prescription. Considering the rising burden of drug costs, we conducted this study to estimate the impoverishing effects of medicine on Iranian households. Method We carried out calculations based on the Iranian National Household Survey for the year 2013. Amoxicillin, atorvastatin and metformin were the drugs selected. Three different poverty lines were applied. Impoverishment was estimated for various scenarios. Additionally, the associations of some demographic factors were tested. Excel 2013 and SPSS v.19 were used. Results Many households fell under the poverty line after purchasing drugs. Procuring original brand (OB) drugs caused more poverty than lowest-priced generic (LPG) equivalents. The logistic regression testing showed that the age, gender and literacy of the head of household and the size of the household were associated with impoverishment. Conclusion This study showed that purchasing medicines increases the impoverishment risk of households. This risk is an index used to assess financial protection against health costs, which is in turn an indicator of health equity. The results will be of practical use for policymakers when addressing different scenarios of setting medicines prices as well as when considering alternatives for cost shifting for cross subsidies in pharmaceutical procurement.
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Affiliation(s)
- Mohammadreza Amiresmaili
- Department of Health Management, Economics and Policy Making, School of Management and Medical Informatics, Kerman University of Medical Sciences, Kerman, Iran
| | - Zahra Emrani
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. .,Health Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.
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Hailemichael Y, Hanlon C, Tirfessa K, Docrat S, Alem A, Medhin G, Lund C, Chisholm D, Fekadu A, Hailemariam D. Catastrophic health expenditure and impoverishment in households of persons with depression: a cross-sectional, comparative study in rural Ethiopia. BMC Public Health 2019; 19:930. [PMID: 31296207 PMCID: PMC6625021 DOI: 10.1186/s12889-019-7239-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 06/25/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The extent of catastrophic health expenditure and impoverishment associated with depression in low-and middle-income countries is not known. The aim of this study was to estimate the incidence and intensity of catastrophic out-of-pocket (OOP) health expenditure, level of impoverishment and coping strategies used by households of persons with and without depression in a rural Ethiopian district. METHODS A comparative cross-sectional survey was conducted, including 128 households of persons with depression and 129 households without. Depression screening was conducted using the Patient Health Questionnaire, nine item version (PHQ-9). People in the depression group were classified into high and low disability groups based on the median value on the World Health Organization Disability Assessment Schedule (WHODAS) polytomous summary score. Health expenditure greater than thresholds of 10 and 25% of total household consumption was used for the primary analyses. The poverty headcount, poverty gap and normalized poverty gap were estimated using retrospective recall of total household expenditure pre- and post-OOP payments for health care. Linear probability model using binreg command in STATA with rr option was used to estimate risk ratio for the occurrence of outcomes among households with and without depression based on level of disability. RESULTS Catastrophic OOP payments at any threshold level for households with depression and high disability were higher than control households. At the 10% threshold level, 24.0% of households of persons with depression and high disability faced catastrophic payments compared with 15.3% for depression and low disability and 12.1% for control households (p = 0.041). Depression and high disability level was an independent predictor of catastrophic OOP payments: RR 2.1; 95% CI:1.1, 4.6. An estimated 5.8% of households of persons with depression and high disability were pushed into poverty because of paying for health care compared with 3.5% for households of persons with depression and low disability and 2.3% for control households (p = 0.039). CONCLUSIONS Households of people with depression and high disability were more likely to face catastrophic expenditures and impoverishment from OOP payments. Financial protection interventions through prepayment schemes, exemptions and fee waiver strategies need to target households of persons with depression.
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Affiliation(s)
- Yohannes Hailemichael
- Department of Reproductive Health and Health Services Management, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Health Economics, Policy and Management, College of Health Sciences, Jimma University, Jimma, Ethiopia
| | - Charlotte Hanlon
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London, UK
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Ababa University, Addis Ababa, Ethiopia
| | - Kebede Tirfessa
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Sumaiyah Docrat
- Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Atalay Alem
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Girmay Medhin
- Aklilu-Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Crick Lund
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London, UK
- Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Dan Chisholm
- Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
| | - Abebaw Fekadu
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Ababa University, Addis Ababa, Ethiopia
- Department of Global Health & Infection, Brighton and Sussex Medical School, Brighton, UK
- Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London, UK
| | - Damen Hailemariam
- Department of Reproductive Health and Health Services Management, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Leng A, Jing J, Nicholas S, Wang J. Catastrophic health expenditure of cancer patients at the end-of-life: a retrospective observational study in China. BMC Palliat Care 2019; 18:43. [PMID: 31122235 PMCID: PMC6533646 DOI: 10.1186/s12904-019-0426-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 05/09/2019] [Indexed: 11/10/2022] Open
Abstract
Background Cancer is the second leading cause of death globally, causing a substantial economic burden on cancer suffers and their families. The aim of this study is to explore the prevalence, determinants and consequences of catastrophic health expenditure (CHE) among urban and rural end-of-life (EOF) cancer patients in China. Methods Using respondent-driven sampling and face-to-face interviews, field research was conducted with a specialist questionnaire. Data were collected on 792 cancer patients who died between June 2013 and June 2016 in China. The determinants of household catastrophic expenditure were identified by multivariate logistic regression. Findings It is found that more than 80% of cancer patients received life-extending treatment. Extremely high rates of CHE were identified among EOL cancer patients, at 94.3% for urban families and 96.1% for rural families. After spending for health, 84.1% of urban and 91.1% rural EOL cancer patient households were impoverished, falling below the poverty line. For both urban and rural households, income was the most significant factor associated with catastrophic health expenditure (CHE). Health insurance did not adequately compensate for CHE. Rural families experienced higher CHE, lower levels of health care utilization, a different mix of health care access and higher rates of borrowing for out-of-pocket (OOP) health care expenditures than urban families. Both urban and rural households suffered long-term economic disadvantage due to CHE and borrowing for OOP medical care expenses. Conclusions EOL cancer patients experienced severe CHE, with families forced into poverty. With only about 1% of EOL cancer patients receiving palliative care, developing palliative care services and expanding the acceptance of palliative care in China is both urgent and essential. To help address impoverishment due to CHE, China should also develop targeted programs to reduce income inequality, especially rural-urban inequalities; increase access to health care; and accelerate health reform. Increasing the retirement age would provide households with more savings and wealth to withstand CHE.
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Affiliation(s)
- Anli Leng
- Center for Health Economics Experiment and Public Policy, School of Public Health, Shandong University; Key Laboratory of Health Economics and Policy Research, NHFPC (Shandong University), Jinan, China. No. 44 Wenhuaxi Road, Lixia District, Jinan, 250012, China
| | - Jun Jing
- Jun Jing Research Center for Public Health, Medical School, Tsinghua University, Room B408, Beijing, 100084, China
| | - Stephen Nicholas
- School of Economics and School of Management, Tianjin Normal University, West Bin Shui Avenue, Tianjin, 300074, China. .,TOP Education Institute 1 Central Avenue Australian Technology Park, Eveleigh, Sydney, NSW, 2015, Australia. .,Research Institute of International Strategies, Guangdong University of Foreign Studies, Baiyun Avenue North, Guangzhou, 510420, People's Republic of China. .,Newcastle Business School, University of Newcastle, University Drive, Newcastle, NSW, Australia.
| | - Jian Wang
- Dong Fureng Institute of Economic and Social Development, Wuhan University, 54 Dongsi Lishi Hutong, Beijing, 100010, China.
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Mutyambizi C, Pavlova M, Hongoro C, Booysen F, Groot W. Incidence, socio-economic inequalities and determinants of catastrophic health expenditure and impoverishment for diabetes care in South Africa: a study at two public hospitals in Tshwane. Int J Equity Health 2019; 18:73. [PMID: 31118033 PMCID: PMC6530010 DOI: 10.1186/s12939-019-0977-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 05/02/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Direct out of pocket (OOP) payments for healthcare may cause financial hardship. For diabetic patients who require frequent visits to health centres, this is of concern as OOP payments may limit access to healthcare. This study assesses the incidence, socio-economic inequalities and determinants of catastrophic health expenditure and impoverishment amongst diabetic patients in South Africa. METHODS Data were taken from a cross-sectional survey conducted in 2017 at two public hospitals in Tshwane, South Africa (N = 396). Healthcare costs and transport costs related to diabetes care were classified as catastrophic if they exceeded the 10% threshold of household's capacity to pay (WHO standard method) or if they exceeded a variable threshold of total household expenditure (Ataguba method). Erreygers concentration indices (CIs) were used to assess socio-economic inequalities. A multivariate logistic regression was applied to identify the determinants of catastrophic health expenditure and impoverishment. RESULTS Transport costs contributed to over 50% of total healthcare costs. The incidence of catastrophic health expenditure was 25% when measured at a 10% threshold of capacity to pay and 13% when measured at a variable threshold of total household expenditure. Depending on the method used, the incidence of impoverishment varied from 2 to 4% and the concentration index for catastrophic health expenditure varied from - 0.2299 to - 0.1026. When measured at a 10% threshold of capacity to pay factors associated with catastrophic health expenditure were being female (Odds Ratio 1.73; Standard Error 0.51), being within the 3rd (0.49; 0.20), 4th (0.31; 0.15) and 5th wealth quintile (0.30; 0.17). When measured using a variable threshold of total household expenditure factors associated with catastrophic health expenditure were not having children (3.35; 1.82) and the 4th wealth quintile (0.32; 0.21). CONCLUSION Financial protection of diabetic patients in public hospitals is limited. This observation suggests that health financing interventions amongst diabetic patients should target the poor and poor women in particular. There is also a need for targeted interventions to improve access to healthcare facilities for diabetic patients and to reduce the financial impact of transport costs when seeking healthcare. This is particularly important for the achievement of universal health coverage in South Africa.
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Affiliation(s)
- Chipo Mutyambizi
- Research Use and Impact Assessment, Human Sciences Research Council, HSRC Building, 134 Pretorius Street, Pretoria, 0002 South Africa
- Department of Health Services Research, CAPHRI, Maastricht University Medical Centre, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Milena Pavlova
- Department of Health Services Research, CAPHRI, Maastricht University Medical Centre, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Charles Hongoro
- Research Use and Impact Assessment, Human Sciences Research Council, HSRC Building, 134 Pretorius Street, Pretoria, 0002 South Africa
| | - Frederik Booysen
- School of Economic and Business Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Wim Groot
- Department of Health Services Research, CAPHRI, Maastricht University Medical Centre, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Nundoochan A, Thorabally Y, Monohur S, Hsu J. Impact of out of pocket payments on financial risk protection indicators in a setting with no user fees: the case of Mauritius. Int J Equity Health 2019; 18:63. [PMID: 31053077 PMCID: PMC6500054 DOI: 10.1186/s12939-019-0959-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 04/16/2019] [Indexed: 12/20/2022] Open
Abstract
Background Mauritius embraces principles of a welfare state with free health care at point of use in any public facilities. However, the health financing landscape changed in 2007 when Private Health Expenditure (PvtHE) surpassed General Government Health Expenditure. PvtHE is predominately out of pocket (OOP) with only 3.4% related to premiums for private insurance. In 2014, Household OOP Expenditure on health accounted for 52.8% of total health expenditure. OOP is known to be regressive and to impact negatively on households’ living standards. Objectives This paper aims to examine trends in OOP in Mauritius, to assess its impacts through an analysis of key indicators of financial protection, namely catastrophic health expenditure (CHE) and impoverishment due to OOP health expenditure. It also aims to predict core determinants of CHEs. Methods Household Budget Surveys (HBS) of 2001/2002, 2006/2007 and 2012 were the primary source data. CHE and impoverishment were used to assess financial hardships resulting from OOP health payments. The incidence of CHE was estimated at three threshold levels (10,25 and 40%), using the budget share and the capacity to pay approaches. Impoverishment due to OOP was measured by changes in the incidence of poverty and intensity of poverty using the US$ 3.1 international poverty line. Logistic regression analysis was used to identify determinants of CHE. Findings Household CHE increased from 5.78% in 2001/02 to 8.85% in 2012 and 0.61% in 2001/02 to 1.25% in 2012, for 10 and 40% thresholds, respectively. The incidence of CHE was significantly higher in urban areas compared to rural areas. The highest levels of CHEs were among households’ heads, who are retired rising from 1.62% in 2001/02 to 3.71% in 2012, followed by households’ head who are widowed from 2.29% in 2001/02 to 2.63% in 2012 and homemakers from 2.12% in 2001/02 to 2.57% in 2012 at the 40% threshold. The share of households pushed below the poverty line due to OOP dropped from 0.4% in 2001/02 to 0.2% in 2006/07 before rising to 0.34% in 2012. In 2012, poverty gap occurred only among households under poorest quintile 1 (0.24%) and quintile 2 (0.03%). Overall poverty gap dropped from 0.08% in 2001/02 to 0.05% in 2012. Logistic regression analysis revealed that the odds ratio of facing CHE were significant only among households with heads being retired and with a presence of an elderly member in the household. Conclusion Despite the rise in incidence of CHE between 2001 and 2012 the impact of OOP on the level of impoverishment and poverty gap has not been significant.
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Affiliation(s)
- Ajoy Nundoochan
- World Health Organization Country Office, Port Louis, Mauritius.
| | | | | | - Justine Hsu
- Department of Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland
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Njagi P, Arsenijevic J, Groot W. Understanding variations in catastrophic health expenditure, its underlying determinants and impoverishment in Sub-Saharan African countries: a scoping review. Syst Rev 2018; 7:136. [PMID: 30205846 PMCID: PMC6134791 DOI: 10.1186/s13643-018-0799-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 08/20/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND To assess the financial burden due to out of pocket (OOP) payments, two mutually exclusive approaches have been used: catastrophic health expenditure (CHE) and impoverishment. Sub-Saharan African (SSA) countries primarily rely on OOP and are thus challenged with providing financial protection to the populations. To understand the variations in CHE and impoverishment in SSA, and the underlying determinants of CHE, a scoping review of the existing evidence was conducted. METHODS This review is guided by Arksey and O'Malley scoping review framework. A search was conducted in several databases including PubMed, EBSCO (EconLit, PsychoInfo, CINAHL), Web of Science, Jstor and virtual libraries of the World Health Organizations (WHO) and the World Bank. The primary outcome of interest was catastrophic health expenditure/impoverishment, while the secondary outcome was the associated risk factors. RESULTS Thirty-four (34) studies that met the inclusion criteria were fully assessed. CHE was higher amongst West African countries and amongst patients receiving treatment for HIV/ART, TB, malaria and chronic illnesses. Risk factors associated with CHE included household economic status, type of health provider, socio-demographic characteristics of household members, type of illness, social insurance schemes, geographical location and household size/composition. The proportion of households that are impoverished has increased over time across countries and also within the countries. CONCLUSION This review demonstrated that CHE/impoverishment is pervasive in SSA, and the magnitude varies across and within countries and over time. Socio-economic factors are seen to drive CHE with the poor being the most affected, and they vary across countries. This calls for intensifying health policies and financing structures in SSA, to provide equitable access to all populations especially the most poor and vulnerable. There is a need to innovate and draw lessons from the 'informal' social networks/schemes as they are reported to be more effective in cushioning the financial burden.
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Affiliation(s)
- Purity Njagi
- United Nations University - Maastricht Economic and social Research institute on Innovation and Technology(UNU-MERIT), Maastricht University, Maastricht, The Netherlands
| | - Jelena Arsenijevic
- Department of Health Services Research, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Faculty of Law, Economics and Governance, Utrecht University, Utrecht, The Netherlands
| | - Wim Groot
- Department of Health Services Research, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Arenliu Qosaj F, Froeschl G, Berisha M, Bellaqa B, Holle R. Catastrophic expenditures and impoverishment due to out-of-pocket health payments in Kosovo. Cost Eff Resour Alloc 2018; 16:26. [PMID: 30069165 PMCID: PMC6064180 DOI: 10.1186/s12962-018-0111-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 07/20/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The current health system reforms in Kosovo aim to improve health status through universal health coverage. Risk pooling and ensuring access to necessary care without financial hardship are envisaged through compulsory health insurance. We measure the level of financial risk protection through two commonly applied concepts: catastrophic health expenditures and impoverishment. METHODS Data from the 2014 Kosovo Household Budget Survey were used to estimate catastrophic health expenditures as a percentage of household consumption expenditures at different thresholds. Poverty head counts and gaps were estimated before and after out-of-pocket (OOP) health payments. RESULTS Approximately 80% of the households in Kosovo incurred OOP health payments. Most of these expenditures were for medicine, pharmaceutical products and medical devices, followed by diagnostic and outpatient services. Hospital services and treatment abroad were less frequent but highly costly. Although households from the upper consumption groups spent more, households from the lower consumption groups spent a greater share of their consumption expenditures on healthcare. The catastrophic health expenditure head count showed an increase, while the impoverishment and poverty gap remained stable compared to 2011. Regression analysis showed that age of the household head, insurance coverage, household size, belonging to the lowest consumption expenditure quintiles, and having disabled and aged household members were significant predictors of the probability of experiencing catastrophic health expenditures. CONCLUSIONS Ongoing financing reforms should target the lower income quintiles and vulnerable groups, pharmaceutical policies should be revisited, and the internal referral system should be strengthened to overcome excessive spending for treatment abroad.
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Affiliation(s)
- Fatime Arenliu Qosaj
- Center for International Health at Ludwig-Maximilians-Universität München, Leopoldstr. 7, 80802 Munich, Germany
| | - Guenter Froeschl
- Center for International Health at Ludwig-Maximilians-Universität München, Leopoldstr. 7, 80802 Munich, Germany
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich (LMU), Leopoldstr. 5, 80802 Munich, Germany
| | - Merita Berisha
- National Institute of Public Health of Kosovo, Rr. Mother Theresa p.n., 10000 Prishtina, Kosovo
- Medical Faculty Prishtina University, Rr. Bulevardi i Dëshmorëve p.n., 10000 Prishtina, Kosovo
| | - Bashkim Bellaqa
- University of Mitrovica, Rr. Parku Industrial p.n., 40000 Mitrovica, Kosovo
| | - Rolf Holle
- Center for International Health at Ludwig-Maximilians-Universität München, Leopoldstr. 7, 80802 Munich, Germany
- Helmholtz Zentrum München, German Research Center for Environmental Health, Ingolstädter Landstr. 1, 85764 Oberschleissheim, Germany
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Akazili J, Ataguba JEO, Kanmiki EW, Gyapong J, Sankoh O, Oduro A, McIntyre D. Assessing the impoverishment effects of out-of-pocket healthcare payments prior to the uptake of the national health insurance scheme in Ghana. BMC Int Health Hum Rights 2017; 17:13. [PMID: 28532403 PMCID: PMC5440955 DOI: 10.1186/s12914-017-0121-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 05/14/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND There is a global concern regarding how households could be protected from relatively large healthcare payments which are a major limitation to accessing healthcare. Such payments also endanger the welfare of households with the potential of moving households into extreme impoverishment. This paper examines the impoverishing effects of out-of-pocket (OOP) healthcare payments in Ghana prior to the introduction of Ghana's national health insurance scheme. METHODS Data come from the Ghana Living Standard Survey 5 (2005/2006). Two poverty lines ($1.25 and $2.50 per capita per day at the 2005 purchasing power parity) are used in assessing the impoverishing effects of OOP healthcare payments. We computed the poverty headcount, poverty gap, normalized poverty gap and normalized mean poverty gap indices using both poverty lines. We examine these indicators at a national level and disaggregated by urban/rural locations, across the three geographical zones, and across the ten administrative regions in Ghana. Also the Pen's parade of "dwarfs and a few giants" is used to illustrate the decreasing welfare effects of OOP healthcare payments in Ghana. RESULTS There was a high incidence and intensity of impoverishment due to OOP healthcare payments in Ghana. These payments contributed to a relative increase in poverty headcount by 9.4 and 3.8% using the $1.25/day and $2.5/day poverty lines, respectively. The relative poverty gap index was estimated at 42.7 and 10.5% respectively for the lower and upper poverty lines. Relative normalized mean poverty gap was estimated at 30.5 and 6.4%, respectively, for the lower and upper poverty lines. The percentage increase in poverty associated with OOP healthcare payments in Ghana is highest among households in the middle zone with an absolute increase estimated at 2.3% compared to the coastal and northern zones. CONCLUSION It is clear from the findings that without financial risk protection, households can be pushed into poverty due to OOP healthcare payments. Even relatively richer households are impoverished by OOP healthcare payments. This paper presents baseline indicators for evaluating the impact of Ghana's national health insurance scheme on impoverishment due to OOP healthcare payments.
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Affiliation(s)
- James Akazili
- Navrongo Health Research Centre, Ghana Health Service, Box 114, Navrongo, Upper East Region Ghana
- INDEPTH Network, Kanda, P.O. Box KD 213, Accra, Ghana
| | - John Ele-Ojo Ataguba
- Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
| | - Edmund Wedam Kanmiki
- Navrongo Health Research Centre, Ghana Health Service, Box 114, Navrongo, Upper East Region Ghana
| | - John Gyapong
- University of Health and Allied Sciences, PMB 31 Ho, Ghana
| | - Osman Sankoh
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Abraham Oduro
- Navrongo Health Research Centre, Ghana Health Service, Box 114, Navrongo, Upper East Region Ghana
| | - Di McIntyre
- Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
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Islam MR, Rahman MS, Islam Z, Nurs CZB, Sultana P, Rahman MM. Inequalities in financial risk protection in Bangladesh: an assessment of universal health coverage. Int J Equity Health 2017; 16:59. [PMID: 28376808 PMCID: PMC5381038 DOI: 10.1186/s12939-017-0556-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Accepted: 03/30/2017] [Indexed: 01/31/2023] Open
Abstract
Background Financial risk protection and equity are major components of universal health coverage (UHC), which is defined as ensuring access to health services for all citizens without any undue financial burden. We investigated progress towards UHC financial risk indicators and assessed variability of inequalities in financial risk protection indicators by wealth quintile. We further examined the determinants of different financial hardship indicators related to healthcare costs. Methods A cross-sectional, three-stage probability survey was conducted in Bangladesh, which collected information from 1600 households from August to November 2011. Catastrophic health payments, impoverishment, and distress financing (borrowing or selling assets) were treated as financial hardship indicators in UHC. Poisson regression models were used to identify the determinants of catastrophic payment, impoverishment and distress financing separately. Slope, relative and concentration indices of inequalities were used to assess wealth-based inequalities in financial hardship indicators. Results The study found that around 9% of households incurred catastrophic payments, 7% faced distress financing, and 6% experienced impoverishing health payments in Bangladesh. Slope index of inequality indicated that the incidence of catastrophic health payment and distress financing among the richest households were 12 and 9 percentage points lower than the poorest households respectively. Multivariable Poisson regression models revealed that all UHC financial hardship indicators were significantly higher among household that had members who received inpatient care or were in the poorest quintile. The presence of a member with chronic illness in a household increased the risk of impoverishment by nearly double. Conclusion This study identified a greater inequality in UHC financial hardship indicators. Rich households in Bangladesh were facing disproportionately less financial hardship than the poor ones. Households can be protected from financial hardship associated with healthcare costs by implementing risk pooling mechanism, increasing GDP spending on health, and properly monitoring subsidized programs in public health facilities. Electronic supplementary material The online version of this article (doi:10.1186/s12939-017-0556-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Md Rashedul Islam
- Department of Computer Science, Uttara Commerce College, Dhaka, Bangladesh
| | - Md Shafiur Rahman
- Department of Global Health Policy, The University of Tokyo, Tokyo, Japan
| | - Zobida Islam
- Department of Public Health, First Capital University of Bangladesh, Chuadanga, Bangladesh
| | | | - Papia Sultana
- Department of Statistics, University of Rajshahi, Rajshahi, Bangladesh
| | - Md Mizanur Rahman
- Department of Global Health Policy, The University of Tokyo, Tokyo, Japan. .,Department of Population Science and Human Resource Development, University of Rajshahi, Rajshahi, 6205, Bangladesh.
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Aregbeshola BS, Khan SM. Determinants Of Impoverishment Due To Out Of Pocket Payments In Nigeria. J Ayub Med Coll Abbottabad 2017; 29:194-199. [PMID: 28718230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Poverty is an extreme consequence of out of pocket payments in countries with health systems that do not provide financial risk protection through mandatory health insurance coverage for people in both the formal and informal sectors. The study assessed the determinants of impoverishment due to out of pocket payments in Nigeria. METHODS Secondary data from the Harmonized Nigeria Living Standard Survey (HNLSS) of 2009/10 was utilized to assess factors associated with impoverishment in Nigeria. Household and individual characteristics associated with impoverishment were determined using binary logistic regression. A significance level of p<0.05 was used. RESULTS Results show that lack of health insurance, having a member above 65 years, large household size, household socio-economic status, type of illness suffered, type of health facility visited, geo-political zones, education of household heads and location were major determinants of impoverishment due to out of pocket health expenditure. CONCLUSIONS Findings from the study show that most households and individuals are vulnerable to financial risk due to this regressive source of payments for health care services. This explains why the level of poverty keeps increasing in spite of the numerous poverty alleviation programs across the country. Policy makers and political actors need to design a new health system financing policy that will increase financial risk protection for people in both the formal and informal sectors. Governments and decision makers have to focus on health as a determinant of economic well-being.
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Affiliation(s)
- Bolaji Samson Aregbeshola
- Department of Community Health & Primary Care, College of Medicine, University of Lagos, Idi-Araba, Mushin, Lagos, Nigeria
| | - Samina Mohsin Khan
- Department of Public Health, Shaheed Zulfiqar Ali Bhutto Medical University, Pakistan Institute of Medical Sciences (PIMS), Islamabad, Pakistan
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Koch KJ, Cid Pedraza C, Schmid A. Out-of-pocket expenditure and financial protection in the Chilean health care system-A systematic review. Health Policy 2017; 121:481-94. [PMID: 28359550 DOI: 10.1016/j.healthpol.2017.02.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 02/19/2017] [Accepted: 02/21/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Protection against financial risk due to medical spending is an explicit health guarantee within Chile's AUGE health reform. This paper seeks to analyze the degree to which out-of-pocket expenditure still expose Chilean households to financial catastrophe and impoverishment, and to explore inequalities in financial protection. METHODS A systematic literature review was conducted to identify empirical studies analyzing financial protection in Chile. The search included databases as well as grey literature, i.e. governmental and institutional webpages. The indicators are based on the conceptual framework of financial protection, as portrayed in the World Health Report 2013. RESULTS We identify n=16 studies that fulfill the inclusion criteria. Empirical studies indicate that 4% of Chilean households faced catastrophic health expenditure defined as out-of-pocket expenditure exceeding 30% of household's capacity to pay, while less than 1% were pushed into poverty in 2012. In contrast to prior studies, recent data report that even publicly insured who should be fully protected from co-payments were affected by catastrophic health expenditure. Also in the private insurance system financial catastrophe is a common risk. CONCLUSION Despite health reform efforts, financial protection is insufficient and varies to the disadvantage of the poor and vulnerable groups. More research is required to understand why current mechanisms are not as effective as expected and to enable according reforms of the insurance system.
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Abstract
BACKGROUND Out of pocket (OOP) health spending can potentially expose households to risk of incurring large medical bills, and this may impact on their welfare. This work investigates the effect of catastrophic OOP on the incidence and depth of poverty in Malawi. METHODS The paper is based on data that was collected from 12,271 households that were interviewed during the third Malawi integrated household survey (IHS-3). The paper considered a household to have incurred a catastrophic health expenditure if the share of health expenditure in the household's non-food expenditure was greater than a given threshold ranging between 10 and 40%. RESULTS As we increase the threshold from 10 to 40%, we found that OOP drives between 9.37 and 0.73% of households into catastrophic health expenditure. The extent by which households exceed a given threshold (mean overshoot) drops from 1.01% of expenditure to 0.08%, as the threshold increased. When OOP is accounted for in poverty estimation, additional 0.93% of the population is considered poor and the poverty gap rises by almost 2.54%. Our analysis suggests that people in rural areas and middle income households are at higher risk of facing catastrophic health expenditure. CONCLUSION We conclude that catastrophic health expenditure increases the incidence and depth of poverty in Malawi. This calls for the introduction of social insurance system to minimize the incidence of catastrophic health expenditure especially to the rural and middle income population.
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Gwatidzo SD, Stewart Williams J. Diabetes mellitus medication use and catastrophic healthcare expenditure among adults aged 50+ years in China and India: results from the WHO study on global AGEing and adult health (SAGE). BMC Geriatr 2017; 17:14. [PMID: 28077072 PMCID: PMC5225610 DOI: 10.1186/s12877-016-0408-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 12/27/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Expenditure on medications for highly prevalent chronic conditions such as diabetes mellitus (DM) can result in financial impoverishment. People in developing countries and in low socioeconomic status groups are particularly vulnerable. China and India currently hold the world's two largest DM populations. Both countries are ageing and undergoing rapid economic development, urbanisation and social change. This paper assesses the determinants of DM medication use and catastrophic expenditure on medications in older adults with DM in China and India. METHODS Using national standardised data collected from adults aged 50 years and above with DM (self-reported) in China (N = 773) and India (N = 463), multivariable logistic regression describes: 1) association between respondents' socio-demographic and health behavioural characteristics and the dependent variable, DM medication use, and 2) association between DM medication use (independent variable) and household catastrophic expenditure on medications (dependent variable) (China: N = 630; India: N = 439). The data source is the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) Wave 1 (2007-2010). RESULTS Prevalence of DM medication use was 87% in China and 71% in India. Multivariable analysis indicates that people reporting lifestyle modification were more likely to use DM medications in China (OR = 6.22) and India (OR = 8.45). Women were more likely to use DM medications in China (OR = 1.56). Respondents in poorer wealth quintiles in China were more likely to use DM medications whereas the reverse was true in India. Almost 17% of people with DM in China experienced catastrophic healthcare expenditure on medications compared with 7% in India. Diabetes medication use was not a statistically significant predictor of catastrophic healthcare expenditure on medications in either country, although the odds were 33% higher among DM medications users in China (OR = 1.33). CONCLUSIONS The country comparison reflects major public policy differences underpinned by divergent political and ideological frameworks. The DM epidemic poses huge public health challenges for China and India. Ensuring equitable and affordable access to medications for DM is fundamental for healthy ageing cohorts, and is consistent with the global agenda for universal healthcare coverage.
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Affiliation(s)
- Shingai Douglas Gwatidzo
- Umeå International School of Public Health, Unit of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Faculty of Medicine, Umeå University, SE-90185 Umeå, Sweden
| | - Jennifer Stewart Williams
- Unit of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Faculty of Medicine, Umeå University, SE-90185 Umeå, Sweden
- Research Centre for Gender, Health and Ageing, Faculty of Health, University of Newcastle, New Lambton Heights, Newcastle, NSW 2305 New South Wales Australia
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Zhou C, Long Q, Chen J, Xiang L, Li Q, Tang S, Huang F, Sun Q, Lucas H, Huan S. The effect of NCMS on catastrophic health expenditure and impoverishment from tuberculosis care in China. Int J Equity Health 2016; 15:172. [PMID: 27756368 PMCID: PMC5069881 DOI: 10.1186/s12939-016-0463-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 10/12/2016] [Indexed: 12/04/2022] Open
Abstract
Background Health expenditure for tuberculosis (TB) care often pushes households into catastrophe and poverty. New Cooperative Medical Scheme (NCMS) aims to protect households from catastrophic health expenditure (CHE) and impoverishment in rural China. This article assesses the effect of NCMS on relieving CHE and impoverishment from TB care in rural China. Methods Three hundred fourty-seven TB cases are included in the analysis. We analyze the incidence and intensity of CHE and poverty, and assess the protective effect of NCMS by comparing the CHE and impoverishment before and after reimbursement. Results After out-of-pocket (OOP) payment for TB care, 16.1 % of non-poor fall below poverty line. The NCMS reduces the incidence of CHE and impoverishment by 11.5 % and 7.3 %. After reimbursement, 46.7 % of the households still experience CHE and 35.4 % are below the poverty line. The NCMS relieves the mean gap, mean positive gap, poverty gap and normalized positive gap by 44.5 %, 51.0 %, US$115.8 and 31.6 % respectively. Conclusions The NCMS has partial effect on protecting households from CHE and impoverishment from TB care. The limited protection could be enhanced by redesigning benefit coverage to improve the “height” of the NCMS and representing fee-for-service with alternative payment mechanisms. Electronic supplementary material The online version of this article (doi:10.1186/s12939-016-0463-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Chengchao Zhou
- Department of Social Medicine and Health Service Management, School of Public Health, Shandong University, Jinan, China.,Collaborative Innovation Center of Social Risks Governance in Health, School of Public Health, Shandong University, Jinan, China.,Key Laboratory of Health Economic and Policy Research, NHFPC, Shandong University, Wen-hua-xi Road No. 44, Jinan City, 250012, China
| | - Qian Long
- Global Health Research Center, Duke Kunshan University, Kunshan, China
| | - Jiaying Chen
- School of Health Policy and Management, Nanjing Medical University, Nanjing, China
| | - Li Xiang
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, China
| | - Qiang Li
- School of Public Health, Xi'an Jiaotong University, Xi'an, China
| | - Shenglan Tang
- Global Health Research Center, Duke Kunshan University, Kunshan, China.,Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Fei Huang
- National Center for TB Control and Prevention, China CDC, Beijing, China
| | - Qiang Sun
- Key Laboratory of Health Economic and Policy Research, NHFPC, Shandong University, Wen-hua-xi Road No. 44, Jinan City, 250012, China. .,Center for Health Management and Policy, Shandong University, Jinan, China.
| | - Henry Lucas
- Institute of Development Studies, Sussex University, Brighton, UK
| | - Shitong Huan
- Bill & Melinda Gates Foundation Beijing Office, Beijing, China
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Kien VD, Van Minh H, Giang KB, Dao A, Tuan LT, Ng N. Socioeconomic inequalities in catastrophic health expenditure and impoverishment associated with non-communicable diseases in urban Hanoi, Vietnam. Int J Equity Health 2016; 15:169. [PMID: 27737663 PMCID: PMC5064924 DOI: 10.1186/s12939-016-0460-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 10/09/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The catastrophic health expenditure and impoverishment indices offer guidance for developing appropriate health policies and intervention programs to decrease financial inequity. This study assesses socioeconomic inequalities in catastrophic health expenditure and impoverishment in relation to self-reported non-communicable diseases (NCD) in urban Hanoi, Vietnam. METHODS A cross-sectional survey was conducted from February to March 2013 in Hanoi, the capital city of Vietnam. We estimated catastrophic health expenditure and impoverishment using information from 492 slum household and 528 non-slum households. We calculated concentration indexes to assess socioeconomic inequalities in catastrophic health expenditure and impoverishment. Factors associated with catastrophic health expenditure and impoverishment were modelled using logistic regression analysis. RESULTS The poor households in both slum and non-slum areas were at higher risk of experiencing catastrophic health expenditure, while only the poor households in slum areas were at higher risk of impoverishment because of healthcare spending. Households with at least one member reporting an NCD were significantly more likely to face catastrophic health expenditure (odds ratio [OR] = 2.4; 95 % confidence interval [CI], 1.8-4.0) and impoverishment (OR = 2.3; 95 % CI, 1.1-6.3) compared to households without NCDs. In addition, households in slum areas, with people age 60 years and above, and belonging to the poorest socioeconomic group were significantly associated with increased catastrophic health expenditure, while only households that lived in slum areas, and belonging to the poor or poorest socioeconomic groups were significantly associated with increased impoverishment because of healthcare spending. CONCLUSION Financial interventions to prevent catastrophic health expenditure and impoverishment should target poor households, especially those with family members suffering from NCDs, with older members and those located in slum areas in Hanoi Vietnam. Potential interventions derived from this study include targeting and monitoring of health insurance enrolment, and developing a specialized NCD service package for Vietnam's social health insurance program.
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Affiliation(s)
- Vu Duy Kien
- Center for Population Health Sciences, Hanoi School of Public Health, Hanoi, Vietnam. .,Unit of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
| | - Hoang Van Minh
- Center for Population Health Sciences, Hanoi School of Public Health, Hanoi, Vietnam
| | - Kim Bao Giang
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam
| | - Amy Dao
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Le Thanh Tuan
- Department of Training and Management, Thanh Hoa Medical College, Thanh Hoa, Vietnam
| | - Nawi Ng
- Unit of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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Dorjdagva J, Batbaatar E, Svensson M, Dorjsuren B, Kauhanen J. Catastrophic health expenditure and impoverishment in Mongolia. Int J Equity Health 2016; 15:105. [PMID: 27401464 PMCID: PMC4939814 DOI: 10.1186/s12939-016-0395-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 07/04/2016] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The social health insurance coverage is relatively high in Mongolia; however, escalation of out-of-pocket payments for health care, which reached 41 % of the total health expenditure in 2011, is a policy concern. The aim of this study is to analyse the incidence of catastrophic health expenditures and to measure the rate of impoverishment from health care payments under the social health insurance scheme in Mongolia. METHODS We used the data from the Household Socio-Economic Survey 2012, conducted by the National Statistical Office of Mongolia. Catastrophic health expenditures are defined an excess of out-of-pocket payments for health care at the various thresholds for household total expenditure (capacity to pay). For an estimate of the impoverishment effect, the national and The Wold Bank poverty lines are used. RESULTS About 5.5 % of total households suffered from catastrophic health expenditures, when the threshold is 10 % of the total household expenditure. At the threshold of 40 % of capacity to pay, 1.1 % of the total household incurred catastrophic health expenditures. About 20,000 people were forced into poverty due to paying for health care. CONCLUSIONS Despite the high coverage of social health insurance, a significant proportion of the population incurred catastrophic health expenditures and was forced into poverty due to out-of-pocket payments for health care.
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Affiliation(s)
- Javkhlanbayar Dorjdagva
- />Department of Health Policy and Management, School of Public Health, Mongolian National University of Medical Sciences, Zorig Street, Ulaanbaatar, 14210 Mongolia
- />Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Enkhjargal Batbaatar
- />Department of Health Policy and Management, School of Public Health, Mongolian National University of Medical Sciences, Zorig Street, Ulaanbaatar, 14210 Mongolia
| | - Mikael Svensson
- />Health Metrics Unit, the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Jussi Kauhanen
- />Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
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Jacobs B, de Groot R, Fernandes Antunes A. Financial access to health care for older people in Cambodia: 10-year trends (2004-14) and determinants of catastrophic health expenses. Int J Equity Health 2016; 15:94. [PMID: 27316716 PMCID: PMC4912821 DOI: 10.1186/s12939-016-0383-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 06/13/2016] [Indexed: 01/10/2023] Open
Abstract
Background Older people make up an increasing proportion of the population in low- and middle-income countries. This brings a number of challenges, as their health needs are greater than, and different from, those of younger people. In general, these health systems are not geared to address their needs, and traditional support systems tend to erode, potentially causing financial hardship when accessing health care. This paper provides an overview of older Cambodians’ financial access to health care over time, using nationally representative data to enable the formulation of appropriate responses. Methods Using data from three nationally representative household surveys from 2004, 2009 and 2014, we assess key indicators of financial access to health care for households with older people (aged 60 years or older), and compare these with households without older members. For 2014 data, the determinants of catastrophic health expenses at the 10 and 40 % threshold were determined for older people. Data was stratified by age and place of residence (urban/rural), and analysed using Stata statistical software. Sample weights were calibrated to reflect accurate population composition at the time of the survey. Monetary values for 2004 and 2009 were transformed into 2014 values using annual inflation rate figures. Results Care-seeking when sick among older people increased considerably from 2004 to 2014, irrespective of gender or place of residence. There were positive trends in the incidence of catastrophic and impoverishing healthcare expenses over the studied time periods. This was also the case for indebtedness. Rural households with older people were considerable more likely to suffer financial hardship due to health-related expenses than their urban equivalents. In 2014, older people spent 50 % more per month on health care than younger people. Determinants of catastrophic health expenditures among households with older people were residing in a rural area, and having a household member with an illness, especially a non-communicable disease. Conclusion In order to make health care more equitable for older people, efforts should be directed to rural areas. Interventions should include improving management of non-communicable diseases at the primary care level, together with a reconfiguration of social health protection schemes to increase the inclusion of older people.
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Affiliation(s)
- Bart Jacobs
- Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GiZ), c/o NIPH, No.2, Street 289, Khan Toul Kork, P.O. Box 1238, Phnom Penh, Cambodia.
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Moghadam MN, Banshi M, Javar MA, Amiresmaili M, Ganjavi S. Iranian Household Financial Protection against Catastrophic Health Care Expenditures. Iran J Public Health 2012. [PMID: 23193508 PMCID: PMC3494217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Protecting households against financial risks is one of objectives of any health system. In this regard, Iran's fourth five year developmental plan act in its 90th article, articulated decreasing household's exposure to catastrophic health expenditure to one percent. Hence, this study aimed to measure percentage of Iranian households exposed to catastrophic health expenditures and to explore its determinants. METHODS The present descriptive-analytical study was carried out retrospectively. Households whose financial contributions to the health system exceeded 40% of disposable income were considered as exposed to catastrophic healthcare expenditures. Influential factors on catastrophic healthcare expenditures were examined by logistic regression and chi-square test. RESULTS Of 39,088 households, 80 were excluded due to absence of food expenditures. 2.8% of households were exposed to catastrophic health expenditures. Influential factors on catastrophic healthcare were utilizing ambulatory, hospital, and drug addiction cessation services as well as consuming pharmaceuticals. Socioeconomics characteristics such as health insurance coverage, household size, and economic status were other determinants of exposure to catastrophic healthcare expenditures. CONCLUSION Iranian health system has not achieved the objective of reducing catastrophic healthcare expenditure to one percent. Inefficient health insurance coverage, different fee schedules practiced by private and public providers, failure of referral system are considered as probable barriers toward decreasing households' exposure to catastrophic healthcare expenditures.
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Affiliation(s)
- M Nekoei Moghadam
- Research Centre for Health Services Management, Kerman University of Medical Sciences, Kerman, Iran
| | - M Banshi
- Research Center for Modeling in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - M Akbari Javar
- Students’ Research Committee, Kerman University of Medical Sciences, Kerman, Iran
| | - M Amiresmaili
- Medical Informatics Research Center, Kerman University of Medical Sciences, Haftbagh Highway, Kerman, Iran,Corresponding Author: Tel: 0098 341 3205158, E-mail address:
| | - S Ganjavi
- Students’ Research Committee, Kerman University of Medical Sciences, Kerman, Iran
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