Evolution of catastrophic health expenditure in a high income country: incidence versus inequalities

Long-term care needs and the risk of household poverty across Europe: a comparative secondary data study

PURPOSE

Population ageing and rising poverty are two of the most pressing issues today, even in Western European nations, growing as a result of the recent global economic crisis and the COVID-19 containment measures. This study explores the relationship between long-term care (LTC) needs and risk of poverty at household level in eight European countries, representing the different European care regimes.

METHODS

The main international databases were scoured for study variables, categorized according to the following conceptual areas: home care, residential care, health expenditure, service coverage, cash benefits, private services, population, family, education, employment, poverty, disability and care recipients, and life expectancy. We initially identified 104 variables regarding 8 different countries (Austria, Finland, Germany, the Netherlands, Italy, Spain, Poland, Romania). Statistical analyses were conducted as described hereafter: analysis of the Pearson's Bivariate Correlation between the dependent variable and all other variables; a Multivariable Linear Regression Model between the Poverty Index (dependent variable) and the covariates identified in the preceding step; a check for geographical clustering effects and a reduced Multivariable Linear Regression Model for each identified European cluster.

RESULTS

The variables that addressed the risk of poverty pertained to the area of policy intervention and service provision. Rising private out-of-pocket health expenditures and proportion of "poor" couples with at least one child are two factors that contributed significantly to poverty increasing. Moreover, rising private out-of-pocket health expenditures for covering LTC needs (even in presence of public financial contribution to the family) is the main contributor to household poverty increasing in presence of ADL disability.

CONCLUSION

The results reveal the existence of a clear correlation between the need for LTC and the risk of poverty in households across Europe. These results highlight the central relevance of LTC policies, which are often still treated as marginal and sectoral, for the future sustainability of integrated care strategies.

Measuring the value of solidarity: The abem financial assistance program for out-of-pocket payments on pharmacy medicines in Portugal

OBJECTIVE

Out-of-pocket payments for prescribed medicines are still comparatively high in Portugal. The abem program was launched in Portugal in May 2016 to aid vulnerable groups by completely covering out-of-pocket costs of prescribed medicines in community pharmacies. This study assesses the impact of the program on poverty and catastrophic health expenditures.

METHODS

A longitudinal study was carried out with the analysis of several program databases (from the beginning of the program in May 2016 to September 2018) covering the cohorts of beneficiaries, daily data on medicines dispensed, social referencing entities, and solidarity pharmacies. The study provides estimates of standard poverty measures (intensity and severity) as well as the incidence of catastrophic health expenditures.

RESULTS

More than 6000 beneficiaries were supported (56.8% female, 34.7% aged 65 or over), encompassing 127,510 medicines (mainly nervous system and cardiovascular system) with an average 26.9% co-payment (payments totalling €1.5 million). The program achieved substantial reductions in poverty (3.4% in intensity, 5.6% in severity), and eliminated cases with catastrophic health expenditures in medicines that would have affected 7.5% of the beneficiaries.

CONCLUSIONS

Findings confirm a continuous increase in the number of beneficiaries, enabling access to medicines especially for the vulnerable elderly, and a sizable impact on eliminating out-of-pocket payments for medicines in the target population.

Has South Korea achieved the goals of national health insurance? Trends in financial protection of households between 2011 and 2018

This study aims to investigate the evolution of financial protection of households against OOP in South Korea, where subsequent policies of expanding benefit coverage have been implemented primarily focusing on several severe diseases, by measuring catastrophic healthcare expenditure (CHE) and the characteristics of households vulnerable to CHE. Using the Korea Health Panel 2011-2018, this study analyzed CHE trends by the targeted severe diseases and other health problems and household income and examined the determinants of CHE using binary logistic regression. Our findings showed that CHE decreased in households with the targeted severe diseases but increased in households experiencing hospitalization that were not related to the targeted diseases, which appeared to have a significantly higher likelihood of CHE in 2018 than households with the targeted severe diseases. In addition, CHE was more prevalent and increased or remained stagnant among households whose heads had health problems than others. Inequalities in CHE also increased, showing increased Concentration Index (CI) and increased incidences of CHE in the lower income quartile during the study period. These results suggest that the current policies are insufficient to achieve its financial protection goals against healthcare expenditure in South Korea. In particular, benefit expansions targeting a specific disease may cause inequitable distribution of resources and may not enhance protection against households' financial burden.

Access for those who want or for those who can? Equity in the use of doctor's appointments in Portugal based on the HIS 2019

Horizontal equity in the use of healthcare implies equal use for equal needs, regardless of other factors - be they predisposing or enabling (Andersen's model). This study aimed to assess equity in the use of doctor's appointments in Portugal in 2019, comparing the results with those obtained in a previous study, based on data from 2014. Data were retrieved from the Health Interview Survey 2019 (HIS 2019). Healthcare is measured by the number of doctor's appointments. Our study adopted the Negative Binomial Model to assess the factors affecting use. The concentration index was calculated to quantify income-related inequality/inequity. Compared to 2014, the effects of self-assessed health, limitations in daily living activities, and longstanding illnesses are more pronounced, and the region, income, household type and marital status are significant for appointments scheduled with a General Practitioner. In the case of appointments with specialists, health insurance lost statistical significance and the effect of education dropped; however, income became significant. The inequity index is not significant for appointments scheduled with a General Practitioner, as in 2014, but the (significant) value of this index increased for appointments with other specialists.

Access for those who want or for those who can? Equity in the use of doctor’s appointments in Portugal based on the HIS 2019

Abstract Horizontal equity in the use of healthcare implies equal use for equal needs, regardless of other factors - be they predisposing or enabling (Andersen’s model). This study aimed to assess equity in the use of doctor’s appointments in Portugal in 2019, comparing the results with those obtained in a previous study, based on data from 2014. Data were retrieved from the Health Interview Survey 2019 (HIS 2019). Healthcare is measured by the number of doctor’s appointments. Our study adopted the Negative Binomial Model to assess the factors affecting use. The concentration index was calculated to quantify income-related inequality/inequity. Compared to 2014, the effects of self-assessed health, limitations in daily living activities, and longstanding illnesses are more pronounced, and the region, income, household type and marital status are significant for appointments scheduled with a General Practitioner. In the case of appointments with specialists, health insurance lost statistical significance and the effect of education dropped; however, income became significant. The inequity index is not significant for appointments scheduled with a General Practitioner, as in 2014, but the (significant) value of this index increased for appointments with other specialists.

Financial Risk Protection and Unmet Healthcare Need in Russia

BACKGROUND

Achieving universal health coverage (UHC) includes financial risk protection. To date, catastrophic healthcare expenditure (CHE), the impoverishing effect of out-of-pocket (OOP) healthcare payments, and unmet healthcare need are the most widely used indicators for assessing the financial risk protection of a healthcare system. This study aimed to estimate the Russian healthcare system's financial risk protection by focusing on CHE, OOP and unmet healthcare need.

METHODS

The study used eight waves of the Russia Longitudinal Monitoring Survey (RLMS) (2010-2017) to analyze the financial risk protection of the Russian healthcare system. Commonly used indicators - CHE, both incidence and intensity, the impoverishing effect of CHE and unmet need -were used.

RESULTS

We found low incidence and intensity of CHE in the Russian Federation. Our results are robust to various definitions of CHE (eg, as a share of total household expenditure or total household income). Furthermore, the impoverishing effect of OOP healthcare payments remains limited, despite the most recent economic slowdown (2014- 2016). This could be explained by a noticeable reduction in CHE during the crisis years, as postponing healthcare was adopted as a coping mechanism, particularly among households heavily affected by the crisis.

CONCLUSION

As stressed by the UHC framework, our findings suggest that CHE only partly captures inefficiencies and inequities in coverage, because one tenth of households forwent medical care for medicines and certain services. As spending on medicines and dental care are the main drivers of CHE, policy interventions should focus on extending coverage for pharmaceutical and dental care and target financial barriers to seeking care, particularly for the poor and vulnerable.

What Policy Approaches Were Effective in Reducing Catastrophic Health Expenditure? A Systematic Review of Studies from Multiple Countries

BACKGROUND

The United Nations set a goal for universal health coverage in all countries by 2030 and selected the catastrophic health expenditure (CHE) indicator as an assessment tool for this goal. Many countries have strived to reduce household CHE. However, no study has compared countries whose policies have had a remarkable effect on decreasing CHE. Therefore, the purpose of this systematic literature review is to find appropriate methods for measuring CHE that can help us to analyze the impact of health policies and identify countries whose health policies are most effective in reducing CHE.

METHOD

PubMed and Web of Science were searched. Studies that measured the incidence or intensity of CHE in multiple years were included. Two independent reviewers screened the literature, extracted the data, and analyzed the studies selected. Thirty-eight studies met the inclusion criteria for the review. We classified the selected research papers to random sampling and quasi-experimental studies.

RESULTS

We graphically presented the results of CHE incidence and intensity rates reported in the collected papers as a time series data set. Since most studies did not use sample weights, it was not easy to confirm whether the time series changes of CHE are significant. Therefore, we could find only two countries that had policy effects. Both countries established policies that focus on the poor.

CONCLUSION

There are so many studies that analyze CHE, but policies that are effective in reducing CHE are unknown. This study uses a systematic literature review methodology to determine effective policies by comparing CHE time series trends among countries. As a policy implication, it was found that because CHE is defined as the ratio of the ability to pay to medical expenses, a policy of differential medical expenses that is based on income level is effective.

Catastrophic health expenditure in sub-Saharan Africa: systematic review and meta-analysis

Objective

To estimate the incidence of, and trends in, catastrophic health expenditure in sub-Saharan Africa.

Methods

We systematically reviewed the scientific and grey literature to identify population-based studies on catastrophic health expenditure in sub-Saharan Africa published between 2000 and 2021. We performed a meta-analysis using two definitions of catastrophic health expenditure: 10% of total household expenditure and 40% of household non-food expenditure. The results of individual studies were pooled by pairwise meta-analysis using the random-effects model.

Findings

We identified 111 publications covering a total of 1 040 620 households across 31 sub-Saharan African countries. Overall, the pooled annual incidence of catastrophic health expenditure was 16.5% (95% confidence interval, CI: 12.9-20.4; 50 datapoints; 462 151 households; I ² = 99.9%) for a threshold of 10% of total household expenditure and 8.7% (95% CI: 7.2-10.3; 84 datapoints; 795 355 households; I ² = 99.8%) for a threshold of 40% of household non-food expenditure. Countries in central and southern sub-Saharan Africa had the highest and lowest incidence, respectively. A trend analysis found that, after initially declining in the 2000s, the incidence of catastrophic health expenditure in sub-Saharan Africa increased between 2010 and 2020. The incidence among people affected by specific diseases, such as noncommunicable diseases, HIV/AIDS and tuberculosis, was generally higher.

Conclusion

Although data on catastrophic health expenditure for some countries were sparse, the data available suggest that a non-negligible share of households in sub-Saharan Africa experienced catastrophic expenditure when accessing health-care services. Stronger financial protection measures are needed.

Financial Burden of Medical Care, Dental Care, and Medicines among Older-Aged Population in Slovenia, Serbia, and Croatia

The aim was to explore the factors associated with the financial burden (FB) of medical care, dental care, and medicines among older-aged people in Slovenia, Serbia, and Croatia using EU-SILC 2017. The highest frequency of FB of medical care and medicines was in Croatia (50% and 69.1%, respectively) and of dental care in Slovenia (48.5%). The multivariate logistic regression analysis with FB as an outcome variable showed that the FB of medical care was associated with being married (OR: 1.54), reporting not severe (OR: 1.51) and severe limitations in daily activities (OR: 2.05), having higher education (OR: 2.03), and heavy burden of housing costs (OR: 0.51) in Slovenia, with very bad self-perceived health (OR: 5.23), having the slight (OR: 0.69) or heavy (OR: 0.47) burden of housing costs, making ends meet fairly easily or with some difficulty (OR: 3.58) or with difficulty or great difficulty (OR: 6.80) in Serbia, and with being married (OR: 1.43), having heavy burden of housing costs (OR: 0.62), and making ends meet fairly easily or with some difficulty (OR: 2.08) or with difficulty or great difficulty (OR: 2.52) in Croatia. The older-aged have the FB of healthcare, especially the poorest or those with health problems.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Trend and status of out-of-pocket payments for healthcare in Iran: equity and catastrophic effect

Background

Equity in the distribution of health care resources and mitigating the risk of out-of-pocket (OOP) catastrophic healthcare expenditures (CHE) are the major objectives of the health system of a country. This study aims to measure equity in OOP payments for healthcare and the incidence of CHE among Iranian households over time.

Methods

This retrospective cross-sectional study utilized data extracted from the household income and expenditure survey (HIES) of Iran, collected by the Statistical Center of Iran. The analysis included a total of 174,341 households’ five yearly data of 6 years starting from 1991 to 2017. Kakwani progressivity index (KPI) was used to measure the equity in OOP payment for each year and examine the households’ incidence of CHE at 20%, 30%, and 40% of their capacities to pay (CTP). The trend series regression analysis was used to examine the trend in the KPI and the incidence of the CHE over time.

Results

The findings indicated that the households’ expenditure on health out of their monthly budgets for the years 1991 and 2017 were 2.1% and 10.1%, respectively. The KPI for the OOP payment was negative for all 6-year observations (1991 = − 0.680; 1996 = − 0.608; 2001 = − 0.554; 2006 = − 0.265; 2011 = − 0.225, and 2017 = − 0.207), indicating that the OOP payments for healthcare are regressive and more concentrated among the socioeconomically disadvantaged households. There was a statistically significant (p = 0.003) increase in the KPI (i.e., decline in the regressivity) over time. The incidence of the CHE (1.12, 1.93, and 3.71%) in 1991 at the CTP levels of 20%, 30%, and 40% was lower than the incidence at the corresponding levels of CTP (5.26, 10.88, and 22.16) in 2017. The findings of the time-series regression indicated a statistically significant (p < 0.05) increase in the incidence of the CHE at the 20%, 30%, and 40% levels of the households’ CTP.

Conclusions

The current study demonstrated that OOP payment as a source of healthcare funding in Iran is inequitable. While the use of interventions such as the prepaid and publicly funded programs may contribute to the reduction of CHE and improvement of equity in healthcare financing, further inequality analyses in the incidence of the CHE among households and its main determinants can contribute to evidence-informed planning to reduce the CHE in the context.