Determinants of catastrophic healthcare expenditure in Peru

Oral Health Care Out-of-Pocket Costs and Financial Hardship: A Scoping Review

The objective of this study is to characterize how financial hardship related to oral health care (OHC) out-of-pocket (OOP) spending has been conceptualized, defined, and measured in the literature and to identify evidence gaps in this area. This scoping review follows Arksey and O'Malley's framework and synthesizes financial hardship from OHC concepts, methodologies, and evidence gaps. We searched Ovid-Medline, Ovid-Embase, PubMed, Web of Science, Scopus, EconLit, Business Source Premier, and the Cochrane Library. Gray literature was sourced from institutional websites (World Health Organization, United Nations, World Bank Group, Organisation for Economic Co-operation and Development, and governmental health agencies) as well as ProQuest Dissertations and Thesis Global. We used defined inclusion and exclusion criteria to select studies published between 2000 and 2023. Of the 1,876 records, 65 met our criteria. The studies conceptualized financial hardship as catastrophic spending, impoverishment, negative coping strategies, bankruptcy, financial burden, food insecurity, and personal financial hardship experience. We found heterogeneity in defining OHC OOP payments and services. Also, financial hardship was frequently measured as catastrophic health expenditure using cross-sectional designs and national household spending surveys from high-income and to a lesser extent lower-middle-income countries. We identify and discuss challenges in terms of conceptualizing financial hardship, study designs, and measurement instruments in the OHC context. Some of the common evidence gaps identified include studying the causal relationship in financial hardship from OHC, assessing the financial hardship and unmet dental needs due to cost relationship, and distinguishing the effect between pain/discomfort and esthetic/cosmetic dental treatments on financial hardship. Financial hardship in OHC needs further exploration and the use of consistent definitions as well must distinguish between treatments alleviating pain/discomfort from esthetic/cosmetic treatments. Our study is relevant for policy makers and researchers aiming to monitor financial protection of OOP payments on OHC in the wake of universal health coverage for oral health.

Household financial burden associated with out-of-pocket payments for healthcare in Iran: insights from a cross-sectional survey

BACKGROUND

One of the key functions and ultimate goals of health systems is to provide financial protection for individuals when using health services. This study sought to evaluate the level of financial protection and its inequality among individuals covered by the Social Security Organization (SSO) health insurance between September and December 2023 in Iran.

METHODS

We collected data on 1691 households in five provinces using multistage sampling to examine the prevalence of catastrophic healthcare expenditure (CHE) at four different thresholds (10%, 20%, 30%, and 40%) of the household's capacity to pay (CTP). Additionally, we explored the prevalence of impoverishment due to health costs and assessed socioeconomic-related inequality in OOP payments for healthcare using the concentration index and concentration curve. To measure equity in out-of-pocket (OOP) payments for healthcare, we utilized the Kakwani progressivity index (KPI). Furthermore, we employed multiple logistic regression to identify the main factors contributing to households experiencing CHE.

FINDINGS

The study revealed that households in our sample allocated approximately 11% of their budgets to healthcare services. The prevalence of CHE at the thresholds of 10%, 20%, 30%, and 40% was found to be 47.1%, 30.1%, 20.1%, and 15.7%, respectively. Additionally, we observed that about 7.9% of the households experienced impoverishment due to health costs. Multiple logistic regression analysis indicated that the age of the head of the household, place of residence, socioeconomic status, utilization of dental services, utilization of medicine, and province of residence were the main factors influencing CHE. Furthermore, the study demonstrated that while wealthy households spend more money on healthcare, poorer households spend a larger proportion of their total income to healthcare costs. The KPI showed that households with lower total expenditures had higher OOP payments relative to their CTP.

CONCLUSION

The study findings underscore the need for targeted interventions to improve financial protection in healthcare and mitigate inequalities among individuals covered by SSO. It is recommended that these interventions prioritize the expansion of coverage for dental services and medication expenses, particularly for lower socioeconomic status household.

Towards the integration of prevention and control of oral diseases within child primary healthcare: The case of Peru

OBJECTIVES

The Peruvian public health norm of primary healthcare (PHC) for growth and development medical check-ups (CRED, Spanish acronym) of children under 5 years of age was updated in 2017 with the inclusion of interdisciplinary prevention and control actions for oral diseases, such as dentist referral. The aim of this study was to explore the association between CRED and oral health services utilization (OHSU), throughout the heterogeneous Peruvian territory.

METHODS

A population-based cross sectional study was conducted using the 2021 Demographic and Family Health Survey of Peru and included data from 15 836 children aged 12-59 months. Poisson generalized linear models were used to evaluate the association between any CRED and OHSU, in the 6 months prior to the survey, including sociodemographic characteristics of the children and their mothers as confounding variables. A possible effect modification by natural region of residence (Metropolitan Lima/rest of the Coast/Highlands/Jungle) was evaluated. To examine the robustness of the regression model, a sensitivity analysis was performed using the cumulative number of CRED.

RESULTS

Children who had at least one CRED were almost twice as likely to report OHSU (aPR: 1.95; 95% CI: 1.73-2.21), which was greater in the regions of rest of the Coast (aPR: 2.56; 95% CI: 2.00-3.17) and Jungle (aPR: 2.03; 95% CI: 1.64-2.56). The sensitivity analysis showed consistent results for the association CRED-OHSU. Nevertheless, within the last 6 months, attendance at CRED and OHSU were only achieved by 43.7% and 13.7% of the children respectively.

CONCLUSIONS

Integrating oral health into Peruvian Child PHC seems to be a promising public health intervention to increase children's OHSU. For a greater scope, it is crucial to drive greater attendance at CRED and continuous monitoring and strengthening of CRED-based oral health promotion in all Peruvian natural regions with an equity-focused approach.

Measurements of Impoverishing and Catastrophic Surgical Health Expenditures in Low- and Middle-Income Countries and Reduction Interventions in the Last 30 Years: A Systematic Review

INTRODUCTION

Approximately 33 million people suffer catastrophic health expenditure (CHE) from surgery and/or anesthesia costs. The aim of this systematic review is to evaluate catastrophic and impoverishing expenditure associated with surgery and anesthesia in low- and middle-income countries (LMICs).

METHODS

We performed a systematic review of all studies from 1990 to 2021 that reported CHE in LMICs for treatment of a condition requiring surgical intervention, including cesarean section, trauma care, and other surgery.

RESULTS

77 studies met inclusion criteria. Tertiary facilities (23.4%) were the most frequently studied facility type. Only 11.7% of studies were conducted in exclusively rural health-care settings. Almost 60% of studies were retrospective in nature. The cost of procedures ranged widely, from $26 USD for a cesarean section in Mauritania in 2020 to $74,420 for a pancreaticoduodenectomy in India in 2018. GDP per capita had a narrower range from $315 USD in Malawi in 2019 to $9955 USD in Malaysia in 2015 (Median = $1605.50, interquartile range = $1208.74). 35 studies discussed interventions to reduce cost and catastrophic expenditure. Four of those studies stated that their intervention was not successful, 18 had an unknown or equivocal effect on cost and CHE, and 13 concluded that their intervention did help reduce cost and CHE.

CONCLUSIONS

CHE from surgery is a worldwide problem that most acutely affects vulnerable patients in LMICs. Existing efforts are insufficient to meet the true need for affordable surgical care unless assistance for ancillary costs is given to patients and families most at risk from CHE.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Factors associated with the use of oral health services in Peruvian children under the age of 12 years

OBJECTIVES

To determine the prevalence and factors associated with the use of oral health services in Peruvian children under 12 years of age.

MATERIAL AND METHODS

A secondary analysis of 2019 Demographic and Family Health Survey was conducted. The sample consisted of 40,751 children. The main variable was the use of dental services (attended/not attended) in the last 6 months, and the independent variables were gender, age, area of residence, wealth quintile, health insurance coverage, information received on oral health care, age, and educational level of the caregivers. Analyses of absolute and relative frequencies, differences in proportions, and multivariate analysis using generalized linear models were performed.

RESULTS

The dental service utilization prevalence during the last 6 months was 31%. Correlation was found with urban area residents (PRa = 0.945; 95% CI: 0.904-0.988), the Jungle geographical domain (PRa = 0.926; 95% CI: 0.877-0.977), the highest wealth quintile (PRa = 1.323; 95% CI: 1.232-1.421), the higher education level of the caregiver (PRa = 1.375; 95% CI: 1.231-1.536), affiliation with the Public Health Insurance (PRa = 1.112; 95% CI: 1.069-1.158), and the condition of having received information on oral health care (PRa = 2.355; 95% CI: 2.263-2.245) with respect to their baseline variables.

CONCLUSIONS

Several socio-demographic factors were correlated with the use of oral health services in Peruvian children under 12 years of age and the percentage of their use was low. Information on oral health care had a more significant impact on both, the population from the highest wealth quintile and the highest educational attainment.

Risk Characteristics of Catastrophic Health Expenditure in Multidimensional Borderline Poor Households in China

Background

Ending poverty and realizing common prosperity are the essential requirements for the localization of Marxism in China. The ongoing COVID-19 pandemic in the post-poverty era further aggravates the risk of catastrophic health expenditure for borderline poor households and increases the uncertainty of returning to poverty due to illness, potentially undermining decades of hard-won efforts to eradicate poverty in China.

Methods

Based on the latest data released by China Health and Retirement Longitudinal Survey (CHARLS) database, this paper uses the Logit model to empirically explore the risk characteristics of catastrophic health expenditure of multidimensional borderline poor households based on identifying multidimensional borderline poor households.

Results

The results show that factors such as family income level, child support, and medical insurance have different impacts on catastrophic health expenditure, and the risk of catastrophic health expenditure of multidimensional borderline poor households is much higher than that of non- multidimensional borderline poor households, and there is a certain difference between urban and rural areas.

Discussion

The government should strengthen and improve the social security system and health service system, such as medical insurance, and more resources should be allocated to multidimensional borderline poor households, especially in rural areas.

Toward mandatory health insurance in low-income countries? An analysis of claims data in Tanzania

Many low-income countries are in the process of scaling up health insurance with the goal of achieving universal coverage. However, little is known about the usage and financial sustainability of mandatory health insurance. This study analyzes 26 million claims submitted to the Tanzanian National Health Insurance Fund (NHIF), which covers two million public servants for whom public insurance is mandatory, to understand insurance usage patterns, cost drivers, and financial sustainability. We find that in 2016, half of policyholders used a health service within a single year, with an average annual cost of 33 US$ per policyholder. About 10% of the population was responsible for 80% of the health costs, and women, middle-age and middle-income groups had the highest costs. Out of 7390 health centers, only five health centers are responsible for 30% of total costs. Estimating the expected health expenditures for the entire population based on the NHIF cost structure, we find that for a sustainable national scale-up, policy makers will have to decide between reducing the health benefit package or increasing revenues. We also show that the cost structure of a mandatory insurance scheme in a low-income country differs substantially from high-income settings. Replication studies for other countries are warranted.

Catastrophic health expenditure in the Northern midlands and mountainous areas and its determinants, Vietnam from 2014 to 2020: a cross-sectional study

OBJECTIVES

The study assesses households' catastrophic health expenditure (CHE) by income group, urban versus rural area, and influencing factors in the Northern midlands and mountainous areas of Vietnam.

DESIGN/SETTING

A cross-sectional study with the four waves of data from 2014, 2016, 2018 and 2020 Vietnam household living standards surveys was used.

PARTICIPANTS

The number of participants in this study were 1658, 1661, 1659 and 1662 households in 2014, 2016, 2018 and 2020, respectively. We included households residing in the Northern midlands and mountain areas of Vietnam.

OUTCOMES MEASURE

We examined out-of-pocket health payments and capacity to pay by income groups and place of residence, the incidence of CHE and impoverishment. A logistic regression model was used to examine the influence of demographic and socioeconomic characteristics on CHE.

RESULTS

The findings showed a remarkable decrease in CHE between 2014 and 2016, followed by a considerable increase between 2016 and 2018. The CHE rates in the region were between 3.5% and 5%, with the highest value observed in 2014. In addition, the differences in household CHE rates according to income and place of residence were observed. The results also indicated that medical impoverishment ranged between 3.4% and 3.9%. Overall, factors such as the burden of disease, rural settlements, increasing use of healthcare services, visiting private health facilities and having an old-aged person in the household were significantly and positively associated with CHE. By contrast, households that were wealthier, participated in health insurance, had a household head employed and female-headed households, were negatively associated with CHE.

CONCLUSIONS

The findings provide useful information that can guide policy-makers to design policies, and interventions necessary to reduce CHE in the region, narrow the gap between the rich and the poor, the rural and urban settlements, and ensure universal health coverage.

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

Background

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

Methods

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

Results

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

Conclusion

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

Supplementary Information

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

Assessing progress towards Sustainable Development Goal 3.8.2 and determinants of catastrophic health expenditures in Malaysia

The Sustainable Development Goal 3.8.2 is an indicator to track a country’s progress toward universal health coverage on the financial protection against catastrophic health expenditure (CHE). The purpose of this study is to determine the proportion of households with catastrophic health expenditure, and its associated factors among Malaysian households. A secondary data analysis was performed using the Household Expenditure Survey 2015/2016. The inclusion criterion was Malaysian households with some health spending in the past 12 months before the date of the survey. Catastrophic health expenditure was defined as out-of-pocket health expenditures exceeding 10% of the total household consumption. The study included a total of 13015 households. The proportion of households with CHE in the sample was 2.8%. Female-led households (AdjOR 1.6; CI 1.25, 2.03; p-value <0.001), households in rural areas (AdjOR 1.29; 95% CI 1.04, 1.61; p-value = 0.022), small household size (AdjOR 2.4; 95% CI 1.81, 3.18; p-value <0.001) and heads of household under 60 years old (AdjOR2.34; 95% CI 1.81, 3.18; p-value <0.001) were significantly associated with CHE. Although the proportion of Malaysian households affected by CHE is small, it is increasing in comparison to previous findings. This is concerning because it may jeopardise efforts to achieve universal health coverage by 2030. To ensure financial protection and access to care, a health financing policy that includes safety net measures for households at risk of CHE is required.

The impact of out-of pocket payments of households for dental healthcare services on catastrophic healthcare expenditure in Iran

BACKGROUND

Dental healthcare is the costliest and single most source of the financial barrier to seeking and use of needed healthcare. Hence, this study aims to analyses impact of out-of-pocket (OOP) payments for dental services on prevalence catastrophic healthcare expenditure (CHE) among Iranian households during 2018.

METHODS

We performed a cross-sectional analysis to determine the prevalence rate of CHE due to use of dental healthcare services among 38,858 Iranian households using the 2018 Household Income and Expenditure Survey (HIES) survey data of Iran. The WHO approach was used to determine the CHE due to use of dental care services at the 40% of household capacity to pay (CTP). Multiple logistic regression models were used to obtain the odds of facing with CHE among households that paid for any dental healthcare services over the last month while adjusting for covariates included in the model. These findings were reported for urban, rural areas and also for low, middle and high human development index HDI across provinces.

RESULTS

The study indicated that the prevalence of CHE among households that used and did not used dental services over the last month was 16.5% (95% CI: 14.9 to 18.3) and 4.3% (95% CI: 4.1 to 4.6), respectively. The adjusted odds ratio (AOR) for the covariates revealed that the prevalence of CHE for the overall households that used dental healthcare service was 6.2 times (95% CI: 5.4 to 7.1) than those that did not use dental healthcare services. The urban households that used dental healthcare had 7.8 times (95%CI: 6.4-9.4) while the rural ones had 4.7 times (95% CI: 3.7-5.7) higher odds of facing CHE than the corresponding households that did not use dental healthcare services.

CONCLUSIONS

The study indicates that out-of-pocket costs for dental care services impose a substantial financial burden on household's budgets at the national and subnational levels. Alternative health care financing strategies and policies targeted to the reduction in CHE in general and CHE due to dental services in particular are urgently required in low and middle income countries such as Iran.

Changes in Catastrophic Health Expenditures Depending on Health Policies in Turkey

Without any financial protection out of pocket health expenses are essential both because their increase causes difficulties in accessing higher quality health services for households and more importantly because it complicates access to most basic health services. As a result of the Health Transformation Program in practice in the Turkish healthcare system since 2003, significant changes have been done in all layers of the health system. Turkish Statistics Institute (TurkStat) publishes the ratio of households that bear catastrophic health expenditures since 2002. According to TurkStat data, the ratio of households with catastrophic expenditure has fallen from 0.81% in 2002 to 0.17% in 2011 with the health transformation project. However, it has started to rise since 2012 and has reached 0.31% in 2014. This study aims to evaluate the expenditure items that may have caused the rise of the ratio of households with catastrophic health expenditures since 2012, which had previously dropped with the Health Transformation Program that has caused fundamental changes in health policies. Methodology and definitions presented in the article named “Distribution of health payments and catastrophic expenditures: Methodology” by Ke Xu published by the World Health Organization in 2005 have been used. Percentages of health expenditure items among the total expenditure of households with positive health expenditure and households with catastrophic health expenditure between 2007 and 2014 have been evaluated using descriptive analysis. Findings have been interpreted in light of the health policies in practice between 2007 and 2014. An overview of the impact of the health policies reveals that medicine expenditures have decreased both for household and public health expenditures. Despite the impact of policies on the pharmaceutical industry was criticized by the industry, the positive impact can be seen by the decrease in the spending on medicine for households spending on health. Hospital service with positive health expenditure is seen to decrease health expenditure. The reasons for the increase in households with catastrophic health expenditure need further research. As a result, the study strives to discuss the possible policy reasons for the observed effects.

Out-of-pocket payments by end-stage kidney disease patients on regular hemodialysis: Cost of illness analysis, experience from Sudan

INTRODUCTION

In Sudan, the number of end-stage kidney disease (ESKD) patients receiving hemodialysis (HD) is growing. Patients and their families incur a high out-of-pocket expenditure (OOPE), given that HD treatment is expensive. There are limited data about OOP spending on HD in the country. This study aims to explore patients' OOP expense on direct medical and nonmedical goods and services and to which extent they can be predicted from sociodemographic characteristics, health insurance status, comorbidity, and accommodation change.

METHODS

This is descriptive a cross-sectional study conducted in Ibn Sina Hospital. One hundred and thirty patients undergo regular HD were randomly selected.

FINDINGS

Among the study participants (130), the median of the overall total OOP (direct medical and direct nonmedical) spending per patients per year was found to be US$ 3859.1 (interquartile range [IQR]: 2298.1-6261.1). As for the medians OOP expenditure on direct medical and nonmedical costs, they were found to be US$ 2327.6 (IQR: 1421.5-3804.8) and US$ 1096 (IQR: 715.2-2345.2), respectively. The direct medical expenditure (355,586 US$) accounted for 60% of the overall total expenses.

DISCUSSION

Medications and investigations were the primary drivers of direct medical spending. Higher OOPE rates were found among those with one or more of these factors; uninsured patients, patient with comorbidity, female gender, and over 40 years aged. The multivariate analysis showed that the significant predictors of direct medical expenditure were health insurance and comorbid conditions, where as the predictors for direct nonmedical expenditure were accommodation change and gender. This study results in a better understanding of OOP spending on direct medical and nonmedical services and its associated predictors among HD patients within the context of Sudan. Further research is needed in this area.

Determinants of catastrophic health expenditure in Vietnam

BACKGROUND

The Government of Vietnam has set the goal of achieving universal health coverage (UHC) by 2025. Health insurance (HI) is being considered a tool to achieve this goal. However, out-of-pocket spending and catastrophic health expenditure (CHE) remain high. Research evidence on how to reduce these expenditures to achieve UHC is essential. Therefore, this study examines the determinants of CHE, especially the HI factor.

METHOD

To identify HI participation status and other factors associated with CHE, we use logistic regression on a dataset from the 2016 Vietnam Household Living Standards Survey.

RESULTS

The study finds that HI is a protective factor against CHE, although this result is not always statistically significant across different subsamples. Moreover, the household head's age and employment status, household size, share of the elderly above 60 years, income, illness status, healthcare utilisation, availability of hospitals, commune health stations with medical doctors and place of residence all correlate with household CHE.

CONCLUSION

Although there has been a rise in HI coverage, the financial protection capacity of HI schemes in Vietnam remains inadequate, particularly for households living in rural areas. Further investigations of the causal effect of HI, other health system factors and CHE in rural settings are necessary to reduce the incidence of CHE. Additionally, policies aimed at groups vulnerable to CHE, such as those with higher incidences of severe illness or inpatient admissions, low income, and higher age, should be considered.

Measuring Out-of-pocket Payment, Catastrophic Health Expenditure and the Related Socioeconomic Inequality in Peru: A Comparison Between 2008 and 2017

OBJECTIVES

Describe out-of-pocket payment (OOP) and the proportion of Peruvian households with catastrophic health expenditure (CHE) and evaluate changes in socioeconomic inequalities in CHE between 2008 and 2017.

METHODS

We used data from the 2008 and 2017 National Household Surveys on Living and Poverty Conditions (ENAHO in Spanish), which are based on probabilistic stratified, multistage and independent sampling of areas. OOP was converted into constant dollars of 2017. A household with CHE was assumed when the proportion between OOP and payment capacity was ≥0.40. OOP was described by median and interquartile range while CHE was described by weighted proportions and 95% confidence intervals (CIs). To estimate the socioeconomic inequality in CHE we computed the Erreygers concentration index.

RESULTS

The median OOP reduced from 205.8 US dollars to 158.7 US dollars between 2008 and 2017. The proportion of CHE decreased from 4.9% (95% CI, 4.5 to 5.2) in 2008 to 3.7% (95% CI, 3.4 to 4.0) in 2017. Comparison of socioeconomic inequality of CHE showed no differences between 2008 and 2017, except for rural households in which CHE was less concentrated in richer households (p<0.05) and in households located on the rest of the coast, showing an increase in the concentration of CHE in richer households (p<0.05).

CONCLUSIONS

Although OOP and CHE reduced between 2008 and 2017, there is still socioeconomic inequality in the burden of CHE across different subpopulations. To reverse this situation, access to health resources and health services should be promoted and guaranteed to all populations.

Catastrophic health expenditure incidence and its equity in China: a study on the initial implementation of the medical insurance integration system

BACKGROUND

By 2013, several regions in China had introduced health insurance integration policies. However, few studies addressed the impact of medical insurance integration in China. This study investigates the catastrophic health expenditure and equity in the incidence of catastrophic health expenditure by addressing its potential determinants in both integrated and non-integrated areas in China in 2013.

METHODS

The primary data are drawn from the fifth China National Health Services Survey in 2013. The final sample comprises 19,788 households (38.4%) from integrated areas and 31,797 households (61.6%) from non-integrated areas. A probit model is employed to decompose inequality in the incidence of catastrophic health expenditure in line with the methodology used for decomposing the concentration index.

RESULTS

The incidence of catastrophic health expenditure in integrated areas is higher than in non-integrated areas (13.87% vs. 13.68%, respectively). The concentration index in integrated areas and non-integrated areas is - 0.071 and - 0.073, respectively. Average household out-of-pocket health expenditure and average capacity to pay in integrated areas are higher than those in non-integrated areas. However, households in integrated areas have lower share of out-of-pocket expenditures in the capacity to pay than households in non-integrated areas. The majority of the observed inequalities in catastrophic health expenditure can be explained by differences in the health insurance and householders' educational attainment both in integrated areas and non-integrated areas.

CONCLUSIONS

The medical insurance integration system in China is still at the exploratory stage; hence, its effects are of limited significance, even though the positive impact of this system on low-income residents is confirmed. Moreover, catastrophic health expenditure is associated with pro-poor inequality. Medical insurance, urban-rural disparities, the elderly population, and use of health services significantly affect the equity of catastrophic health expenditure incidence and are key issues in the implementation of future insurance integration policies.

The catastrophic and impoverishing effects of out-of-pocket healthcare payments in Kenya, 2018

Introduction

Progress towards effective service coverage and financial protection-the two dimensions of Universal Health Coverage (UHC)-has been limited in Kenya in the last decade. The government of Kenya has embarked on a highly ambitious reform programme currently being piloted in four Kenyan counties and aiming at national rollout by 2022. This study provides an updated assessment of the performance of the Kenyan health system in terms of financial protection allowing to monitor trends over time. In light of the UHC initiative, the study provides a baseline to assess the impact of the UHC pilot programme and inform scale-up plans. It also investigates household characteristics associated with catastrophic payments.

Methods

Using data from the Kenya Household Health Expenditure and Utilization Survey (KHHEUS) 2018, we investigated the incidence and intensity of catastrophic and impoverishing health expenditure. We used a logistic regression analysis to assess households' characteristics associated with the probability of incurring catastrophic health expenditures.

Results

The results show that the incidence of catastrophic payments is more severe for the poorest households and in the rural areas and mainly due to outpatient services. Results for the impoverishing effect suggest that after accounting for out-of-pocket(OOP) payments, the proportion of poor people increases by 2.2 percentage points in both rural and urban areas. Thus, between 1 and 1.1 million individuals are pushed into poverty due to OOP payments. Among the characteristics associated with the probability of incurring OOP expenditures, socioeconomic conditions, the presence of elderly and of people affected by chronic conditions showed significant results.

Conclusion

Kenya is still lagging behind in terms of protecting its citizens against financial risks associated with ill health and healthcare seeking behaviour. More effort is needed to protect the most vulnerable population groups from the high costs of illness.

The catastrophic and impoverishing effects of out-of-pocket healthcare payments in Kenya, 2018

INTRODUCTION

Progress towards effective service coverage and financial protection-the two dimensions of Universal Health Coverage (UHC)-has been limited in Kenya in the last decade. The government of Kenya has embarked on a highly ambitious reform programme currently being piloted in four Kenyan counties and aiming at national rollout by 2022. This study provides an updated assessment of the performance of the Kenyan health system in terms of financial protection allowing to monitor trends over time. In light of the UHC initiative, the study provides a baseline to assess the impact of the UHC pilot programme and inform scale-up plans. It also investigates household characteristics associated with catastrophic payments.

METHODS

Using data from the Kenya Household Health Expenditure and Utilization Survey (KHHEUS) 2018, we investigated the incidence and intensity of catastrophic and impoverishing health expenditure. We used a logistic regression analysis to assess households' characteristics associated with the probability of incurring catastrophic health expenditures.

RESULTS

The results show that the incidence of catastrophic payments is more severe for the poorest households and in the rural areas and mainly due to outpatient services. Results for the impoverishing effect suggest that after accounting for out-of-pocket(OOP) payments, the proportion of poor people increases by 2.2 percentage points in both rural and urban areas. Thus, between 1 and 1.1 million individuals are pushed into poverty due to OOP payments. Among the characteristics associated with the probability of incurring OOP expenditures, socioeconomic conditions, the presence of elderly and of people affected by chronic conditions showed significant results.

CONCLUSION

Kenya is still lagging behind in terms of protecting its citizens against financial risks associated with ill health and healthcare seeking behaviour. More effort is needed to protect the most vulnerable population groups from the high costs of illness.

Dental expenditure and catastrophic dental expenditure in Eastern Saudi Arabia: Pattern and associated factors

Background

Dental services have one of the highest expenses among health services. The aims of the study were to assess (1) dental expenditure (DE), (2) catastrophic dental expenditure (CDE), (3) dental services payment and (4) factors associated with DE and CDE.

Material and Methods

A cross sectional study was conducted in 2018 in Saudi Arabia. Using convenience sample, participants were recruited from governmental and private dental clinics/hospitals. A questionnaire assessed (a) personal information, (b) dental background: payment methods, type of clinics visited, perceived oral health status, frequency of pain and (c) payment for dental services received. The number of remaining teeth was clinically assessed. Two outcome variables were assessed (1) total DE in linear regression and (b) CDE (DE exceeds 10% of income) in logistic regression. Personal and dental background variables were explanatory variables.

Results

The response rate was 83.8% (419/500) with 43% reporting expenditure, 16.5% facing CDE and 36.3% using multiple payment methods. The greatest DE was for crowns and bridges, root canal therapy, fillings and implants. Income, payment method and pain were associated with DE and CDE.

Conclusions

Participants used multiple payment methods including out of pocket and faced CDE. The bulk of expenditure was for rehabilitative services. The availability and quality of health-insured primary care services may reduce the financial burden facing dental patients.

Key words:Health expenditure, Saudi Arabia, dental care, insurance, dental, universal health insurance.