Catastrophic Health Care Expenditure among Older People with Chronic Diseases in 15 European Countries

Incidence and intensity of catastrophic health expenditure and impoverishment among the elderly: an empirical evidence from India

World health statistics (2022) report that about 1.4 billion people have incurred catastrophic health expenditure (CHE), and half of its population have pushed into extreme poverty due to healthcare payments. The elderly population faces a higher risk of ill health, and seeking treatment reflects in high out-of-pocket health spending (OOPHS) that results in CHE and further impoverishment. This study aims to investigate the incidence and intensity of OOPHS, CHE, and impoverishment among the older adults in India. Data utilizes from the 75th round of the national sample survey (NSS) based on household social consumption: health (schedule 25.0), 2018. The incidence and intensity of CHE and impoverishment among older adults in India estimated by using standard measures. The older adults spend about 17.4% of household consumption expenditure on healthcare services. The poorest older adults are spending the highest share of consumption expenditure (24.8%) on healthcare among economic quantiles. Similarly, the elderly from rural (20.3%), male (18.4%), scheduled castes (21.5%), and Hinduism (17.9%) show a larger share of consumption expenditure on healthcare services. The incidence and intensity of CHE among older adults are 46.5% and 16.1% at 10% threshold level of household consumption expenditure, respectively. However, as the threshold level rises the incidence and intensity of CHE decline. The estimates of normalized poverty gap using the poverty line of Tendulkar committee as well as Rangarajan committee show that the intensity of impoverishment among older adults are 56.4% and 57.9% respectively, which is quite high. Financial protection along with vision might mitigate the risk of CHE and impoverishment among older adults in India.

Households catastrophic health expenditure among older people with noncommunicable diseases: A cross-sectional study from Iran

Background and Aims

Noncommunicable diseases are one of the main difficulties faced by older adults in many countries. The study aimed to investigate the households' catastrophic health expenditure (CHE) among older people with noncommunicable diseases.

Methods

This cross-sectional study was conducted between October and December 2022 in Semnan, Iran, with the participation of 400 older individuals suffering from diabetes and hypertension. The Content Validity Ratio (which is calculated based on necessity criterion) and Content Validity Index (which calculated based on relevance, transparency, and simplicity criteria) values of 0.94 and 0.89, respectively, confirmed the content validity of the researcher-made questionnaire. The occurrence of CHE was estimated using the World Health Organization's rule of "allocating at least 40% of non-food household costs to healthcare." Due to the qualitative nature of the data, the χ 2 test was utilized to assess the statistical association between demographic and background variables and occurrence of CHE.

Results

Older people with diabetes and hypertension had an annual direct medical costs of $821 averagely, which includes 9.7% for diagnosis, 23.9% for doctor visits, and 66.4% for treatment. Direct medical costs account for around 0.26 of nonfood costs, with 12.5% of seniors facing high medical charges. Age, marital status, type of basic health insurance, diabetes, the time elapsed since initial diabetes diagnosis, the severity of diabetes complications, and the development of diabetes-related visual impairments, are associated with CHE (p < 0.05).

Conclusion

While the prevalence of CHE among elderly individuals with diabetes and hypertension is reasonably manageable, targeted promotional efforts are still necessary to protect those at high risk.

Increase of catastrophic and impoverishing health expenditures in Mexico associated to policy changes and the COVID-19 pandemic

Background

In 2003, the Mexican Congress approved a major reform to provide health care services to the poor population through the public insurance scheme Seguro Popular. This program was dismantled in 2019 as part of a set of health system reforms and substituted with the Health Institute for Welfare (INSABI). These changes were implemented during the initial phases of the coronavirus (COVID-19) pandemic. We aimed to examine the impact of these reforms and the COVID-19 pandemic on financial risk protection in Mexico between 2018 and 2020.

Methods

We performed a population-based analysis using cross-sectional data from the 2018 and 2020 rounds of the National Household Income and Expenditures Survey. We used a pooled fixed-effects multivariable two-stage probit model to determine the likelihood of catastrophic health expenditure (CHE), impoverishing health expenditure (IHE), and excessive health expenditure (EHE) among Mexican households. We also mapped the quintiles of changes in EHE in households without health insurance by state.

Results

The percentage of households without health insurance almost doubled from 8.8% (three million households) in 2018 to 16.5% (5.8 million households) in 2020. We also found large increases in the proportion of households incurring in CHE (18.4%; 95% confidence interval (CI) = 6.1, 30.7) and EHE (18.7%; 95% CI = 7.9, 29.5). Significant increases in CHE, IHE, and EHE were only observed among households without health insurance (CHE: 90.7%; 95% CI = 31.6, 149.7, EHE: 73.5%; 95% CI = 25.3, 121.8). Virtually all Mexican states (n/N = 31/32) registered an increase in EHE among households without health insurance. This increase has a systematic territorial component affecting mostly central and southern states (range = -1.0% to 194.4%).

Conclusions

The discontinuation of the Seguro Popular Program and its substitution with INSABI during the first stages of the COVID-19 pandemic reduced the levels of health care coverage in Mexico. This reduction and the pandemic increased out-of-pocket expenditure in health and the portion of CHE and EHE in the 2018-2020 period. The effect was higher in households without health insurance and households in central and southern states of the country. Further studies are needed to determine the specific effect both of recent policy changes and of the COVID-19 pandemic on the levels of financial protection in health in Mexico.

Catastrophic health care spending in managing type 2 diabetes before and during the COVID-19 pandemic in Tanzania

COVID-19 disrupted health care provision and access and reduced household income. Households with chronically ill patients are more vulnerable to these effects as they access routine health care. Yet, a few studies have analysed the effect of COVID-19 on household income, health care access costs, and financial catastrophe due to health care among patients with type 2 diabetes (T2D), especially in developing countries. This study fills that knowledge gap. We used data from a cross-sectional survey of 500 people with T2D, who were adults diagnosed with T2D before COVID-19 in Tanzania (March 2020). Data were collected in February 2022, reflecting the experience before and during COVID-19. During COVID-19, household income decreased on average by 16.6%, while health care costs decreased by 0.8% and transport costs increased by 10.6%. The overall financing burden for health care and transport relative to household income increased by 32.1% and 45%, respectively. The incidences of catastrophic spending above 10% of household income increased by 10% (due to health care costs) and by 55% (due to transport costs). The incidences of catastrophic spending due to health care costs were higher than transport costs, but the relative increase was higher for transport than health care costs (10% vs. 55% change from pre-COVID-19). The likelihood of incurring catastrophic health spending was lower among better educated patients, with health insurance, and from better-off households. COVID-19 was associated with reduced household income, increased transport costs, increased financing burden and financial catastrophe among patients with T2D in Tanzania. Policymakers need to ensure financial risk protection by expanding health insurance coverage and removing user fees, particularly for people with chronic illnesses. Efforts are also needed to reduce transport costs by investing more in primary health facilities to offer quality services closer to the population and engaging multiple sectors, including infrastructure and transportation.

Relationship between the Prevalence of Metabolic Disease and Impaired Mobility, Diet, Physical Activity, and Socio-Demographic Characteristics in the Polish Elderly-A Cross-Sectional Study

Maintaining good health for as long as possible presents a great challenge for the elderly. As the elderly population is growing, there is an ongoing need to identify health risk factors affecting older individuals. The study aimed to explore relationships between sociodemographic characteristics, diet, physical activity, and prevalence of metabolic diseases and impaired mobility in the Polish elderly. A cross-sectional study was carried out on 417 elderlies in May-July 2021. Cluster analysis was applied to separate four homogeneous clusters based on the prevalence of metabolic disease and impaired mobility. Logistic regression analysis was used to verify associations between variables. Being overweight or having obesity, as well as following a diet, increased the probability of being affected by metabolic disease. Being well educated, having a better financial situation, positive perception of own health, and having at least moderate physical activity decreased the probability of suffering from mobility impairments. Eating behaviors were not found to be predictors of the disease. However, they differentiated the selected clusters. The results confirmed the heterogeneity of factors that may impact healthy aging. Thus, they should be taken into account by public health authorities to develop health promotion actions adjusted to the needs of specific subgroups.

Catastrophic health expenditure on chronic non-communicable diseases among elder population: A cross-sectional study from a sub-metropolitan city of Eastern Nepal

INTRODUCTION

This study was conducted with the objective to analyze the out-of-pocket (OOP) healthcare expenditure and catastrophic healthcare expenditure (CHE) on chronic non-communicable diseases (CNCD) among the elderly population, and the association of CHE on CNCD with associated factors among the same population.

MATERIALS AND METHODS

We collected data from the elderly population of Dharan Sub-metropolitan city of the Eastern Nepal via door-to-door survey and face-to-face interview. The ten wards out of twenty were chosen by lottery method, and the equal proportion out of 280 samples was purposively chosen from each of ten wards (28 participants from each selected ward). The data were entered in Microsoft Excel 2019 v16.0 and statistical analysis was performed by using statistical package for social sciences, IBM SPSS® v21. The chi-square test was used to test the group differences. Multivariable logistic regression was used to determine independent factors associated with CHE (all variables with P < 0.20), and adjusted odds ratios (AOR) were calculated at 95% confidence interval (CI).

RESULTS

The median household, food and health expenditures were 95325 (72112.50-126262.50), 45000 (33000-60000) and 2100 (885.00-6107.50) NPR respectively. The proportion of the participants with CHE was 14.6%. The single living participants had 3.4 times higher odds of catastrophic health expenditure (AOR = 3.4, 95% CI = 1.2-9.6, P-value = 0.022) than those who are married. Similarly, those who had cancer had 0.1 times lower odds of CHE (AOR = 0.1, 95% CI = 0.0-0.2, P-value = <0.001) than those without cancer.

CONCLUSION

The elder population had significant financial health shocks due to chronic health ailments. There should be the provision of mandatory health insurance programmes for elderly to cut down the catastrophic healthcare expenditure. Similarly, there should be the provision of exemption scheme for vulnerable elderly who are more likely to face catastrophic expenditure from all available health facilities.

Household financial burden associated with healthcare for older people in Viet Nam: a cross-sectional survey

BACKGROUND

Population ageing and the associated increase in the healthcare needs of older people are putting pressure on the healthcare system in Viet Nam. The country prioritizes healthcare for older people and has developed financial protection policies to mitigate financial hardship due to out-of-pocket health expenditures (OOPHEs) borne by their households. This study examines the level and determinants of the financial burden of OOPHE among households with people aged ≥ 60 years in Viet Nam.

METHODS

A cross-sectional household survey was conducted among a sample of 1536 older people living in 1477 households in three provinces representing the North, Central and South regions of Viet Nam during 2019-2020. The financial outcomes were catastrophic health expenditure (CHE), using WHO's definition, and financial distress due to OOPHE. Multivariate binary logistic regression analysis was employed to determine the factors associated with these outcomes.

RESULTS

OOPHE for older household members accounted for 86.3% of total household health expenditure. Of households with older people, 8.6% (127) faced CHE, and 12.2% (181) experienced financial distress due to OOPHE. Households were at a higher risk of incurring financial burdens related to health expenditures if they had fewer household members; included only older people; were in rural or remote, mountainous areas; and had older members with noncommunicable diseases. There was no significant association between health insurance coverage and financial burden. However, when older people sought tertiary care or private care, the possibility of a household facing CHE increased. Regardless of the type and level of care, health service utilization by older people results in a higher likelihood of a household encountering financial distress.

CONCLUSIONS

This study reveals that OOPHE for older people can impose substantial financial burdens on households, leading them to face CHE and financial distress. This study provides evidence to justify reforming financial protection policies and introducing policy interventions targeted at better protecting older people and their households from the financial consequences of OOPHE. There is also the need to strengthen the grassroots health facilities to provide primary care closer to home at lower costs, particularly for the management of noncommunicable diseases.

Comparison of catastrophic out-of-pocket medical expenditure among older adults in the United States and South Korea: what affects the apparent difference?

Background

Medical spending rises sharply with age. Even with universal health insurance, older adults may be at risk of catastrophic out-of-pocket medical spending. We aimed to compare catastrophic out-of-pocket medical spending among adults ages 65 and older in the United States, where seniors have near-universal coverage through Medicare, versus South Korea, where all residents have national health insurance.

Methods

We used the 2016 Health and Retirement Study and the Korean Longitudinal Study of Aging. The study population were adults ages 65 and over in the US (n = 9,909) and South Korea (n = 4,450; N = 14,359). The primary outcome of interest was older adults’ exposure to catastrophic out-of-pocket medical expenditure, defined as out-of-pocket medical spending over the past two years that exceeded 50% of annual household income. To examine the factors affecting catastrophic out-of-pocket medical spending of older adults in both countries, we performed logistic regression analyses. To compare the contribution of demographic factors versus health system-level factors to catastrophic out-of-pocket medical spending, we performed a Blinder-Oaxaca decomposition.

Results

The proportion of respondents with catastrophic out-of-pocket medical expenditure was 5.8% and 3.0% in the US and South Korea, respectively. A Blinder-Oaxaca decomposition showed that the difference in the rate of catastrophic out-of-pocket medical expenditure spending between the two countries was attributable largely to unobservable system-level factors, rather than observed differences in the sociodemographic characteristics.

Conclusions

Exposure to catastrophic out-of-pocket medical spending is considerably higher in the US than South Korea. Most of the difference can be attributed to unobserved health system-level factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08575-1.

Catastrophic Health Expenditure and Impoverishment from Non-Communicable Diseases: A comparison of Private and Public Health Facilities in Ekiti State, Southwest Nigeria

Background

Catastrophic health expenditure and impoverishment are the outcomes of poor financing mechanisms. Little is known about the prevalence and predictors of these outcomes among non-communicable disease patients in private and public health facilities.

Methods

A health facility-based comparative cross-sectional study was conducted among 360 patients with non-communicable diseases (180 per group) selected through multistage sampling. Data were collected with a semi-structured, interviewer-administered questionnaire and analyzed with IBM SPSS for Windows, Version 22.0. Two prevalences of catastrophic health expenditure were calculated utilizing both the World Bank (CHE1) and the WHO (CHE2) methodological thresholds.

Results

The prevalence of CHE1 (Private:42.2%, Public:21.7%, p<0.001) and CHE2 (Private:46.8%, Public:28.0%, p<0.001) were higher in private health facilities. However, there was no significant difference between the proportion of impoverishment (Private:24.3%, Public:30.9%, p=0.170). The identified predictors were occupation, number of complications and clinic visits for catastrophic health expenditure and socioeconomic status for impoverishment in private health facilities. Level of education, occupation, socioeconomic status, number of complications and alcohol predicted catastrophic health expenditure while the level of education, socioeconomic status and the number of admissions predicted impoverishment in public health facilities.

Conclusions

Catastrophic health expenditure and impoverishment were high among the patients, with the former more prevalent in private health facilities. Therefore, we recommend expanding the coverage and scope of national health insurance among these patients to provide them with financial risk protection. Identified predictors should be taken into account by the government and other stakeholders when designing policies to limit catastrophic health expenditure and impoverishment among them.

Catastrophic household expenditure associated with out-of-pocket payments for dental healthcare in Spain

OBJECTIVE

To estimate the prevalence of catastrophic health expenditure due to dental healthcare (CHED) in Spain, quantify its intensity and examine the related sociodemographic household characteristics.

METHODS

Data from the Spanish Household Budget Survey, which addresses more than 20,000 households each year for the period 2008-2015 were included, and the methodology proposed by Wagstaff and van Doorslaer was followed. The prevalence (number of households that devote more than a certain threshold of their income to such payments) and intensity (amount that exceeds a certain percentage of income) were estimated. Ordered logistic regression models were estimated to analyse the sociodemographic factors associated with the prevalence of catastrophic payments.

RESULTS

The prevalence and intensity remained stable during the period under analysis. In terms of prevalence, a mean proportion of 7.36% of the population dedicated, in terms of intensity, more than 10% of their resources to dental care payments [mean: €292.75 per year (SD €2144.14)] and 2.05% dedicated more than 40% [mean: €143.02 per year (SD €1726.42)]. This represents 36.32% and 51.34% (for the thresholds of 10% and 40%) of the total catastrophic expenditure derived from out-of-pocket payments for dental healthcare in Spain.

CONCLUSION

This study shows that a significant proportion of catastrophic healthcare payments correspond to dental services. Being male, aged over 40 years, unattached (single, separated, divorced or widowed), having a low level of education, a low household income, being unemployed and living in an urban area are all associated with a greater risk of CHED. This finding highlights the need to establish policies aimed at increasing dental care coverage to mitigate related financial burdens on a large part of the Spanish population.

Out of pocket payments and access to NCD medication in two regions in Albania

Objective

The financial burden from noncommunicable diseases (NCDs) is a threat worldwide, alleviated only when good social protection schemes are in place. Albeit the Government in Albania has committed to Universal Healthcare Coverage (UHC), Out-of-Pockets (OOPs) persist. Through this study, we aimed to assess the OOPs related to consultations, diagnostic tests, and medicine prescriptions as self-reported by people suffering from NCDs.

Methods

A household survey was conducted in two regions of Albania. The present analysis includes respondents who suffered from chronic health conditions and consulted a health care provider within the last 8 weeks (n = 898). Mixed logistic regression models with random intercepts at the level of communities were employed in order to assess the association of OOPs with age, gender, urban vs. rural residency, health insurance, marital status, barriers experienced, type of chronic condition(s) and region.

Results

Of those who consulted a provider, 95% also received a drug prescription. Among them, 94% were able to obtain all the drugs prescribed. Out-of-pocket payments occurred throughout the NCD treatment process; specifically, for consultation (36%), diagnostic tests (33%), and drugs purchased (88%). Drug expenditures accounted for 62% of all household expenditures. Respondents with health insurance were less likely to pay for consultation and drugs. The elderly (patients above 60 years old) were less likely to pay for consultations and tests. Those who lived in urban areas were less likely to pay for drugs and consultations. Patients encountering any form of barrier when seeking care had increased odds of OOPs for consultations (OR; 2.25 95%-CI; 1.57; 3.23) and tests (OR; 1.71 95%-CI; 1.19; 2.45).

Conclusion

Out-of-pocket payments by NCD patients principally made up through the purchase of prescribed drugs, remain important. Tackling the high costs of drugs will be important to accelerate the UHC agenda. Here, it is important to raise the population’s awareness on patients’ knowledge of their entitlements to health insurance, and on the current health reforms.

Health insurance status and its determinants among patients with type 2 diabetes mellitus in a tertiary teaching hospital in Malaysia

Introduction

Even in a country with a tax-based healthcare financing system, health insurance can play an important role, especially in the management of chronic diseases with high disease and economic burden such as Type 2 Diabetes Mellitus (T2DM). The insurance coverage among T2DM patients in Malaysia is currently unclear. The aim of this study was to determine the insurance status of T2DM patients in public and private healthcare facilities in Malaysia, and the association between this status and patients’ sociodemographic and economic factors.

Methods

A cross-sectional study among T2DM patients seeking inpatient or outpatient treatment at a public tertiary hospital (Hospital Canselor Tuanku Muhriz) and a private tertiary hospital (Universiti Kebangsaan Malaysia Specialist Centre) in Kuala Lumpur between August 2019 and March 2020. Patients were identified via convenience sampling using a self-administered questionnaire. Data collection focused on identifying insurance status as the dependent factor while the independent factors were the patients’ sociodemographic characteristics and economic factors.

Results

Of 400 T2DM patients, 313 responded (response rate, 78.3%) and 76.0% were uninsured. About 69.6% of the respondents had low monthly incomes of <RM5000. Two-thirds of participants (59.1%) spent RM100–500 for outpatient visits whilst 58.5% spent <RM100 on medicines per month (RM1 = USD0.244). Patients who visited a private facility had five times more likely to have insurance than patients who visited a public facility. Participants aged 18–49 years with higher education levels were 4.8 times more likely to be insured than participants aged ≥50 years with low education levels (2 times).

Conclusions

The majority of T2DM patients were uninsured. The main factors determining health insurance status were public facilities, age of ≥ 50 years, low education level, unemployment, and monthly expenditure on medicines.

Financial difficulties in breast cancer survivors with and without migration background in Germany-results from the prospective multicentre cohort study BRENDA II

Purpose

We aimed to explore the trajectory of financial difficulties among breast cancer survivors in the German health system and its association with migration background.

Methods

In a multicentre prospective study, breast cancer survivors were approached four times (before surgery, before and after adjuvant therapy, five years after surgery) and asked about their migration history and financial difficulties.

Migrants were defined as born/resided outside Germany or having citizenship/nationality other than German. Financial difficulties were ascertained with the financial difficulties item of the European Organisation for Research and Treatment of Cancer Core Instrument (EORTC QLQ-C30) at each time-point (cut-off > 17). Financial difficulties were classified in trajectories: always (every time-point), never (no time-point), initial (first, not fourth), delayed (only fourth), and acquired (second and/or third, not first).

A logistic regression was conducted with the trajectories of financial difficulties as outcome and migration background as exposure. Age, trends in partnership status, and educational level were considered as confounders.

Results

Of the 363 participants included, 49% reported financial difficulties at at least one time-point.

Financial difficulties were reported always by 7% of the participants, initially by 5%, delayed by 10%, and acquired by 21%.

Migrants were almost four times more likely to report delayed (odds ratio [OR] = 3.7; 95% confidence interval [CI] 1.3, 10.5) or acquired (OR = 3.6; 95% CI 1.6, 8.4) financial difficulties compared to non-migrant participants.

Conclusion

Survivors with a migration background are more likely to suffer from financial difficulties, especially in later stages of the follow-up. A linguistically/culturally competent active enquiry about financial difficulties and information material regarding supporting services/insurances should be considered.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-022-07074-7.

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.

"Ready for the future?" - Status of national and cross-country horizon scanning systems for medicines in European countries

Background: Horizon scanning aims to systematically identify upcoming health technologies and thus allows policy-makers to be better prepared for the entry of new medicines with possibly high price tags into the national health system. The aim of this study is to survey the existence of national and cross-national horizon scanning systems for medicines in European countries.

Methods: Experts working in public authorities (members of the Pharmaceutical Pricing and Reimbursement Information/PPRI network) in the WHO European region participated in surveys in 2014 and 2019 and informed about the status of horizon scanning in their country (response rate: 14 and 44 countries, respectively). Identified advanced horizon scanning systems as of 2019 were further investigated based on a literature review.

Results: In 2019, six countries (Iceland, Italy, the Netherlands, Norway, Sweden, United Kingdom) reported systematic use of horizon scanning for some new medicines, and four countries (Austria, Denmark, France, Ireland) had some horizon scanning activities ongoing. No systematic use of horizon scanning was reported from the remaining 34 countries. The findings of the survey undertaken five years earlier were similar, with even fewer systems in place. A recent development is the establishment of cross-country initiatives of governments that aim, among others, to jointly perform horizon scanning; the International Horizon Scanning Initiative (IHSI) initiated by the Beneluxa collaboration is the most advanced undertaking in this respect. Countries with systematic use tend to have horizon scanning fully integrated in a system for the management of new medicines, and they use horizon scanning outcomes to inform decisions as to whether or not a Health Technology Assessment will be conducted and price negotiations be started. Differences between existing horizon scanning systems mainly concern the timings of scanning and reporting, the sources for the inputs and the accessibility of the findings.

Conclusion: There appears to be a discrepancy between the perceived importance of horizon scanning based on some eye-opening examples in the past and its actual implementation in European health systems. The latter is likely attributable to horizon scanning being resource-intensive. The establishment of new national and international horizon scanning systems offers the opportunity to investigate their impact on sustainable access to affordable medicines from the start.

Health Care Utilization and Out-of-Pocket Payments among Elderly with Cognitive Frailty in Malaysia

Background: Cognitive frailty (CF) as a potential risk factor for dementia, functional disability, poor quality of life, and mortality. The aim of this study was to explore the health care-related utilization and out-of-pocket (OOP) expenditures, sociodemographic characteristics, and comorbidities among elderly Malaysians with CF. Methods: A cross-sectional study targeting elderly Malaysian aged ≥65 years was conducted. The study included all participants of the fourth phase of the Malaysian representative Long-Term-Research-Grant-Scheme Towards-Useful-Aging (LRGS-TUA) community-based study. A structured and validated interview questionnaire was used. Results: In total, 1006 elderly were interviewed, with a 66.18% response rate. Only 730 respondents met the inclusion criteria. Of the eligible respondents, the CF prevalence was 4.5%. Around 60.6% of the participants with CF had utilized outpatient care at government clinics within the past 6 months. The estimated mean total OOP payments for CF during the past 6 months was 84 Malaysian Ringgit (RM) (SD 96.0). Conclusions: CF among elderly Malaysians is within the internationally recognized range of prevalence. The OOP payments for seeking health care among CF elderly are not different from that of other elderly categories. There is a high possibility of underutilization of the health care services of CF cases while they are still needy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Sociodemographic and health factors associated with the risk of financial catastrophe when informal care for patients with haematological neoplasms is replaced by formal care

BACKGROUND

Cancer is one of the diseases with the highest incidence and mortality in the world, and one that requires greater care (formal and informal). At present, the traditional informal caregiver is disappearing. The objective is to analyse the sociodemographic and health factors associated with the possible catastrophic financial effect on households of replacing informal care by formal care for patients with blood cancer, during the different stages of treatment in Spain.

METHODS

A total of 139 patients with haematological neoplasm who underwent stem cell transplantation completed a longitudinal questionnaire during each of three treatment phases. Of this population, 88.49% received informal care. The households were classified into those where the replacement of informal care with formal care would impose a financial burden exceeding 40% of equivalent household income, versus those who would not suffer this consequence. Three logistic regression models (one for each treatment phase) were estimated and the corresponding marginal effects determined.

RESULTS

The factors associated with a higher probability of financial catastrophe were married marital status, low education level, fair to very poor self-perceived health status, the diagnosis of leukaemia in the pre-transplant and first-year post-transplant phases and of multiple myeloma disease in the final post-transplant phase.

CONCLUSIONS

These findings reveal the need to design social policies to meet the care needs of patients with blood cancer which at present are covered by informal care. Given the foreseeable elimination of this option, these families must be protected from the financial burden incurred from the use of privately-contracted assistance.

Catastrophic Health Expenditure Associated With Frailty in Community-Dwelling Chinese Older Adults: A Prospective Cohort Analysis

Background: Catastrophic health expenditure (CHE) represents a key indicator for excessive financial burden due to out-of-pocket (OOP) healthcare costs, which could push the household into poverty and is highly pronounced in households with members at an advanced age. Previous studies have been devoted to understanding the determinants for CHE, yet little evidence exists on its association with frailty, an important geriatric syndrome attracting growing recognition. We thus aim to examine the relationship between frailty and CHE and to explore whether this effect is moderated by socioeconomic-related factors. Methods: A total of 3,277 older adults were drawn from two waves (2011 and 2013) of the China Health and Retirement Longitudinal Study (CHARLS). CHE was defined when OOP healthcare expenditure exceeded a specific proportion of the capacity of the household to pay. Frailty was measured following the Fried Phenotype (FP) scale. Mixed-effects logistic regression models were employed to assess the longitudinal relationship between frailty and CHE, and stratification analyses were conducted to explore the moderation effect. Results: The incidence of CHE among Chinese community-dwelling older adults was 21.76% in 2011 and increased to 26.46% in 2013. Compared with non-frail individuals, prefrail or frail adults were associated with higher odds for CHE after controlling for age, gender, residence, education, marriage, income, health insurance, smoking, drinking, and comorbidity (prefrail: odds ratio (OR) = 1.32, 95%CI = 1.14-1.52; frail: OR = 1.67, 95%CI = 1.13-2.47). Three frailty components including weakness, exhaustion, and shrinking contributed to a significantly increased likelihood of CHE (all p < 0.05), while the other two components including slowness and inactivity showed a non-significant effect (all p > 0.05). Similar effects from frailty on CHE were observed across socioeconomic-related subgroups differentiated by gender, residence, education, household income, and social health insurance. Conclusions: Frailty is a significant predictor for CHE in China. Developing and implementing cost-effective strategies for the prevention and management of frailty is imperative to protect households from financial catastrophe.

Ten-Year Poverty Alleviation Effect of the Medical Insurance System on Families With Members Who Have a Non-communicable Disease: Evidence From Heilongjiang Province in China

Aims: Non-communicable diseases (NCD) drag the NCD patients' families to the abyss of poverty. Medical insurance due to weak control over medical expenses and low benefits levels, may have actually contributed to a higher burden of out-of-pocket payments. By making a multi-dimensional calculation on catastrophic health expenditure (CHE) in Heilongjiang Province over 10 years, it is significant to find the weak links in the implementation of medical insurance to achieve poverty alleviation.

Methods: A logistic regression was undertaken to predict the determinants of catastrophic health expenditure.

Results: The average CHE of households dropped from 18.9% in 2003 to 14.9% in 2013. 33.2% of the households with three or more NCD members suffered CHE in 2013, which was 7.2 times higher than the households without it (4.6%). The uninsured households with cardiovascular disease had CHE of 12.0%, which were nearly 10% points lower than insured households (20.4–22.4%). For Medical Insurance for Urban Employees Scheme enrolled households, the increasing number of NCD members raised the risk of impoverishment from 3.4 to 20.0% in 2003, and from 0.3 to 3.1% in 2008. Households with hospital in-patient members were at higher risk of CHE (OR: 3.10–3.56).

Conclusions: Healthcare needs and utilization are one of the most significant determinants of CHE. Households with NCD and in-patient members are most vulnerable groups of falling into a poverty trap. The targeting of the NCD groups, the poorest groups, uninsured groups need to be primary considerations in prioritizing services that are contained in medical insurance and poverty alleviation.

The out-of-pocket medication burden: Which health problems impact the Czech population aged 50+?

Adults 50-years-old and greater form the group most vulnerable to a high burden from payments for medication. These Czech older adults devote around 60% of out-of-pocket payments for medication, which might influence their consumption patterns and access to health care. This paper extends the empirical evidence of the out-of-pocket burden and catastrophic payments by addressing the consumption of medication among the Czech population aged 50 and higher. Data from the Survey of Health, Ageing and Retirement in Europe, wave 6, is used. A generalised linear model is applied for estimating the out-of-pocket medication burden; a binary logistic regression is used for the investigation of catastrophic medication expenditure. The results showed that medications for pain, joint pain/joint inflammation, anxiety and depression, heart diseases and high blood pressure are robust predictors for the medication burden and risk factors for catastrophic payments. Special attention should also be paid to medications for suppressing inflammation and sleep problems. Despite universal coverage in the Czech Republic, taking medications for specific health problems, especially those related to the nervous system, influences the well-being of older individuals. Policy makers should revise the prescription practice and related reimbursement policies and reconsider current protection from the high medication burden.

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.

Financial protection in health among the middle-aged and elderly: Evidence from the Greek economic recession

Since the late 2000s, the Greek economy has entered a long period of recession, with reforms and retrenchment in health care being among the main public policy priorities. This study investigates the extent to which financial protection in health has changed among older households during the Greek crisis. We focus on the middle-aged and elderly, the heavy users of health services, who have faced a substantial health and financial burden during the crisis. Our analysis shows that the headcount and overshoot of catastrophic health expenditure (CHE) substantially increased from 2007 to 2015, suggesting that financial protection has eroded to a great extent. Prior to the crisis, CHE was mainly due to inpatient care, followed by outpatient care and medicines. However, the contribution of spending for outpatient medicines to CHE substantially increased during the study period. The headcount of CHE rose across all socioeconomic groups we examined, with low-income households and households with chronic patients being disproportionately affected. In 2007, we do not report signs of socioeconomic inequalities in the risk of CHE. On the contrary, our results show that households of low socioeconomic status are more likely to incur CHE in 2015, revealing substantial inequalities in the risk of CHE. This finding raises significant distributional and equity concerns. Strengthening financial protection among older households is an imperative challenge for the Greek health system, and several policy responses need to be adopted towards this direction.

Urban-rural differences in catastrophic health expenditure among households with chronic non-communicable disease patients: evidence from China family panel studies

Background

The prevalence of chronic non-communicable diseases (NCDs) challenges the Chinese health system reform. Little is known for the differences in catastrophic health expenditure (CHE) between urban and rural households with NCD patients. This study aims to measure the differences above and quantify the contribution of each variable in explaining the urban-rural differences.

Methods

Unbalanced panel data were obtained from the China Family Panel Studies (CFPS) conducted between 2012 and 2018. The techniques of Fairlie nonlinear decomposition and Blinder-Oaxaca decomposition were employed to measure the contribution of each independent variable to the urban-rural differences.

Results

The CHE incidence and intensity of households with NCD patients were significantly higher in rural areas than in urban areas.

The urban-rural differences in CHE incidence increased from 8.07% in 2012 to 8.18% in 2018, while the urban-rural differences in CHE intensity decreased from 2.15% in 2012 to 2.05% in 2018. From 2012 to 2018, the disparity explained by household income and self-assessed health status of household head increased to some extent. During the same period, the contribution of education attainment to the urban-rural differences in CHE incidence decreased, while the contribution of education attainment to the urban-rural differences in CHE intensity increased slightly.

Conclusions

Compared with urban households with NCD patients, rural households with NCD patients had higher risk of incurring CHE and heavier economic burden of diseases. There was no substantial change in urban-rural inequality in the incidence and intensity of CHE in 2018 compared to 2012. Policy interventions should give priority to improving the household income, education attainment and health awareness of rural patients with NCDs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10887-6.

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

Background

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

Methods

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

Results

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

Conclusion

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

Does the medical insurance system play a real role in reducing catastrophic economic burden in elderly patients with cardiovascular disease in China? Implication for accurately targeting vulnerable characteristics

BACKGROUND

The vulnerability of cardiovascular disease (CVD) patients' health abilities, combined with the severity of the disease and the overlapping risk factors, leads such people to bear the economic burden of the disease due to the medical services. We estimated the economic burden of CVD and identified the weak link in the design of the medical insurance.

METHODS

Data from 5610 middle-aged and elderly with CVD were drawn from the 2015 wave of "China Health and Retirement Longitudinal Study" (CHARLS). The recommended method of the "World Health Organization" (WHO) was adopted to calculate "catastrophic health expenditure" (CHE), "impoverishment by medical expenses" (IME), and applied the treatment-effect model to analyze the determinants of CHE.

RESULTS

The incidence of CHE was 19.9% for the elderly families with CVD members, which was 3.6% higher than for uninsured families (16.3%). Families with CVD combined with > 3 other chronic diseases (38.88%) were the riskiest factor for the high CHE in the new rural cooperative medical system (NCMS). Moreover, families with members > 75 years old (33.33%), having two chronic disease (30.74%), and families having disabled members (33.33%), hospitalization members (32.41%) were identified as the high risky determinants for the high CHE in NCMS.

CONCLUSIONS

Elderly with physical vulnerabilities were more prone to CHE. The medical insurance only reduced barriers to accessing health resources for elderly with CVD; however it lacked the policy inclination for high-utilization populations, and had poorly accurate identification of the vulnerable characteristics of CVD, which in turn affects the economic protection ability of the medical insurance. The dispersion between the multiple medical security schemes leads to the existence of blind spots in the economic risk protection of individuals and families.

The protective effect of hesperidin against renal ischemia-reperfusion injury involves the TLR-4/NF-κB/iNOS pathway in rats

Renal injury is reported to have a high mortality rate. Additionally, there are several limitations to current conventional treatments that are used to manage it. This study evaluated the protective effect of hesperidin against ischemia/reperfusion (I/R)-induced kidney injury in rats. Renal injury was induced by generating I/R in kidney tissues. Rats were then treated with hesperidin at a dose of 10 or 20 mg/kg intravenously 1 day after surgery for a period of 14 days. The effect of hesperidin on renal function, serum mediators of inflammation, and levels of oxidative stress in renal tissues were observed in rat kidney tissues after I/R-induced kidney injury. Moreover, protein expression and mRNA expression in kidney tissues were determined using Western blotting and RT-PCR. Hematoxylin and eosin (H&E) staining was done for histopathological observation of kidney tissues. The data suggest that the levels of blood urea nitrogen (BUN) and creatinine in the serum of hesperidin-treated rats were lower than in the I/R group. Treatment with hesperidin also ameliorated the altered level of inflammatory mediators and oxidative stress in I/R-induced renal-injured rats. The expression of p-IκBα, caspase-3, NF-κB p65, Toll-like receptor 4 (TLR-4) protein, TLR-4 mRNA, and inducible nitric oxide synthase (iNOS) was significantly reduced in the renal tissues of hesperidin-treated rats. Histopathological findings also revealed that treatment with hesperidin attenuated the renal injury in I/R kidney-injured rats. In conclusion, our results suggest that hesperidin protects against renal injury induced by I/R by involving TLR-4/NF-κB/iNOS signaling.

The out-of-pocket burden of chronic diseases: the cases of Belgian, Czech and German older adults

BACKGROUND

Out-of-pocket payments have a diverse impact on the burden of those with a higher morbidity or the chronically ill. As the prevalence of chronic diseases increases with age, older adults are a vulnerable group. The paper aims to evaluate the impact of chronic diseases on the out-of-pocket payments burden of the 50+ populations in Belgium, the Czech Republic and Germany.

METHODS

Data from the sixth wave of the Survey of Health, Ageing and Retirement in Europe is used. A two-part model with a logit model in the first part and a generalised linear model in the second part is applied.

RESULTS

The diseases increasing the burden in the observed countries are heart attacks, high blood pressure, cancer, emotional disorders, rheumatoid arthritis and osteoarthritis. Reflecting country differences Parkinson's disease and its drug burden is relevant in Belgium, the drugs burden related to heart attack and outpatient care burden to chronic kidney disease in the Czech Republic and the outpatient care burden of cancer and chronic lung disease in Germany. In addition, we confirm the regressive character of out-of-pocket payments.

CONCLUSIONS

We conclude that the burden is not equitably distributed among older adults with chronic diseases. Identification of chronic diseases with a high burden can serve as a supplementary protective feature.

Catastrophic Household Expenditure Associated with Out-of-Pocket Healthcare Payments in Spain

Background. The financial effect of households’ out-of-pocket payments (OOP) on access and use of health systems has been extensively studied in the literature, especially in emerging or developing countries. However, it has been the subject of little research in European countries, and is almost nonexistent after the financial crisis of 2008. The aim of the work is to analyze the incidence and intensity of financial catastrophism derived from Spanish households’ out-of-pocket payments associated with health care during the period 2008–2015. Methods. The Household Budget Survey was used and catastrophic measures were estimated, classifying the households into those above the threshold of catastrophe versus below. Three ordered logistic regression models and margins effects were estimated. Results. The results reveal that, in 2008, 4.42% of Spanish households dedicated more than 40% of their income to financing out-of-pocket payments in health, with an average annual gap of EUR 259.84 (DE: EUR 2431.55), which in overall terms amounts to EUR 3939.44 million (0.36% of GDP). Conclusion. The findings of this study reveal the existence of catastrophic households resulting from OOP payments associated with health care in Spain and the need to design financial protection policies against the financial risk derived from facing these types of costs.

Economic burden of cardiovascular diseases before and after Iran's health transformation plan: evidence from a referral hospital of Iran

Background

Different countries have set different policies to control and decrease the costs of cardiovascular diseases (CVDs). Iran was aiming to reduce the economic burden of different disease by a recent reform from named as health transformation plan (HTP). This study aimed to examine the economic burden of CVDs before and after of HTP.

Methods

This cross-sectional study was conducted on 600 patients with CVDs, who were randomly selected from a specialized cardiovascular hospital in the north-west of Iran. Direct and indirect costs of CVDs were calculated using the cost of illness and human capital approaches. Data were collected using a researcher-made checklist obtained from several sources including structured interviews, the Statistical Center of Iran, Iran’s Ministry of Cooperatives, Labor, and Social Welfare, the central bank of Iran, and the data of global burden of disease obtained from the Institute for Health Metrics and Evaluation to estimate direct and mortality costs. All costs were calculated in Iranian Rials (IRR).

Results

Total costs of CVDs were about 5571 and 6700 billion IRR before and after the HTP, respectively. More than 62% of the total costs of CVDs accounted for premature death before (64.89%) and after (62.01%) the HTP. The total hospitalization costs of CVDs was significantly increased after the HTP (p = 0.038). In both times, surgical services and visiting had the highest and lowest share of hospitalization costs, respectively. The OOP expenditure decreased significantly and reached from 54.2 to 36.7%. All hospitalization costs, except patients’ OOP expenditure, were significantly increased after the HTP about 1.3 times. Direct non-medical costs reached from 2.4 to 3.3 billion before and after the HTP, respectively.

Conclusion

Economic burden of CVDs increased in the north-west of Iran after the HTP due to the increase of all direct and indirect costs, except the OOP expenditure. Non-allocation of defined resources, which coincided with the international and national political and economic challenges in Iran, led to unsustainable resources of the HTP. So, no results of this study can be attributed solely to the HTP. Therefore, more detailed studies should be carried out on the reasons for the significant increase in CVDs costs in the region.

Cumulative Burden of Financial Hardship From Medical Bills Across the Spectrum of Diabetes Mellitus and Atherosclerotic Cardiovascular Disease Among Non-Elderly Adults in the United States

Background Atherosclerotic cardiovascular disease (ASCVD) has a strong association with diabetes mellitus (DM), accounting for approximately two thirds of deaths in this patient population. Many individuals with ASCVD and DM are vulnerable to financial hardship associated with treatment-related expenses. Therefore, we examined the burden of financial hardship from medical bills across the spectrum of ASCVD status with and without DM. Methods and Results Using data from the National Health Interview Survey from 2013 to 2017, we used logistic regression analysis to examine the association of ASCVD and DM status with financial hardship and an inability to pay medical bills from a representative sample of non-elderly adults in the United States. Our study population consisted of 121 672 individuals. Approximately 3.1% of the weighted population had ASCVD, 5.6% had DM, and 1.3% had both ASCVD and DM. Nearly 50% of individuals with ASCVD and DM reported financial hardship from medical bills (23% being unable to pay medical bills at all), whereas ≈28% of those with neither ASCVD nor DM reported financial hardship from medical bills (8% being unable to pay medical bills at all). Individuals with concurrent ASCVD and DM had the highest relative odds of expressing an inability to pay at all when compared with those with neither condition (odds ratio, 2.69; 95% CI, 2.21-3.28). Conclusions Individuals with concurrent ASCVD and DM are at a disproportionately high risk of being unable to pay their medical bills. The findings provide strong evidence for developing more effective public health policies that protect vulnerable populations from financial hardship.

Does the medical insurance system really achieved the effect of poverty alleviation for the middle-aged and elderly people in China? Characteristics of vulnerable groups and failure links

BACKGROUND

We examined the physiological, household, and spatial agglomeration characteristics of the health poverty population in China. We identified weak links that affect the implementation of the medical insurance and further improve its effectiveness for health poverty alleviation.

METHODS

A national representative sample from the China Health and Retirement Longitudinal Study (CHARLS) was analyzed. The WHO recommended method was adopted to calculate catastrophic health expenditure (CHE) and impoverishment by medical expenses (IME). We created a binary indicator for IME as the outcome variable and applied the treatment-effect model to analyze the determinants of IME.

RESULTS

The incidence of IME was 7.2% of the overall population, compared to 20.3% of the sample households trapped in CHE. The incidence of IME enrolled in insurance schemes was 7.4% higher than that of uninsured families (4.8%). Economic level, living area, family size, age of household head, having hospitalized members, and participating in insurance were statistically significant for the occurrence of IME.

CONCLUSIONS

The original poverty-promoting policies has not reached the maximum point of convergence with China's current demand for health. The overlapped health vulnerabilities exacerbated the risk of poverty among the elderly and households with high health needs and utilization. In addition, the medical insurance schemes have proven to be insufficient for protection against economic burden of poor households. So, special health needs, age, and household capacity to pay should be comprehensively considered while strengthening the connection between the disease insurance scheme with supplementary insurance.

Affordability Assessment from a Static to Dynamic Concept: A Scenario-Based Assessment of Cardiovascular Medicines

The out-of-pocket payments for prescription medications can impose a financial burden on patients from low- and middle- incomes and who suffer from chronic diseases. The present study aims at evaluating the affordability of cardiovascular disease (CVD) medication in Iran. This includes measuring affordability through World Health Organization/Health Action International (WHO/HAI) methodology. In this method, affordability is characterized as the number of days’ wages of the lowest-paid unskilled government worker. The different medication therapy scenarios are defined in mono-and combination therapy approaches. This method adds on to WHO/HAI methodology to discover new approaches to affordability assessments. The results show the differences in the medicines affordability when different approaches are used in mono-and combination therapy between 6 main sub-therapeutic groups of CVD. It indicates the medicine affordability is not a static concept and it changes dynamically between CVD therapeutic subgroups when it used alone or in combination with other medicines regarding patients’ characteristics and medical conditions. Hypertension and anti-arrhythmia therapeutic groups had the most non-affordability and hyperlipidemia had the most affordable medicines. Therefore, affordability can be considered as a dynamic concept, which not only affected by the medicine price but significantly affected by a patient’s characteristics, the number of medical conditions, and insurance coverage.

Financial Burden of Prescribed Medicines Included in Outpatient Benefits Package Schemes: Comparative Analysis of Co-Payments for Reimbursable Medicines in European Countries

OBJECTIVE

The study aimed to analyse the financial burden that co-payments for prescribed and reimbursed medicines pose on patients in European countries.

METHODS

Five medicines used in acute conditions (antibiotic, analgesic) and in chronic care (hypertension, asthma, diabetes) were selected. Co-payments (standard and five defined population groups, e.g. low-income people, patients with high consumption) were surveyed based on information retrieved from national price lists (September 2017) and co-payment regulation in nine countries (Albania, Austria, England, France, Germany, Greece, Hungary, Kyrgyzstan and Sweden). The financial burden of the selected medicines (originator and lowest-priced generic) was described as the percentage of patients' payments for 1 month's therapy or treatment of one episode in comparison to the national minimum monthly wage.

RESULTS

The study showed large variation in co-payments between the countries. Financial burden resulting from co-payments for reimbursed medicines tended to be higher in lower-income countries (Kyrgyzstan: 9% of minimum monthly wage for generic amlodipine; 2-4% for generic and originator salbutamol; Albania: approximately 3% for originator amoxicillin/clavulanic acid and metformin). Most studied countries applied reduction or exemption mechanisms (children were exempt in five countries, no or lower co-payments for low-income people in five countries, exemptions from co-payments upon reaching a threshold of expenses in six countries).

CONCLUSIONS

Co-payments for prescribed medicines can pose a substantial financial burden for outpatients, particularly in lower-income countries. The price of a medicine, availability of lower-priced medicines and the design of co-payments, including exemptions and reductions for specific groups, can considerably impact patients' expenses for medicines.

Trends and socio-economic disparities in catastrophic health expenditure and health impoverishment in China: 2010 to 2016

OBJECTIVES

To investigate trends and socio-economic disparities in the catastrophic health expenditure (CHE) and health impoverishment in China after major reform of the health system and to examine the impacts of the chronic disease on CHE and impoverishment.

METHODS

We obtained data from four rounds of the China Family Panel Studies 2010-2016, with a sample size of 14 960 households. We defined CHE as the point at which annual household health payments exceeded 40% of annual capacity to pay. Impoverishment is measured by the $1.90 per day poverty line. Multivariate logistic regression models were performed to identify impacts of the family member with chronic disease on CHE and impoverishment.

RESULTS

Between 2010 and 2016, the incidence of CHE in China decreased from 19.37% to 15.11% and from 7.39% to 5.14% for health impoverishment; however, the decrease in level of impoverishment was less in rural areas (from 6.16% down to 3.03%) than in urban areas (from 8.46% down to 7.81%). The gap between impoverishment rates across the income quartiles is growing. Multivariable analysis showed that households with two or more members suffering chronic diseases were significantly more likely to incur CHE (aOR: 2.46, 95% CI: 1.93-3.13) and impoverishment (aOR: 2.66, 95% CI: 1.87-3.78) than households with no members suffering chronic diseases, after adjusting for sociodemographic covariates.

CONCLUSIONS

Important advances have been made in achieving greater financial protection for Chinese citizens. Nevertheless, greater attention to the poor households with chronic disease members is needed. Policymakers in China should focus on optimising integrated rural-urban health insurance by expanding the current benefit packages and strengthening poverty alleviation efforts.

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

BACKGROUND

Catastrophic health expenditure (CHE) is well established as an indicator of financial protection on which there is extensive literature. However, most works analyse mainly low to middle income countries and do not address the different distributional dimensions of CHE. We argue that, besides incidence, the latter are crucial to better grasp the scope and nature of financial protection problems. Our objectives are therefore to analyse the evolution of CHE in a high income country, considering both its incidence and distribution.

METHODS

Data are taken from the last three waves of the Portuguese Household Budget Survey conducted in 2005/2006, 2010/2011 and 2015/2016. To identify CHE, the approach adopted is capacity to pay/normative food spending, at the 40% threshold. To analyse distribution, concentration curves and indices (CI) are used and adjusted odds ratios are calculated.

RESULTS

The incidence of CHE was 2.57, 1.79 and 0.46%, in 2005, 2010 and 2015, respectively. CHE became highly concentrated among the poorest (the respective CI evolved from - 0.390 in 2005 to - 0.758 in 2015) and among families with elderly people (the absolute CI evolved from 0.520 in 2005 to 0.740 in 2015). Absolute CI in geographical context also increased over time (0.354 in 2015, 0.019 in 2005). Medicines represented by far the largest share of catastrophic payments, although, in this case concentration decreased (the median share of medicines diminished from 93 to 43% over the period analysed). Contrarily, the weight of expenses incurred with consultation fees has been growing (even for General Practitioners, despite the NHS coverage of primary care).

CONCLUSIONS

The incidence of CHE and inequality in its distribution might progress in the same direction or not, but most importantly policy makers should pay attention to the distributional dimensions of CHE as these might provide useful insight to target households at risk. Greater concentration of CHE can actually be regarded as an opportunity for policy making, because interventions to tackle CHE become more confined. Monitoring the distribution of payments across services can also contribute to early detection of emerging (and even, unexpected) drivers of catastrophic payments.

Leaving no one behind? Social inclusion of health insurance in low- and middle-income countries: a systematic review

BACKGROUND

One way to achieve universal health coverage (UHC) in low- and middle-income countries (LMIC) is the implementation of health insurance schemes. A robust and up to date overview of empirical evidence assessing and substantiating health equity impact of health insurance schemes among specific vulnerable populations in LMICs beyond the more common parameters, such as income level, is lacking. We fill this gap by conducting a systematic review of how social inclusion affects access to equitable health financing arrangements in LMIC.

METHODS

We searched 11 databases to identify peer-reviewed studies published in English between January 1995 and January 2018 that addressed the enrolment and impact of health insurance in LMIC for the following vulnerable groups: female-headed households, children with special needs, older adults, youth, ethnic minorities, migrants, and those with a disability or chronic illness. We assessed health insurance enrolment patterns of these population groups and its impact on health care utilization, financial protection, health outcomes and quality of care.

RESULTS

The comprehensive database search resulted in 44 studies, in which chronically ill were mostly reported (67%), followed by older adults (33%). Scarce and inconsistent evidence is available for individuals with disabilities, female-headed households, ethnic minorities and displaced populations, and no studies were yielded reporting on youth or children with special needs. Enrolment rates seemed higher among chronically ill and mixed or insufficient results are observed for the other groups. Most studies reporting on health care utilization found an increase in health care utilization for insured individuals with a disability or chronic illness and older adults. In general, health insurance schemes seemed to prevent catastrophic health expenditures to a certain extent. However, reimbursements rates were very low and vulnerable individuals had increased out of pocket payments.

CONCLUSION

Despite a sizeable literature published on health insurance, there is a dearth of good quality evidence, especially on equity and the inclusion of specific vulnerable groups in LMIC. Evidence should be strengthened within health care reform to achieve UHC, by redefining and assessing vulnerability as a multidimensional process and the investigation of mechanisms that are more context specific.

Catastrophic long-term care expenditure: associated socio-demographic and economic factors

OBJECTIVE

An increasing number of persons across the world require long-term care (LTC). In Spain, access to LTC involves individuals incurring out-of-pocket (OOP) expenditure. There is a large body of literature on the incidence of catastrophic OOP payments in access and participation in health systems, but not in the field of LTC nor the determinants of these expenses. Our aim was to analyse the socio-demographic and economic factors associated with different levels of catastrophic LTC expenditure in the form of private out-of-pocket payments among dependent persons in Spain.

MATERIALS AND METHODS

The study used the Spanish Disability and Dependency Survey (SDDS) conducted by the Spanish National Statistics Institute to obtain the socioeconomic, demographic and health profiles. The households were classified into those below the poverty threshold and those above the threshold of catastrophe, using measures of impoverishment and catastrophe. We estimated two logistic regression models, one binary (impoverishment) and one ordinal (catastrophe).

RESULTS

The results show that OOP expenditure on LTC increases the probability of impoverishment by 18.90%. The factors associated with higher probability of experiencing catastrophe were age, being single, widowed or separated, lower levels of household income and education, higher level of dependence and living in an autonomous community with lower per capita income.

CONCLUSIONS

These findings highlight the need to include exemptions or insurance in the design of LTC policies to protect dependent persons from the risk of financial burden.

Decomposing inequality in catastrophic health expenditure for self-reported hypertension household in Urban Shaanxi, China from 2008 to 2013: two waves' cross-sectional study

OBJECTIVE

Despite the latest wave of China's healthcare reform initiated in 2009 has achieved unprecedented progress in rural areas, little is known for specific vulnerable groups' catastrophic health expenditure (CHE) in urban China. This study aims to estimate the trend of incidence, intensity and inequality of CHE in hypertension households (households with one or more than one hypertension patient) in urban Shaanxi, China from 2008 to 2013.

METHODS

Based on the fourth and the fifth National Health Service Surveys of Shaanxi, we identified 460 and 1289 households with hypertension in 2008 and 2013, respectively for our analysis. We classified hypertension households into two groups: simplex households (with hypertension only) and mixed households (with hypertension plus other non-communicable diseases). CHE would be identified if out-of-pocket healthcare expenditure was equal to or higher than 40% of a household's capacity to pay. Concentration index and its decomposition based on Probit regressions were employed to measure the income-related inequality of CHE.

RESULTS

We find that CHE occurred in 11.2% of the simplex households and 22.1% of the mixed households in 2008, and the 21.5% of the simplex households and the 46.9% of mixed households incurred CHE in 2013. Furthermore, there were strong pro-poor inequalities in CHE in the simplex households (-0.279 and -0.283) and mixed households (-0.362 and -0.262) both in 2008 and 2013. The majority of observed inequalities in CHE could be associated with household economic status, household head's health status and having elderly members.

CONCLUSION

We find a sharp increase of CHE occurrence and the sustained strong pro-poor inequalities for simplex and mixed households in urban Shaanxi Province of China from 2008 to 2013. Our study suggests that more concerns are needed for the vulnerable groups such as hypertension households in urban areas of China.

The Relationship between Lifestyle and Costs Related to Medicine Use in Adults

BACKGROUND

The unhealthy lifestyle is growing and this can have repercussions on health status demanding actions on the occurrence of diseases and leads to increased expenses.

OBJECTIVE

To examine the interrelationship between the costs of medicine use and lifestyle behaviors.

METHODS

A cohort study with 118 participants, age around 51.7 ± 7.1 years old. It was collected personal and anthropometric data and information about medicine of continuous use to calculate the costs. Lifestyle variables included habitual physical activity (PA) assessed by pedometer, sedentary behavior by Baecke questionnaire, sleep quality by mini sleep questionnaire and self-report of smoke and alcohol consumption. Statistical analyses were performed by BioEstat (version 5.2) and the significance level set at p-value < 0.05.

RESULTS

In 12 months, 62 subjects bought 172 medicines, representing an overall cost of US$ 3,087.01. Expenditures with drugs were negatively related to PA (r = -0.194, p-value = 0.035 and r = -0.281, p-value = 0.002), but positively related with sleep quality (r = 0.299, p-value=0.001 and r = 0.315, p-value = 0.001) and age (r = 0.274, p-value = 0.003). Four multivariate models were executed considering lifestyle behaviors in different moments of cohort and medicine costs, and all these models identify important relationship between lifestyle behaviors with expenditures with drugs.

CONCLUSION

Worse sleep quality seems to increase the costs related to medicine use in adults, while obesity and ageing play a relevant role in this phenomenon and alcohol consumption seems a variable with relevant economic impact.

"Let's talk about money": how do poor older people finance their healthcare in rural Ghana? A qualitative study

BACKGROUND

Older people utilise more healthcare services and are likely to incur higher healthcare expenditure, however, data on their healthcare financing mechanisms are scarce in low-and middle- income countries including Ghana. In this study, we aimed at exploring how poor older people finance their healthcare in rural Ghana.

METHODS

We conducted in-depth interviews and focus group discussions with 60 study participants comprising 30 poor older people, 15 healthcare providers and 15 caregivers in Atwima Nwabiagya District of Ghana. Data were analysed using thematic analytical framework and presented based on an a posteriori inductive reduction approach.

RESULTS

The study revealed that poor older people finance their healthcare through personal income, family support, Livelihood Empowerment Against Poverty grants and National Health Insurance Scheme subscription. It was also found that poor older people spent between GH¢ 20 and 250 on drugs, laboratory test and hospitalisation anytime they access a healthcare facility.

CONCLUSION

The findings contribute to our understanding of how poor older people finance their healthcare in rural Ghana. We argue that health stakeholders should strengthen healthcare financing mechanisms for poor older people for optimal healthcare use.

Empirical Analysis of the Status and Influencing Factors of Catastrophic Health Expenditure of Migrant Workers in Western China

Objective: To understand the current situation and influencing factors of catastrophic health expenditure (CHE) of migrant workers in Western China. Method: Sample data were obtained by cluster random sampling. Data were entered and sorted using Epidata 3.1 and SPSS 21.0. The statistical analysis involved a descriptive analysis, chi-square tests, multivariate unconditional logistic regression, and multiple correspondence analysis (MCA). Results: A total of 1271 households were surveyed, and the incidence of CHE was 12.5% (159/1271). The multivariate logistic regression showed that households with elderly people over 65 years old (0R = 2.05, 95% CI = 1.42–2.97), children under five years old (0R = 2.61, 95% CI = 1.53–4.48), at least one person with no basic medical insurance (0R = 2.96, 95% CI = 2.08–4.23), chronically ill patients (0R = 1.85, 95% CI = 1.23–2.77), and hospitalized patients (0R = 3.61, 95% CI = 2.31–5.62) contributed to the risk of CHE. Compared to migrant workers in the >30,000 Yuan household per capita annual income group, the 10,001–20,000 Yuan income group (0R = 2.35, 95% CI = 1.44–3.82) and ≤10,000 Yuan income group (0R = 3.72, 95% CI = 2.09–6.62) had a higher risk of CHE occurrence. Compared to migrant workers in the university and above head-of-household education group, those in the primary level or below education group (0R = 5.90, 95% CI = 3.02–11.5) had a higher risk of CHE occurrence. MCA revealed a strong interrelationship between the following risk factors and CHE: household per capita annual income ≤10,000 Yuan, primary school education level or below for the head of the household, and having at least one person in the household with no basic medical insurance. Conclusions: CHE incidence amongst migrant workers in Western China is a serious issue, and policymakers should pay more attention to these migrant workers’ households that are more prone to CHE than others, so as to decrease the incidence of CHE in this group.

The relationship between catastrophic health expenditure and health-related quality of life

Objectives

The objective of our study was to investigate the relationship between catastrophic health expenditure (CHE) and health-related quality of life (HRQoL) in general population.

Methods

We used Korean Health Panel Survey data from 2011 to 2013, which included data from 8850 baseline participants of 19 years of age or older. We defined CHE as total annual out-of-pocket health payment that was 40% greater than the household’s capacity to pay. HRQoL was measured using the EuroQol-visual analogue scale (EQ-VAS). We used generalized estimating equations to perform a longitudinal regression analysis.

Results

A total of 4.5% of the participants (n = 398) experienced CHE. Those with CHE tended to have a lower EQ-VAS index score compared with those without CHE (β: − 1.34, p = 0.013). A subgroup analysis revealed that individuals experiencing CHE had significant decreases as the number of chronic diseases increased (three or more, β: − 1.85, p = 0.014).

Conclusions

Catastrophic health expenditure influences HRQoL, which was more pronounced in patient with chronic disease. The efforts should focus on people who suffer from excessive health expenditures and chronic diseases.

Variations in catastrophic health expenditure across the states of India: 2004 to 2014

BACKGROUND

Financial protection is a key dimension of universal health coverage. Catastrophic health expenditure (CHE) has increased in India over time. The overall figures mask the subnational heterogeneity crucial for designing insurance coverage for 1.3 billion population across India. We estimated CHE in every state of India and the changes over a decade.

METHODS

We used National Sample Survey data on health care utilisation in 2004 and 2014. The states were placed in four groups based on epidemiological transition level (ETL), defined on the basis of ratio of disability-adjusted life-years from communicable diseases to those from non-communicable diseases and injuries combined, with a low ratio denoting high ETL state group. CHE was defined as the proportion of households that had out-of-pocket payments for health care equalling or exceeding 10% of the household expenditure. We assessed variation in the magnitude and distribution of CHE between ETL state groups and between states of India.

RESULTS

In 2014, CHE was higher in the high (30.3%, 95% confidence interval: 28.5 to 32.1) and higher-middle (27.4%, 26.3 to 28.6) ETL state groups than the low (21.8%, 20.8 to 22.8) and lower-middle (19.0%, 17.1 to 21.0) groups. From 2004 to 2014, CHE increased only in the high and higher-middle ETL groups (1.19 and 1.34 times, respectively). However, the individual states with substantial increase in CHE were spread across all ETL groups. The gap between the highest CHE of an individual state and the lowest was 8-fold in 2014. CHE was disproportionately concentrated among the rich in 2004 for most of India, but in 2014 CHE was distributed equally among the rich and poor because of the substantial increase in CHE among the poor over time.

CONCLUSIONS

Better provision of quality health care should be accompanied by financial protection measures to safeguard the poor from increasing CHE in India. The state-specific CHE trends can provide useful input for the planning of the recently launched National Health Protection Mission such that it meets the requirement of each state.

A survey of availability, price and affordability of essential medicines from 2011 to 2016 in Chinese secondary and tertiary hospitals

Background

Essential medicines are those drugs that satisfy the priority health care needs of the population and help with functioning healthcare systems. Although many countries have formulated an essential medicine list, almost half of the global population still lack regular access to essential medicines. Research about the initiation of National Essential Medicines Policy in Chinese secondary and tertiary hospitals is inadequate, and the long-term effect on access after the reform is still unknown. This study’s objective was to investigate the access to essential medicines in mainland China’s secondary and tertiary hospitals.

Methods

Data on the access to 30 essential medicines from China’s National Essential Medicine List were obtained from China Medicine Economic Information database covering 396 secondary hospitals and 763 tertiary hospitals. We improved the standard methodology developed by the World Health Organization and the Health Action International to measure the availability, median price ratio (MPR) and the incidence of catastrophic drug expenditure (CDE).

Results

Five essential medicines had > 50% availability and the nationwide availability kept steady; availability of drugs in eastern regions of China was significantly higher than the central and western regions. The median MPR of 30 drugs nationwide kept steady approximately 5; MPR of drugs in the eastern regions was significantly higher than the central and western regions and the ratio of MPR of innovator brands to generics increased from 3.66 to 6.32 during the study period. The incidence of CDE caused by essential medicines decreased from 2011 to 2014; brand name medicines were more likely to cause CDE than generics and rural patients have a greater tendency to fall into CDE.

Conclusions

After the implementation of National Essential Medicines Policy, the MPR of essential medicines was well controlled and became more affordable in the context of steady availability. This has highlighted the problems associated with region disparity and inequity between rural and urban areas in the delivery of essential medicines and sustainable mechanisms are needed to deepen the National Essential Medicines Policy in mainland China.

Electronic supplementary material

The online version of this article (10.1186/s12939-018-0870-5) contains supplementary material, which is available to authorized users.

Trends in catastrophic health expenditure in India: 1993 to 2014

Objective

To investigate trends in out-of-pocket health-care payments and catastrophic health expenditure in India by household age composition.

Methods

We obtained data from four national consumer expenditure surveys and three health-care utilization surveys conducted between 1993 and 2014. Households were divided into five groups by age composition. We defined catastrophic health expenditure as out-of-pocket payments equalling or exceeding 10% of household expenditure. Factors associated with catastrophic expenditure were identified by multivariable analysis.

Findings

Overall, the proportion of catastrophic health expenditure increased 1.47-fold between the 1993–1994 expenditure survey (12.4%) and the 2011–2012 expenditure survey (18.2%) and 2.24-fold between the 1995–1996 utilization survey (11.1%) and the 2014 utilization survey (24.9%). The proportion increased more in the poorest than the richest quintile: 3.00-fold versus 1.74-fold, respectively, across the utilization surveys. Catastrophic expenditure was commonest among households comprising only people aged 60 years or older: the adjusted odds ratio (aOR) was 3.26 (95% confidence interval, CI: 2.76–3.84) compared with households with no older people or children younger than 5 years. The risk was also increased among households with both older people and children (aOR: 2.58; 95% CI: 2.31–2.89), with a female head (aOR: 1.32; 95% CI: 1.19–1.47) and with a rural location (aOR: 1.27; 95% CI: 1.20–1.35).

Conclusion

The proportion of households experiencing catastrophic health expenditure in India increased over the past two decades. Such expenditure was highest among households with older people. Financial protection mechanisms are needed for population groups at risk for catastrophic health expenditure.