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Kazibwe J, Tran PB, Kaiser AH, Kasagga SP, Masiye F, Ekman B, Sundewall J. The impact of health insurance on maternal and reproductive health service utilization and financial protection in low- and lower middle-income countries: a systematic review of the evidence. BMC Health Serv Res 2024; 24:432. [PMID: 38580960 PMCID: PMC10996233 DOI: 10.1186/s12913-024-10815-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 03/01/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Low- and middle-income countries have committed to achieving universal health coverage (UHC) as a means to enhance access to services and improve financial protection. One of the key health financing reforms to achieve UHC is the introduction or expansion of health insurance to enhance access to basic health services, including maternal and reproductive health care. However, there is a paucity of evidence of the extent to which these reforms have had impact on the main policy objectives of enhancing service utilization and financial protection. The aim of this systematic review is to assess the existing evidence on the causal impact of health insurance on maternal and reproductive health service utilization and financial protection in low- and lower middle-income countries. METHODS The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search included six databases: Medline, Embase, Web of Science, Cochrane, CINAHL, and Scopus as of 23rd May 2023. The keywords included health insurance, impact, utilisation, financial protection, and maternal and reproductive health. The search was followed by independent title and abstract screening and full text review by two reviewers using the Covidence software. Studies published in English since 2010, which reported on the impact of health insurance on maternal and reproductive health utilisation and or financial protection were included in the review. The ROBINS-I tool was used to assess the quality of the included studies. RESULTS A total of 17 studies fulfilled the inclusion criteria. The majority of the studies (82.4%, n = 14) were nationally representative. Most studies found that health insurance had a significant positive impact on having at least four antenatal care (ANC) visits, delivery at a health facility and having a delivery assisted by a skilled attendant with average treatment effects ranging from 0.02 to 0.11, 0.03 to 0.34 and 0.03 to 0.23 respectively. There was no evidence that health insurance had increased postnatal care, access to contraception and financial protection for maternal and reproductive health services. Various maternal and reproductive health indicators were reported in studies. ANC had the greatest number of reported indicators (n = 10), followed by financial protection (n = 6), postnatal care (n = 5), and delivery care (n = 4). The overall quality of the evidence was moderate based on the risk of bias assessment. CONCLUSION The introduction or expansion of various types of health insurance can be a useful intervention to improve ANC (receiving at least four ANC visits) and delivery care (delivery at health facility and delivery assisted by skilled birth attendant) service utilization in low- and lower-middle-income countries. Implementation of health insurance could enable countries' progress towards UHC and reduce maternal mortality. However, more research using rigorous impact evaluation methods is needed to investigate the causal impact of health insurance coverage on postnatal care utilization, contraceptive use and financial protection both in the general population and by socioeconomic status. TRIAL REGISTRATION This study was registered with Prospero (CRD42021285776).
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Affiliation(s)
- Joseph Kazibwe
- Department of Clinical Sciences, Lund University, Jan Waldenströms Gata, 35205 02, Malmö, Sweden.
| | - Phuong Bich Tran
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Andrea Hannah Kaiser
- Department of Clinical Sciences, Lund University, Jan Waldenströms Gata, 35205 02, Malmö, Sweden
| | | | - Felix Masiye
- Department of Economics, University of Zambia, Lusaka, Zambia
| | - Björn Ekman
- Department of Clinical Sciences, Lund University, Jan Waldenströms Gata, 35205 02, Malmö, Sweden
| | - Jesper Sundewall
- Department of Clinical Sciences, Lund University, Jan Waldenströms Gata, 35205 02, Malmö, Sweden
- HEARD, University of KwaZulu-Natal, Durban, South Africa
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Forse R, Yoshino CA, Nguyen TT, Phan THY, Vo LNQ, Codlin AJ, Nguyen L, Hoang C, Basu L, Pham M, Nguyen HB, Van Dinh L, Caws M, Wingfield T, Lönnroth K, Sidney-Annerstedt K. Towards universal health coverage in Vietnam: a mixed-method case study of enrolling people with tuberculosis into social health insurance. Health Res Policy Syst 2024; 22:40. [PMID: 38566224 PMCID: PMC10985876 DOI: 10.1186/s12961-024-01132-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 03/13/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Vietnam's primary mechanism of achieving sustainable funding for universal health coverage (UHC) and financial protection has been through its social health insurance (SHI) scheme. Steady progress towards access has been made and by 2020, over 90% of the population were enrolled in SHI. In 2022, as part of a larger transition towards the increased domestic financing of healthcare, tuberculosis (TB) services were integrated into SHI. This change required people with TB to use SHI for treatment at district-level facilities or to pay out of pocket for services. This study was conducted in preparation for this transition. It aimed to understand more about uninsured people with TB, assess the feasibility of enrolling them into SHI, and identify the barriers they faced in this process. METHODS A mixed-method case study was conducted using a convergent parallel design between November 2018 and January 2022 in ten districts of Hanoi and Ho Chi Minh City, Vietnam. Quantitative data were collected through a pilot intervention that aimed to facilitate SHI enrollment for uninsured individuals with TB. Descriptive statistics were calculated. Qualitative interviews were conducted with 34 participants, who were purposively sampled for maximum variation. Qualitative data were analyzed through an inductive approach and themes were identified through framework analysis. Quantitative and qualitative data sources were triangulated. RESULTS We attempted to enroll 115 uninsured people with TB into SHI; 76.5% were able to enroll. On average, it took 34.5 days to obtain a SHI card and it cost USD 66 per household. The themes indicated that a lack of knowledge, high costs for annual premiums, and the household-based registration requirement were barriers to SHI enrollment. Participants indicated that alternative enrolment mechanisms and greater procedural flexibility, particularly for undocumented people, is required to achieve full population coverage with SHI in urban centers. CONCLUSIONS Significant addressable barriers to SHI enrolment for people affected by TB were identified. A quarter of individuals remained unable to enroll after receiving enhanced support due to lack of required documentation. The experience gained during this health financing transition is relevant for other middle-income countries as they address the provision of financial protection for the treatment of infectious diseases.
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Affiliation(s)
- Rachel Forse
- Friends for International TB Relief, Hanoi, Vietnam.
- Department of Global Public Health, WHO Collaboration Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Clara Akie Yoshino
- Department of Global Public Health, WHO Collaboration Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Luan N Q Vo
- Friends for International TB Relief, Hanoi, Vietnam
- Department of Global Public Health, WHO Collaboration Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Andrew J Codlin
- Friends for International TB Relief, Hanoi, Vietnam
- Department of Global Public Health, WHO Collaboration Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Stockholm, Sweden
| | | | | | | | | | | | | | - Maxine Caws
- Centre for TB Research, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Birat Nepal Medical Trust, Kathmandu, Nepal
| | - Tom Wingfield
- Department of Global Public Health, WHO Collaboration Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Stockholm, Sweden
- Centre for TB Research, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Knut Lönnroth
- Department of Global Public Health, WHO Collaboration Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Kristi Sidney-Annerstedt
- Department of Global Public Health, WHO Collaboration Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Stockholm, Sweden
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O'Donnell O. Health and health system effects on poverty: A narrative review of global evidence. Health Policy 2024; 142:105018. [PMID: 38382426 DOI: 10.1016/j.healthpol.2024.105018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 02/23/2024]
Abstract
Ill-health causes poverty. The effect runs through multiple mechanisms that span lifetimes and cross generations. Health systems can reduce poverty by improving health and weakening links from ill-health to poverty. This paper maps routes through which ill-health can cause poverty and identifies those that are potentially amenable to health policy. The review confirms that ill-health is an important contributor to poverty and it finds that the effect through health-related loss of earnings is often larger than that through medical expenses. Both effects are smaller in countries that are closer to universal health coverage and have higher social safety nets. The paper also reviews evidence from low- and middle-income countries (LMICs) and the United States (US) on the poverty-reduction effectiveness of public health insurance (PubHI) for low-income households. This reveals that PubHI does not always deliver financial protection to its targeted population in LMICs. Countries that have succeeded in achieving this goal often combine extension of coverage with supply-side interventions to build capacity and avoid perverse provider incentives in response to insurance. In the US, PubHI is effective in reducing poverty by shielding low-income households with children from healthcare costs and, consequently, generating long-run improvements in health that increase lifetime earnings. Poverty reduction is a potentially important co-benefit of health systems.
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Affiliation(s)
- Owen O'Donnell
- Erasmus University Rotterdam, P.O. Box 1738, Rotterdam 3000 DR, the Netherlands.
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Cui C, Zhang Y, Ding R, He P. Impact of the Essential Public Health Service program on financial protection and health outcomes among hypertensive patients: A quasi-experimental study in China. Soc Sci Med 2024; 345:116705. [PMID: 38422688 DOI: 10.1016/j.socscimed.2024.116705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 01/24/2024] [Accepted: 02/19/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND The Chinese government launched the Essential Public Health Service (EPHS) program nationwide in 2009. However, prior studies have not provided clear and integrated evidence on whether the EPHS program improves health outcomes and prevents financial risks among individuals. Because hypertension is the chronic disease with the highest prevalence, this study evaluated the impact of the EPHS program among hypertensive patients to provide evidence for the progress of the program. METHODS A cohort of hypertensive patients was identified from the 2011-2018 China Health and Retirement Longitudinal Study (CHARLS). The outcomes assessed included hospitalization expenditure, outpatient expenditure and cardiovascular disease (heart attack and stroke). The key independent variable was whether an individual received EPHS-covered blood pressure measurements in 2013-2015. Based on the International Health Partnership+ (IHP+) common monitoring and evaluation (M&E) framework, a difference-in-differences (DID) method with propensity score matching (PSM) was used to examine the impact of the EPHS program on hypertensive patients. RESULTS The results showed that among hypertensive patients covered by the EPHS program, outpatient total costs/OOP costs were reduced by 29.8% and 30.8%, respectively, and hospitalization total costs/OOP costs were reduced by 34.9% and 35.6%, respectively. The EPHS program reduced the probability of heart attack and stroke among hypertensive patients by 3.5% and 2.7%, respectively. Mechanistic tests showed that the EPHS program improved health outcomes by reducing alcohol consumption and increasing physical activity, thereby further reducing health expenditure among hypertensive patients. The impacts of the EPHS program on hypertensive patients varied by age, educational attainment, residential region, and alcohol consumption status. CONCLUSION The EPHS program in China significantly improved health outcomes and prevented financial risks for hypertensive patients. This evidence provides a valuable reference for low- and middle-income countries with their essential public health service programs.
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Affiliation(s)
- Chengsen Cui
- School of Public Health, Peking University, No.38 Xueyuan Road, Haidian District, Beijing, 100191, China; China Center for Health Development Studies, Peking University, No.38 Xueyuan Road, Haidian District, Beijing, 100191, China.
| | - Yue Zhang
- School of Accountancy, Central University of Finance and Economics, No.39 South College Road, Haidian District, Beijing, 100081, China.
| | - Ruoxi Ding
- Peking University Sixth Hospital, Peking University Institute of Mental Health, National Health Commission Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), No.51 Hua Yuan Bei Road, Haidian District, Beijing, 100191, China.
| | - Ping He
- China Center for Health Development Studies, Peking University, No.38 Xueyuan Road, Haidian District, Beijing, 100191, China.
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Thomson S, Cylus J, Al Tayara L, Martínez MG, García-Ramírez JA, Gregori MS, Cerezo-Cerezo J, Karanikolos M, Evetovits T. Monitoring progress towards universal health coverage in Europe: a descriptive analysis of financial protection in 40 countries. Lancet Reg Health Eur 2024; 37:100826. [PMID: 38362555 PMCID: PMC10866929 DOI: 10.1016/j.lanepe.2023.100826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 11/22/2023] [Accepted: 12/07/2023] [Indexed: 02/17/2024]
Abstract
Background Ensuring that access to health care is affordable for everyone-financial protection-is central to universal health coverage (UHC). Financial protection is commonly measured using indicators of financial barriers to access (unmet need for health care) and financial hardship caused by out-of-pocket payments for health care (impoverishing and catastrophic health spending). We aim to assess financial hardship and unmet need in Europe and identify the coverage policy choices that undermine financial protection. Methods We carry out a cross-sectional study of financial hardship in 40 countries in Europe in 2019 (the latest available year of data before COVID-19) using microdata from national household budget surveys. We define impoverishing health spending as out-of-pocket payments that push households below or further below a relative poverty line and catastrophic health spending as out-of-pocket payments that exceed 40% of a household's capacity to pay for health care. We link these results to survey data on unmet need for health care, dental care, and prescribed medicines and information on two aspects of coverage policy at country level: the main basis for entitlement to publicly financed health care and user charges for covered services. Findings Out-of-pocket payments for health care lead to financial hardship and unmet need in every country in the study, particularly for people with low incomes. Impoverishing health spending ranges from under 1% of households (in six countries) to 12%, with a median of 3%. Catastrophic health spending ranges from under 1% of households (in two countries) to 20%, with a median of 6%. Catastrophic health spending is consistently concentrated in the poorest fifth of the population and is largely driven by out-of-pocket payments for outpatient medicines, medical products, and dental care-all forms of treatment that should be an essential part of primary care. The median incidence of catastrophic health spending is three times lower in countries that cover over 99% of the population than in countries that cover less than 99%. In 16 out of the 17 countries that cover less than 99% of the population, the basis for entitlement is payment of contributions to a social health insurance (SHI) scheme. Countries that give greater protection from user charges to people with low incomes have lower levels of catastrophic health spending. Interpretation It is challenging to identify with certainty the coverage policy choices that undermine financial protection due to the complexity of the policies involved and the difficulty of disentangling the effects of different choices. The conclusions we draw are therefore tentative, though plausible. Countries are more likely to move towards UHC if they reduce out-of-pocket payments in a progressive way, decreasing them for people with low incomes first. Coverage policy choices that seem likely to achieve this include de-linking entitlement from payment of SHI contributions; expanding the coverage of outpatient medicines, medical products, and dental care; limiting user charges; and strengthening protection against user charges, particularly for people with low incomes. Funding The European Union (DG SANTE and DG NEAR) and the Government of the Autonomous Community of Catalonia, Spain.
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Affiliation(s)
- Sarah Thomson
- WHO Barcelona Office for Health Systems Financing, Barcelona, Spain
| | - Jonathan Cylus
- WHO Barcelona Office for Health Systems Financing, Barcelona, Spain
- European Observatory on Health Systems and Policies, London, United Kingdom
| | - Lynn Al Tayara
- WHO Barcelona Office for Health Systems Financing, Barcelona, Spain
| | | | | | | | | | - Marina Karanikolos
- WHO Barcelona Office for Health Systems Financing, Barcelona, Spain
- European Observatory on Health Systems and Policies, London, United Kingdom
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Tamás Evetovits
- WHO Barcelona Office for Health Systems Financing, Barcelona, Spain
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Okamoto S, Sata M, Rosenberg M, Nakagoshi N, Kamimura K, Komamura K, Kobayashi E, Sano J, Hirazawa Y, Okamura T, Iso H. Universal health coverage in the context of population ageing: catastrophic health expenditure and unmet need for healthcare. Health Econ Rev 2024; 14:8. [PMID: 38289516 PMCID: PMC10826197 DOI: 10.1186/s13561-023-00475-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 12/18/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND Universal health coverage means that all people can access essential health services without incurring financial hardship. Even in countries with good service coverage and financial protection, the progress towards universal health coverage may decelerate or be limited with respect to the growing older population. This study investigates the incidence/prevalence, determinants, and consequences of catastrophic health expenditure (CHE) and unmet need for healthcare and assesses the potential heterogeneity between younger (≤ 64 years) and older people (65 years≤). METHODS Utilising an annual nationally representative survey of Japanese aged 20 years and over, we estimated the incidence of CHE and unmet need for healthcare using disaggregated estimates by household members' age (i.e. ≤64 years vs. 65 years≤) between 2004 and 2020. Using a fixed-effects model, we assessed the determinants of CHE and unmet need along with the consequences of CHE. We also assessed the heterogeneity by age. RESULTS Households with older members were more likely to have their healthcare needs met but experienced CHE more so than households without older members. The financial consequences of CHE were heterogeneous by age, suggesting that households with older members responded to CHE by reducing food and social expenditures more so than households without older members reducing expenditure on education. Households without older members experienced an income decline in the year following the occurrence of CHE, while this was not found among households with older members. A U-shaped relationship was observed between age and the probability of experiencing unmet healthcare need. CONCLUSIONS Households with older members are more likely to experience CHE with different financial consequences compared to those with younger members. Unmet need for healthcare is more common among younger and older members than among their middle-aged counterparts. Different types and levels of health and financial support need to be incorporated into national health systems and social protection policies to meet the unique needs of individuals and households.
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Affiliation(s)
- Shohei Okamoto
- Research Team for Social Participation and Healthy Aging, Tokyo Metropolitan Institute for Geriatrics and Gerontology, 35-2 Sakae-cho, Itabashi City, Tokyo, 1730015, Japan.
- Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku City, Tokyo, Japan.
- Research Center for Financial Gerontology, Keio University, 2-15-45 Mita, Minato City, Tokyo, Japan.
| | - Mizuki Sata
- Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku City, Tokyo, Japan
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, 35 Shinanomachi, Shinjuku City, Tokyo, Japan
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Campus USÖ, Örebro, SE-701 82, Sweden
| | - Megumi Rosenberg
- World Health Organization Centre for Health Development, I.H.D. Centre Building, 9th Floor 7. 1-5-1 Wakinohama-Kaigandori, Chuo-ku, Kobe City, Hyogo, Japan
| | - Natsuko Nakagoshi
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, 35 Shinanomachi, Shinjuku City, Tokyo, Japan
| | - Kazuki Kamimura
- Research Center for Financial Gerontology, Keio University, 2-15-45 Mita, Minato City, Tokyo, Japan
- Hirao School of Management, Konan University, 8-33 Takamatsucho, Nishinomiya City, Hyogo, Japan
| | - Kohei Komamura
- Research Center for Financial Gerontology, Keio University, 2-15-45 Mita, Minato City, Tokyo, Japan
- Faculty of Economics, Keio University, 2-15-45 Mita, Minato City, Tokyo, Japan
| | - Erika Kobayashi
- Research Team for Social Participation and Healthy Aging, Tokyo Metropolitan Institute for Geriatrics and Gerontology, 35-2 Sakae-cho, Itabashi City, Tokyo, 1730015, Japan
| | - Junko Sano
- Research Center for Financial Gerontology, Keio University, 2-15-45 Mita, Minato City, Tokyo, Japan
- Tokyo Kasei Gakuin University, 22 Sanbancho, Chiyoda City, Tokyo, Japan
| | - Yuzuki Hirazawa
- Faculty of Economics, Keio University, 2-15-45 Mita, Minato City, Tokyo, Japan
| | - Tomonori Okamura
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, 35 Shinanomachi, Shinjuku City, Tokyo, Japan
| | - Hiroyasu Iso
- Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku City, Tokyo, Japan
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Serván-Mori E, Orozco-Núñez E, Guerrero-López CM, Miranda JJ, Jan S, Downey L, Feeny E, Heredia-Pi I, Flamand L, Nigenda G, Norton R, Lozano R. A Gender-Based and Quasi-Experimental Study of the Catastrophic and Impoverishing Health-Care Expenditures in Mexican Households with Elderly Members, 2000-2020. Health Syst Reform 2023; 9:2183552. [PMID: 37014089 DOI: 10.1080/23288604.2023.2183552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
Abstract
Latin America has experienced a rise in noncommunicable diseases (NCDs) which is having repercussions on the structuring of healthcare delivery and social protection for vulnerable populations. We examined catastrophic (CHE) and excessive (EHE, impoverishing and/or catastrophic) health care expenditures in Mexican households with and without elderly members (≥65 years), by gender of head of the households, during 2000-2020. We analyzed pooled cross-sectional data for 380,509 households from eleven rounds of the National Household Income and Expenditure Survey. Male- and female-headed households (MHHs and FHHs) were matched using propensity scores to control for gender bias in systematic differences regarding care-seeking (demand for healthcare) preferences. Adjusted probabilities of positive health expenditures, CHE and EHE were estimated using probit and two-stage probit models, respectively. Quintiles of EHE by state among FHHs with elderly members were also mapped. CHE and EHE were greater among FHHs than among MHHs (4.7% vs 3.9% and 5.5% vs 4.6%), and greater in FHHs with elderly members (5.8% vs 4.9% and 6.9% vs 5.8%). EHE in FHHs with elderly members varied geographically from 3.9% to 9.1%, being greater in less developed eastern, north-central and southeastern states. Compared with MHHs, FHHs face greater risks of CHE and EHE. This vulnerability is exacerbated in FHHs with elderly members, because of gender intersectional vulnerability. The present context, marked by a growing burden of NCDs and inequities amplified by COVID-19, makes key interlinkages across multiple Sustainable Development Goals (SDGs) apparent, and calls for urgent measures that strengthen social protection in health.
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Affiliation(s)
- Edson Serván-Mori
- Center for Health Systems Research, The National Institute of Public Health, Cuernavaca, Mexico
| | - Emanuel Orozco-Núñez
- Center for Health Systems Research, The National Institute of Public Health, Cuernavaca, Mexico
| | - Carlos M Guerrero-López
- Center for Health Systems Research, The National Institute of Public Health, Cuernavaca, Mexico
| | - J Jaime Miranda
- The George Institute for Global Health, School of Public Health, Imperial College London, London, UK
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Stephen Jan
- The George Institute for Global Health, School of Public Health, Imperial College London, London, UK
- School of Public Health, The George Institute for Global Health, Imperial College London, London, UK
- Center for Health Economics and Policy Innovation, Business School, Imperial College London, London, UK
| | - Laura Downey
- The George Institute for Global Health, School of Public Health, Imperial College London, London, UK
- School of Public Health, The George Institute for Global Health, Imperial College London, London, UK
| | - Emma Feeny
- School of Public Health, The George Institute for Global Health, Imperial College London, London, UK
| | - Ileana Heredia-Pi
- Center for Health Systems Research, The National Institute of Public Health, Cuernavaca, Mexico
| | - Laura Flamand
- Center for International Studies, The College of Mexico, Mexico City, Mexico
| | - Gustavo Nigenda
- The National School of Nursing and Obstetrics, National Autonomous University of Mexico, Mexico City, Mexico
| | - Robyn Norton
- The George Institute for Global Health, School of Public Health, Imperial College London, London, UK
- School of Public Health, The George Institute for Global Health, Imperial College London, London, UK
| | - Rafael Lozano
- Health Metrics Science Department. Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
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Cressman S, Ghanbarian S, Edwards L, Peterson S, Bunka M, Hoens AM, Riches L, Austin J, Vijh R, McGrail K, Bryan S. Costs of major depression covered / not covered in British Columbia, Canada. BMC Health Serv Res 2023; 23:1446. [PMID: 38124043 PMCID: PMC10734183 DOI: 10.1186/s12913-023-10474-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 12/12/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Major depressive disorder (MDD) is one of the world's leading causes of disability. Our purpose was to characterize the total costs of MDD and evaluate the degree to which the British Columbia provincial health system meets its objective to protect people from the financial impact of illness. METHODS We performed a population-based cohort study of adults newly diagnosed with MDD between 2015 and 2020 and followed their health system costs over two years. The expenditure proportion of MDD-related, patient paid costs relative to non-subsistence income was estimated, incidences of financial hardship were identified and the slope index of inequality (SII) between the highest and lowest income groups compared across regions. RESULTS There were 250,855 individuals diagnosed with MDD in British Columbia over the observation period. Costs to the health system totalled >$1.5 billion (2020 CDN), averaging $138/week for the first 12 weeks following a new diagnosis and $65/week to week 52 and $55/week for weeks 53-104 unless MDD was refractory to treatment ($125/week between week 12-52 and $101/week over weeks 53-104). The proportion of MDD-attributable costs not covered by the health system was 2-15x greater than costs covered by the health system, exceeding $700/week for patients with severe MDD or MDD that was refractory to treatment. Population members in lower-income groups and urban homeowners had disadvantages in the distribution of financial protection received by the health system (SII reached - 8.47 and 15.25, respectively); however, financial hardship and inequities were mitigated province-wide if MDD went into remission (SII - 0.07 to 0.6). CONCLUSIONS MDD-attributable costs to health systems and patients are highest in the first 12 weeks after a new diagnosis. During this time, lower income groups and homeowners in urban areas run the risk of financial hardship.
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Affiliation(s)
- Sonya Cressman
- The Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada.
- The School of Public and Population Health, University of British Columbia, Vancouver, BC, Canada.
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.
| | - Shahzad Ghanbarian
- The Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
- The School of Public and Population Health, University of British Columbia, Vancouver, BC, Canada
| | - Louisa Edwards
- The Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
- The School of Public and Population Health, University of British Columbia, Vancouver, BC, Canada
| | - Sandra Peterson
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, BC, Canada
| | - Mary Bunka
- The Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
- The School of Public and Population Health, University of British Columbia, Vancouver, BC, Canada
| | - Alison M Hoens
- Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada
| | - Linda Riches
- The School of Public and Population Health, University of British Columbia, Vancouver, BC, Canada
- Patient Partner, University of British Columbia, Vancouver, BC, Canada
| | - Jehannine Austin
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Rohit Vijh
- The School of Public and Population Health, University of British Columbia, Vancouver, BC, Canada
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
| | - Kimberlyn McGrail
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, BC, Canada
| | - Stirling Bryan
- The Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
- The School of Public and Population Health, University of British Columbia, Vancouver, BC, Canada
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9
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Khatooni E, Ahmadnezhad E, Olyaeemanesh A, Majdzadeh R. The Dilemma of Underutilized Health Insurance: A Matched Case-Control Study Investigating Reasons in Iran's Free Universal Health Insurance. Iran J Public Health 2023; 52:2643-2650. [PMID: 38435764 PMCID: PMC10903310 DOI: 10.18502/ijph.v52i12.14325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/19/2022] [Indexed: 03/05/2024]
Abstract
Background In May 2014, the Iranian government announced it would cover all uninsured Iranians. Despite free-of-charge insurance, the studies found that the coverage still needed to be completed (93%). This study aimed to understand why certain population groups remain without insurance despite the accessibility of free-of-charge coverage. This issue is not unique to Iran; it is prevalent in many other countries where, despite free coverage, not all individuals avail themselves of it, thereby exposing themselves to risks. Methods In a matched case-control study, 89 non-insured patients were compared with 178 hospital-based controls with health insurance (2:1). The samples were recruited at one of the leading public hospitals in the country (Imam Khomeini Hospital Complex in Tehran) in 2019. Two insured controls were selected and matched for age (± five years) and sex for each person without insurance. A conditional logistic regression was performed to assess the magnitude of effects and the goodness of fit test used to examine the model. Results Unemployment (Odds Ratio (OR)=8.33, 95% Confidence interval (CI): 1.05-50.0), being single (OR=3.69, CI: 1.18-11.55), low economic status (OR=1.85, CI: 1.02-3.33) and attitude towards performance of health insurance (OR=0.86, CI: 0.75-0.99) were affected not having health insurance. Conclusion Approaches that cover the entire population may struggle to ensure no one is left without needed services. There is a need for greater focus on vulnerable groups to achieve universal health coverage conscientiously. Moreover, improved services and education can positively shape public perceptions of insurance efficacy, affecting their enrollment choices.
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Affiliation(s)
- Elham Khatooni
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Elham Ahmadnezhad
- National Institute of Health Research, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Olyaeemanesh
- National Institute of Health Research, Health Equity Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Majdzadeh
- Department of Epidemiology and Biostatistics, School of Public Health, Knowledge Utilization Research Center and Community-Based Participatory Research, Tehran University of Medical Sciences, Tehran, Iran
- Interdisciplinary Research and Practice Division, School of Health and Social Care, University of Essex, Colchester, UK
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10
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Kaiser AH, Okorafor O, Ekman B, Chhim S, Yem S, Sundewall J. Assessing progress towards universal health coverage in Cambodia: Evidence using survey data from 2009 to 2019. Soc Sci Med 2023; 321:115792. [PMID: 36842307 DOI: 10.1016/j.socscimed.2023.115792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/27/2022] [Accepted: 02/17/2023] [Indexed: 02/22/2023]
Abstract
Over the past decades, many low- and middle-income countries have implemented health financing and system reforms to progress towards universal health coverage (UHC). In the case of Cambodia, out-of-pocket expenditure (OOPE) remains the main source of current health expenditure after several decades of reform, exposing households to financial risks when accessing healthcare and violating UHC's key tenet of financial protection. We use pre-pandemic data from the nationally representative Cambodia Socio-Economic Surveys of 2009 to 2019 to assess progress in financial protection to evaluate the reforms and obtain internationally comparable estimates. We find that following strong improvements in financial protection between 2009 and 2017, there was a reversal in the trend thereafter. The OOPE budget share rose, and the incidence of catastrophic spending and impoverishment increased in nearly all geographical and socioeconomic strata. For example, 17.7% of households experienced catastrophic health expenditure in 2019 at the threshold of 10% of total household consumption expenditure, and 3.9% of households were pushed into poverty by OOPE. The distribution of all financial protection indicators varied strongly across socioeconomic and geographical strata in all years. Fundamentally, the demonstrated trend reversal may jeopardize Cambodia's ability to progress towards UHC. To improve financial protection in the short term, there is a need to address the burden created by OOPE through targeted interventions to household groups that are most affected. In the medium term, our findings emphasize the importance of expanding health pre-payment schemes to currently uncovered vulnerable groups, specifically the near-poor. The government also needs to consider extending the scope of services covered and the range of providers to include the private sector under these schemes to reduce reliance on OOPE.
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Affiliation(s)
- Andrea Hannah Kaiser
- Lund University, Department of Clinical Sciences, Malmö (IKVM), Division of Social Medicine and Global Health (SMGH), CRC, Jan Waldenströms Gata 35, Malmö, Sweden; Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH Cambodia, Improving Social Protection and Health Project, Sayon Building, Samdach Pan Ave No. 41, 12211, Phnom Penh, Cambodia.
| | - Okore Okorafor
- Forte Metrix Consulting, 58 Sara Circle, Langeberg Heights, Durbanville, 7550, Western Cape, South Africa.
| | - Björn Ekman
- Lund University, Department of Clinical Sciences, Malmö (IKVM), Division of Social Medicine and Global Health (SMGH), CRC, Jan Waldenströms Gata 35, Malmö, Sweden.
| | - Srean Chhim
- National Institute of Public Health Cambodia, Lot 80, Street 566 & Corner with Street 289, Boeung Kak 2, Toul Kork, Phnom Penh, Cambodia.
| | - Sokunthea Yem
- National Institute of Public Health Cambodia, Lot 80, Street 566 & Corner with Street 289, Boeung Kak 2, Toul Kork, Phnom Penh, Cambodia.
| | - Jesper Sundewall
- Lund University, Department of Clinical Sciences, Malmö (IKVM), Division of Social Medicine and Global Health (SMGH), CRC, Jan Waldenströms Gata 35, Malmö, Sweden; HEARD, University of KwaZulu-Natal, South Africa.
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11
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Jia Y, Hu M, Fu H, Yip W. Provincial variations in catastrophic health expenditure and medical impoverishment in China: a nationwide population-based study. Lancet Reg Health West Pac 2023; 31:100633. [PMID: 36879785 DOI: 10.1016/j.lanwpc.2022.100633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 09/30/2022] [Accepted: 10/19/2022] [Indexed: 11/14/2022]
Abstract
Background Financial protection, as a key dimension of Universal Health Coverage (UHC), has been under increasing attention in recent years. A series of studies have examined the nationwide extent of catastrophic health expenditure (CHE) and medical impoverishment (MI) in China. However, disparities in financial protection at the province level have rarely been studied. The aim of this study was to investigate provincial variations in financial protection as well as its inequality across provinces. Methods Using data from the 2017 China Household Finance Survey (CHFS), this study estimated the incidence and intensity of CHE and MI for 28 Chinese provinces. Ordinary least square (OLS) estimation, using robust standard errors, was used to explore the factors associated with financial protection at the province level. Moreover, this study examined the urban-rural differences in financial protection within each province, and calculated the concentration index of CHE and MI indicators for each province using household income per capita. Findings The study revealed large provincial variations in financial protection within the nation. The nationwide CHE incidence was 11.0% (95% CI: 10.7%, 11.3%), ranging from 6.3% (95% CI: 5.0%, 7.6%) in Beijing to 16.0% (95% CI: 14.0%, 18.0%) in Heilongjiang; the national MI incidence was 2.0% (95% CI: 1.8%, 2.1%), ranging from 0.03% (95% CI: 0.00%, 0.06%) in Shanghai to 4.6% (95% CI: 3.3%, 5.9%) in Anhui province. We also found similar patterns for provincial variations in intensity of CHE and MI. Moreover, substantial provincial variations in income-related inequality and urban-rural gap existed across provinces. Eastern developed provinces in general had much lower inequality within them, compared with central and western provinces. Interpretation Despite the great advances towards UHC in China, substantial provincial variations exist in financial protection across provinces. Policymakers should pay special attention to low-income households in central and western provinces. Provision of better financial protection for these vulnerable groups will be key to achieving UHC in China. Funding This research was supported by the National Natural Science Foundation of China (Grant Number: 72074049) and the Shanghai Pujiang Program (2020PJC013).
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12
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Abstract
BACKGROUND Diagnostic testing for SARS-CoV-2 is critical to manage the pandemic and its different waves. The requirement to pay out-of-pocket (OOP) for testing potentially represents both a financial barrier to access and, for those who manage to make the payment, a source of financial hardship, as they may be forced to reduce spending on other necessities. This study aims to assess age-related inequality in affordability of COVID-19 tests. METHODS Daily data from the Global COVID-19 Trends and Impact Survey among adult respondents across 83 countries from July 2020 to April 2021 was used to monitor age-related inequalities across three indicators: the experiences of, first, reducing spending on necessities because of paying OOP for testing, second, facing financial barriers to get tested (from January to April 2021), and third, having anxiety related to household finance in the future. Logistic regressions were used to assess the association of age with each of these. RESULTS Among the population ever tested, the adjusted odds of reducing spending on necessities due to the cost of the test decreased non-linearly with age from 2.3 [CI95%: 2.1-2.5] among ages 18-24 to 1.6 [CI95%: 1.5-1.8] among ages 45-54. Among the population never tested, odds of facing any type of barrier to testing were highest among the youngest age group 2.5 [CI95%:2.4-2.5] and decreased with age. Finally, among those reporting reducing spending on necessities, the odds of reporting anxiety about their future finances decreased non-linearly with age, with the two younger groups being 2.4-2.5 times more anxious than the oldest age group. Among those reporting financial barriers due to COVID-19 test cost, there was an inverse U-shape relationship. CONCLUSIONS COVID-19 testing was associated with a reduction in spending on necessities at varying levels by age. Younger people were more likely to face financial barrier to get tested. Both negative outcomes generated anxiety across all age-groups but more frequently among the younger ones. To reduce age-related inequalities in the affordability of COVID-19 test, these findings support calls for exempting everyone from paying OOP for testing and, removing other type of barriers than financial ones.
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Affiliation(s)
- Gabriela Flores
- Economic Evaluation and Analysis, Health Systems Governance and Financing, World Health Organization, Avenua Appia 20, 1211, Geneva, Switzerland.
| | - Asiyeh Abbasi
- grid.3575.40000000121633745Consultant, World Health Organization, Avenua Appia 20, 1211 Geneva, Switzerland
| | - Catherine Korachais
- grid.3575.40000000121633745Consultant, World Health Organization, Avenua Appia 20, 1211 Geneva, Switzerland
| | - Rouselle Lavado
- grid.3575.40000000121633745Economic Evaluation and Analysis, Health Systems Governance and Financing, World Health Organization, Avenua Appia 20, 1211 Geneva, Switzerland
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Wang J, Qi X, Shan L, Wang K, Tan X, Kang Z, Ning N, Liang L, Gao L, Jiao M, Cui Y, Hao Y, Wu Q, Li Y. What fragile factors hinder the pace of China's alleviation efforts of the poverty-stricken population? A study from the perspective of impoverishment caused by medical expenses. BMC Health Serv Res 2022; 22:963. [PMID: 35906603 PMCID: PMC9336080 DOI: 10.1186/s12913-022-08237-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 06/14/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE China has made remarkable achievements in poverty alleviation. However, with the change in economic development and age structure, the population stricken by poverty due to medical expenses and disability accounted for 42.3 and 14.4% of the total poverty-stricken population, respectively. Accordingly, it is crucial to accurately pinpoint the characteristics of people who are about to become poor due to illness. In this study, we analyzed the incidence of impoverishment by medical expense at the provincial, family, and different medical insurance scheme levels to identify the precise groups that are vulnerable to medical-related poverty. METHOD Data were extracted from the Fifth National Health Service Survey in China in 2013 through a multi-stage, stratified, and random sampling method, leaving 93,570 households (273,626 people) for the final sample. The method recommended by World Health Organization (WHO) was adopted to calculate impoverishment by medical expense, and logistic regression was adopted to evaluate its determinants. RESULTS The poverty and impoverishment rate in China were 16.2 and 6.3% respectively. The poverty rate in western region was much higher than that of central and eastern regions. The rate of impoverishment by medical expense (IME) was higher in the western region (7.2%) than that in the central (6.5%) and eastern (5.1%) regions. The New Cooperative Medical Scheme (NCMS) was associated with the highest rate (9.1%) of IME cases. The top three diseases associated with IME were malignant tumor, congenital heart disease, and mental disease. Households with non-communicable disease members or hospitalized members had a higher risk on IME. NCMS-enrolled, poorer households were more likely to suffer from IME. CONCLUSION The joint roles of economic development, health service utilization, and welfare policies result in medical impoverishment for different regions. Poverty and health service utilization are indicative of households with high incidence of medical impoverishment. Chronic diseases lead to medical impoverishment. The inequity existing in different medical insurance schemes leads to different degrees of risk of IME. A combined strategy to precise target multiple vulnerabilities of poor population would be more effective.
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Affiliation(s)
- Jiahui Wang
- Centre of Health Policy & Management, Health Management College, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China.,Department of Social Medicine, School of Public Health, Health Management College, Harbin Medical University, No.157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Xinye Qi
- Centre of Health Policy & Management, Health Management College, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China.,Department of Social Medicine, School of Public Health, Health Management College, Harbin Medical University, No.157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Linghan Shan
- Centre of Health Policy & Management, Health Management College, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China.,Department of Social Medicine, School of Public Health, Health Management College, Harbin Medical University, No.157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Kexin Wang
- Centre of Health Policy & Management, Health Management College, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China.,Department of Social Medicine, School of Public Health, Health Management College, Harbin Medical University, No.157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Xiao Tan
- Shenzhen Hospital of Guangzhou University of traditional Chinese Medicine (Futian), 6001 Beihuan Avenue, Futian District, Shenzhen, Guangdong Province, China
| | - Zheng Kang
- Centre of Health Policy & Management, Health Management College, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China.,Department of Social Medicine, School of Public Health, Health Management College, Harbin Medical University, No.157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Ning Ning
- Centre of Health Policy & Management, Health Management College, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China.,Department of Social Medicine, School of Public Health, Health Management College, Harbin Medical University, No.157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Libo Liang
- Centre of Health Policy & Management, Health Management College, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China.,Department of Social Medicine, School of Public Health, Health Management College, Harbin Medical University, No.157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Lijun Gao
- Centre of Health Policy & Management, Health Management College, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China.,Department of Social Medicine, School of Public Health, Health Management College, Harbin Medical University, No.157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Mingli Jiao
- Centre of Health Policy & Management, Health Management College, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China.,Department of Social Medicine, School of Public Health, Health Management College, Harbin Medical University, No.157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Yu Cui
- Centre of Health Policy & Management, Health Management College, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China.,Department of Social Medicine, School of Public Health, Health Management College, Harbin Medical University, No.157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Yanhua Hao
- Centre of Health Policy & Management, Health Management College, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China.,Department of Social Medicine, School of Public Health, Health Management College, Harbin Medical University, No.157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Qunhong Wu
- Centre of Health Policy & Management, Health Management College, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China. .,Department of Social Medicine, School of Public Health, Health Management College, Harbin Medical University, No.157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China.
| | - Ye Li
- Centre of Health Policy & Management, Health Management College, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China. .,Department of Social Medicine, School of Public Health, Health Management College, Harbin Medical University, No.157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China.
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14
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Pan Y, Zhong WF, Yin R, Zheng M, Xie K, Cheng SY, Ling L, Chen W. Does direct settlement of intra-province medical reimbursements improve financial protection among middle-aged and elderly population in China? Evidence based on CHARLS data. Soc Sci Med 2022; 308:115187. [PMID: 35849965 DOI: 10.1016/j.socscimed.2022.115187] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 06/21/2022] [Accepted: 06/27/2022] [Indexed: 11/20/2022]
Abstract
In low- and middle-income countries, social health insurance schemes are the main focus of efforts to achieve universal health coverage (UHC) by promoting access to health care and financial protection. Problems with financial protection in China are caused mainly by health insurance fragmentation and a rapid rise in medical expenditure. In this context, China implemented a policy of direct settlement of intra-provincial medical reimbursement in 2014. We evaluated the impact of the policy on financial protection with a population aged 45 and above based on the China Health and Retirement Longitudinal Study from 2011 to 2018. We estimated the policy effects using the difference-in-differences method, based on coarsened exact matching. We found that the policy significantly reduced the catastrophic health expenditures (CHEs) rate by approximately 10% in the population, whether middle-aged or elderly. Subgroup analyses indicated that middle-aged and elderly people living in western China and with lower household incomes received greater protection from the policy. The CHEs rate for the two age groups in western China was reduced by 16.26% and 20.12%, respectively. The CHEs rate was reduced by 24.51% and 17.32% for middle-aged individuals in the lowest and second household income quartiles, respectively, and by 21.31% for older adults in the second household income quartile. The new rural cooperative medical scheme exerted a smaller protective effect than urban medical insurance among the participants aged 60 and older. We found that in addition to optimizing health insurance schemes, more health care reform measures, such as adopting more efficient payment methods and rationalizing medical expenditures, should be combined to help reduce health inequities and accelerate progress toward achieving UHC and the Sustainable Development Goals.
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Affiliation(s)
- Yan Pan
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Wen-Fang Zhong
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Rong Yin
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Meng Zheng
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Kun Xie
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Shu-Yuan Cheng
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Li Ling
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Wen Chen
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, China.
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15
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Winkelmann J, Gómez Rossi J, Schwendicke F, Dimova A, Atanasova E, Habicht T, Kasekamp K, Gandré C, Or Z, McAuliffe Ú, Murauskiene L, Kroneman M, de Jong J, Kowalska-Bobko I, Badora-Musiał K, Motyl S, Figueiredo Augusto G, Pažitný P, Kandilaki D, Löffler L, Lundgren C, Janlöv N, van Ginneken E, Panteli D. Exploring variation of coverage and access to dental care for adults in 11 European countries: a vignette approach. BMC Oral Health 2022; 22:65. [PMID: 35260137 PMCID: PMC8905841 DOI: 10.1186/s12903-022-02095-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 02/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Oral health, coupled with rising awareness on the impact that limited dental care coverage has on oral health and general health and well-being, has received increased attention over the past few years. The purpose of the study was to compare the statutory coverage and access to dental care for adult services in 11 European countries using a vignette approach. METHODS We used three patient vignettes to highlight the differences of the dimensions of coverage and access to dental care (coverage, cost-sharing and accessibility). The three vignettes describe typical care pathways for patients with the most common oral health conditions (caries, periodontal disease, edentulism). The vignettes were completed by health services researchers knowledgeable on dental care, dentists, or teams consisting of a health systems expert working together with dental specialists. RESULTS Completed vignettes were received from 11 countries: Bulgaria, Estonia, France, Germany, Republic of Ireland (Ireland), Lithuania, the Netherlands, Poland, Portugal, Slovakia and Sweden. While emergency dental care, tooth extraction and restorative care for acute pain due to carious lesions are covered in most responding countries, root canal treatment, periodontal care and prosthetic restoration often require cost-sharing or are entirely excluded from the benefit basket. Regular dental visits are also limited to one visit per year in many countries. Beyond financial barriers due to out-of-pocket payments, patients may experience very different physical barriers to accessing dental care. The limited availability of contracted dentists (especially in rural areas) and the unequal distribution and lack of specialised dentists are major access barriers to public dental care. CONCLUSIONS According to the results, statutory coverage of dental care varies across European countries, while access barriers are largely similar. Many dental services require substantial cost-sharing in most countries, leading to high out-of-pocket spending. Socioeconomic status is thus a main determinant for access to dental care, but other factors such as geography, age and comorbidities can also inhibit access and affect outcomes. Moreover, coverage in most oral health systems is targeted at treatment and less at preventative oral health care.
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Affiliation(s)
- Juliane Winkelmann
- Department of Healthcare Management, Technische Universität Berlin, H 80, Straße des 17. Juni 135, 10623, Berlin, Germany.
| | - Jesús Gómez Rossi
- Charité Universitätsmedizin, Department of Oral Diagnostics, Digital Health and Health Services Research, Aßmannshauser Straße 4-6, 14197, Berlin, Germany
| | - Falk Schwendicke
- Charité Universitätsmedizin, Department of Oral Diagnostics, Digital Health and Health Services Research, Aßmannshauser Straße 4-6, 14197, Berlin, Germany
| | - Antoniya Dimova
- Medical University - Varna, 55 Marin Drinov str, Varna, 9002, Bulgaria
| | - Elka Atanasova
- Medical University - Varna, 55 Marin Drinov str, Varna, 9002, Bulgaria
| | - Triin Habicht
- WHO Barcelona Office for Health Systems Financing, Sant Pau Art Nouveau Site (La Mercè pavilion), Sant Antoni Maria Claret, 167, 08025, Barcelona, Spain
| | | | - Coralie Gandré
- Institute for Research and Information in Health Economics (IRDES), 117, bis Rue Manin, 75019, Paris, France
| | - Zeynep Or
- Institute for Research and Information in Health Economics (IRDES), 117, bis Rue Manin, 75019, Paris, France
| | - Úna McAuliffe
- Oral Health Services Research Centre and School of Public Health, University College Cork, Cork, T12K8AF, Ireland
| | - Liubove Murauskiene
- Department of Public Health, Institute of Health Sciences, Faculty of Medicine, Vilnius University, M. K. Čiurlionio g. 21/ 27, 03101, Vilnius, Lithuania
| | - Madelon Kroneman
- Nivel, Netherlands Institute for Health Services Research, Otterstraat 118, 3513 CR, Utrecht, The Netherlands
| | - Judith de Jong
- Nivel, Netherlands Institute for Health Services Research, Otterstraat 118, 3513 CR, Utrecht, The Netherlands
| | - Iwona Kowalska-Bobko
- Faculty of Health Science, Institute of Public Health, Jagiellonian University Medical College, ul. Skawińska 8, 31-066, Kraków, Poland
| | - Katarzyna Badora-Musiał
- Faculty of Health Science, Institute of Public Health, Jagiellonian University Medical College, ul. Skawińska 8, 31-066, Kraków, Poland
| | - Sylwia Motyl
- Institute of Dentistry, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Gonçalo Figueiredo Augusto
- Public Health Research Centre, National School of Public Health, Nova University Lisbon, Rua da Junqueira, 100, 1349-008, Lisbon, Portugal
| | - Peter Pažitný
- Prague University of Economics and Business, W. Churchill Sq. 1938/4, 130 67, Prague 3, Žižkov, Czech Republic
| | - Daniela Kandilaki
- Prague University of Economics and Business, W. Churchill Sq. 1938/4, 130 67, Prague 3, Žižkov, Czech Republic
| | | | - Carl Lundgren
- Vardanalys, Drottninggatan 89, 113 60, Stockholm, Sweden
| | - Nils Janlöv
- Vardanalys, Drottninggatan 89, 113 60, Stockholm, Sweden
| | - Ewout van Ginneken
- Department of Healthcare Management, Technische Universität Berlin, H 80, Straße des 17. Juni 135, 10623, Berlin, Germany.,European Observatory on Health Systems and Policies, WHO European Centre for Health Policy, Eurostation (Office 07C020), Place Victor Horta/Victor Hortaplein, 40/10, 1060, Brussels, Belgium
| | - Dimitra Panteli
- European Observatory on Health Systems and Policies, WHO European Centre for Health Policy, Eurostation (Office 07C020), Place Victor Horta/Victor Hortaplein, 40/10, 1060, Brussels, Belgium
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Garg S, Bebarta KK, Tripathi N, Krishnendhu C. Catastrophic health expenditure due to hospitalisation for COVID-19 treatment in India: findings from a primary survey. BMC Res Notes 2022; 15:86. [PMID: 35241144 PMCID: PMC8892404 DOI: 10.1186/s13104-022-05977-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/16/2022] [Indexed: 11/28/2022] Open
Abstract
Objective The COVID-19 pandemic has caused widespread illness and a significant proportion of the infected required hospitalisation for treatment. People in developing countries like India were vulnerable to high hospitalisation costs. Despite its crucial importance, few primary studies are available on this aspect of the pandemic. This study was aimed at finding out the out of pocket expenditure (OOPE) and incidence of catastrophic expenditure on hospitalisation of persons infected with COVID-19. A primary survey of 492 randomly selected hospitalisations of individuals tested positive for COVID-19 in high-burden districts during August to November 2020 was carried out telephonically in Chhattisgarh state of India. Results Public hospitals accounted for 69% of the hospitalisations for COVID-19 treatment. Mean OOPE per hospitalisation was Indian Rupees (INR) 4871 in public hospitals and INR 169,504 in private hospitals. Around 3% of hospitalisations in public hospitals and 59% in private hospitals resulted in catastrophic expenditure, at a threshold of 40% of non-food annual household expenditure. Enrolment under publicly or privately funded health insurance was not effective in curtailing OOPE. Multivariate analysis showed that utilisation of private hospitals was a key determinant of incurring catastrophic expenditure. Supplementary Information The online version contains supplementary material available at 10.1186/s13104-022-05977-6.
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Affiliation(s)
- Samir Garg
- State Health Resource Centre, Raipur, Chhattisgarh, India.
| | | | | | - C Krishnendhu
- State Health Resource Centre, Raipur, Chhattisgarh, India
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Patel JR, Rupani MP. Costs incurred by patients with oral potentially malignant disorders: is there a public health need for financial protection in India? BMC Res Notes 2021; 14:396. [PMID: 34689827 PMCID: PMC8543918 DOI: 10.1186/s13104-021-05814-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 10/15/2021] [Indexed: 12/03/2022] Open
Abstract
Objectives Financial protection mechanisms are in place to overcome the costs of a few diseases in India. Our objective was to estimate the costs incurred due to Oral Potentially Malignant Disorders (OPMD) and to determine predictors of such costs. Results We found that the median (Interquartile range IQR) total costs of OPMD was Indian Rupees (INR) 500 (350–750), direct medical costs was INR 0 (0–50), direct non-medical costs was INR 150 (40–200) and indirect costs was INR 350 (250–500). The travel cost to attend the health facilities [INR 100 (40–150)] and the patient’s loss of wages [INR 200 (150–400)] mainly accounted for the direct non-medical and indirect costs respectively. The median expenditure on smokeless and smoking forms of tobacco was INR 6000 (5400–7200) and INR 2400 (1800–3600) respectively. On multiple linear regression analysis, rural residence, belonging to below poverty line family, being a sole earner in the family, number of months since diagnosis and first visit at a private provider were found to be the significant predictors of total costs of OPMD. Financial protection mechanisms are needed for covering the direct non-medical and indirect costs. Early management of OPMD might mitigate the costs of OPMD. Supplementary Information The online version contains supplementary material available at 10.1186/s13104-021-05814-2.
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Affiliation(s)
- Jay R Patel
- Department of Community Medicine, Government Medical College Bhavnagar (Maharaja Krishnakumarsinhji Bhavnagar University), Near ST bus stand, Jail Road, Bhavnagar, Gujarat, 364001, India
| | - Mihir P Rupani
- Division of Clinical Epidemiology, ICMR-National Institute of Occupational Health (NIOH), Meghani Nagar, Ahmedabad, Gujarat, 380016, India.
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Grépin KA, Irwin BR, Sas Trakinsky B. On the Measurement of Financial Protection: An Assessment of the Usefulness of the Catastrophic Health Expenditure Indicator to Monitor Progress Towards Universal Health Coverage. Health Syst Reform 2021; 6:e1744988. [PMID: 33416439 DOI: 10.1080/23288604.2020.1744988] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Ensuring financial protection (FP) against health expenditures is a key component of Sustainable Development Goal (SDG) 3.8, which aims to achieve Universal Health Coverage (UHC). While the proportion of households with catastrophic health expenditures exceeding a proportion of their total income or consumption has been adopted as the official SDG indicator, other approaches exist and it is unclear how useful the official indicator is in tracking progress toward the FP sub-target across countries and across time. This paper evaluates the usefulness of the official SDG indicator to measure FP using the RACER framework and discusses how alternative indicators may improve upon the limitations of the official SDG indicator for global monitoring purposes. We find that while all FP indicators have some disadvantages, the official SDG indicator has some properties that severely limit its usefulness for global monitoring purposes. We recommend more research to understand how alternative indicators may enhance global monitoring, as well as improvements to the quality and quantity of underlying data to construct FP indicators in order to improve efforts to monitor progress toward UHC.
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Affiliation(s)
- Karen A Grépin
- Department of Health Sciences, Wilfrid Laurier University , Waterloo, Canada
| | - Bridget R Irwin
- Department of Health Sciences, Wilfrid Laurier University , Waterloo, Canada
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Etemadi M, Kenis P, Ashtarian K, Abolghasem Gorji H, Mohammadi Kangarani H. Network governance theory as basic pattern for promoting financial support system of the poor in Iranian health system. BMC Health Serv Res 2021; 21:556. [PMID: 34092230 PMCID: PMC8183031 DOI: 10.1186/s12913-021-06581-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 05/26/2021] [Indexed: 11/17/2022] Open
Abstract
Background The share of out-of-pocket payments in Iranian families has the greatest burden on the poor and lead to an impoverishment caused by catastrophic health expenditures. In order to improve access of the poor to public resources, it is necessary to create a better governance system and effective policy-making. The purpose of this study is to improve network effectiveness of the Iranian health system and to design a financial protection network for the poor, based on the network governance theory. Methods We are using a quantitative method framework in conjunction with a Social network analysis (SNA) strategy. To draw an optimal network, we conducted interviews with experts by focusing on the arrangement and relationship among different institutions. The research sample was purposefully selected. We used UCINET software for data analysis and NetDraw software to draw networks. Results In this article, an optimal network was proposed with the following characteristics: First, the problem of the density of relationships among several central institutions and the isolation of the other institutions have been solved. Second, in our model, the relationships have been distributed in a balanced manner among all institutions in the network. Third, the number of participants has been reduced and consensus on poor people support policies has been achieved in this optimal network. Forth, executive organizations keep their central positions and upper institutions are not at the central position, so that the power is distributed in favor of more balanced governance. However, in order to increase efficiency and to have coherent decision-making, it is necessary to establish a “core” for this optimal network. The “core” has to include the organizations with the most relationship with others. Conclusion The result revealed that the usefulness of network analysis as a tool for proposing the effectiveness of governance. By strengthening the relationship among the main actors, an organized system of network management can be achieved. The network has to include all actors from different levels, from policy-making to implementation. The network also has to clarify the tasks from identifying the poor to covering costs. From an academic perspective, this study showed the adequacy of network analysis as a tool for policy sciences. Governance in our optimal health financial protection model follows the shared-governance pattern due to its high density, low centralization and low distance. The model of network governance can be the source of changes in the health governance system. It is a necessary structural condition to provide access to universal health coverage.
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Affiliation(s)
- Manal Etemadi
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Patrick Kenis
- Department of Public Governance, Tilburg University, Tilburg School of Economics and Management, Tilburg, Netherlands
| | - Kioomars Ashtarian
- Department of Public Policy, School of Law and Political Sciences, University of Tehran, Tehran, Iran.
| | - Hasan Abolghasem Gorji
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
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Kyriopoulos I, Nikoloski Z, Mossialos E. Financial protection in health among the middle-aged and elderly: Evidence from the Greek economic recession. Health Policy 2021; 125:1256-1266. [PMID: 34226052 DOI: 10.1016/j.healthpol.2021.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 05/18/2021] [Accepted: 05/21/2021] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Ilias Kyriopoulos
- Department of Health Policy, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, United Kingdom.
| | - Zlatko Nikoloski
- Department of Health Policy, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, United Kingdom.
| | - Elias Mossialos
- Department of Health Policy, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, United Kingdom.
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21
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Darvishi A, Amini-Rarani M, Mehrolhassani MH, Yazdi-Feyzabadi V. Fairness in household financial contribution to the Iran's healthcare system from 2008 to 2018. BMC Res Notes 2021; 14:190. [PMID: 34001249 PMCID: PMC8130119 DOI: 10.1186/s13104-021-05606-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 05/07/2021] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE Enhancing financial protection in health is one of the main goals of Iran's health transformation program (HTP), a recent reform conducted in early 2014. This study aimed to measure financial protection using the fair financial contribution index (FFCI) in urban and rural areas before (2008-2013) and after (2014-2018) the HTP implementation. Using a retrospective study on annual national cross-sectional surveys of households' income and expenditure, FFCI was measured. The total sample sizes for urban and rural areas from 2008 to 2018 were 207,980 and 212,249 households, respectively. RESULTS The worst fair contributions to health expenditure in urban (FFCI = 0.684) and rural areas (FFCI = 0.530) were related to 2010 and 2009, respectively. Otherwise, the best fair contributions for urban (FFCI = 0.858) and rural (FFCI = 0.836) areas were made in 2011. Before the HTP implementation began, FFCI showed minor changes from 0.834 in 2008 to 0.833 in 2013. Following the HTP implementation, the FFCI values in urban and rural populations declined (worsened) from 0.842 to 0.836 and 0.816 to 0.809, respectively.On average more fair financial contributions had been made following five years after the HTP, especially in rural areas, but less than that expected in upstream documents (as determined 0.9).
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Affiliation(s)
- Ali Darvishi
- Students’ Scientific Research Center (SSRC), Tehran University of Medical Sciences (TUMS), Tehran, Iran
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mostafa Amini-Rarani
- Social Determinants of Health Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Hossein Mehrolhassani
- Social Determinants of Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Vahid Yazdi-Feyzabadi
- Health Services Management Research Center,
Institute for Futures Studies in Health, Kerman University of Medical Sciences
, 7616913555 Kerman, Iran
- Department of Health Management, Policy and Economics, Faculty of Management and Medical Information Sciences
, Kerman, Iran
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Hsu J, Majdzadeh R, Mills A, Hanson K. A dominance approach to analyze the incidence of catastrophic health expenditures in Iran. Soc Sci Med 2021; 285:114022. [PMID: 34384625 DOI: 10.1016/j.socscimed.2021.114022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/28/2021] [Accepted: 05/06/2021] [Indexed: 11/22/2022]
Abstract
Financial protection is a health system goal for all countries. Assessing progress on this relies on measuring the incidence of catastrophic health expenditures (proportion of the population whose out-of-pocket (OOP) payments for health surpass a certain threshold of household resources). Standard approaches rely on selective thresholds, however this masks varying intensities of financial hardship and poses a measurement challenge as incidence is sensitive to the choice of the threshold. We address this problem by applying the dominance approach, which tests differences in catastrophic incidence curves over a continuous range of thresholds. Iran is an interesting country for empirical application of the dominance approach given its historically high reliance on OOP payments to finance its health system and its commitment to improving financial protection through several national health policies over the last two decades. Using data from annual Household Income and Expenditure Surveys from 2005 to 2017 (sample size: 26,851-39,088 households), incidence was analyzed following this novel approach. Distribution of incidence across socio-economic status was also analyzed by estimating concentration indices and across health services or products by estimating average shares of each item. Results showed that over time catastrophic health expenditures increased for thresholds lower than 25% and decreased for thresholds higher than 35%. Catastrophic health expenditures were more equally distributed across income levels at lower thresholds, becoming concentrated amongst the rich as the threshold rose. Medicines represented the largest share of catastrophic spending for the poorest; medicines, dentistry, inpatient and ancillary services for the richest. This is the first study to apply dominance methods to analyze catastrophic health expenditures in a country over time. The analysis provides a nuanced picture of who incurs catastrophic health expenditures, to what extent hardship is experienced and what were the drivers of these expenditures - thus providing a better basis for policy responses.
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Long Q, Jiang WX, Zhang H, Cheng J, Tang SL, Wang WB. Multi-source financing for tuberculosis treatment in China: key issues and challenges. Infect Dis Poverty 2021; 10:17. [PMID: 33750460 PMCID: PMC7943260 DOI: 10.1186/s40249-021-00809-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/09/2021] [Indexed: 12/03/2022] Open
Abstract
Background The End Tuberculosis (TB) Strategy of the World Health Organization highlights the need for patient-centered care and social protection measures that alleviate the financial hardships faced by many TB patients. In China, TB treatments are paid for by earmarked government funds, social health insurance, medical assistance for the poor, and out-of-pocket payments from patients. As part of Phase III of the China-Gates TB project, this paper introduces multi-source financing of TB treatment in the three provinces of China and analyzes the challenges of moving towards universal coverage and its implications of multi-sectoral engagement for TB care. Main text The new financing policies for TB treatment in the three provinces include increased reimbursement for TB outpatient care, linkage of TB treatment with local poverty alleviation programs, and use of local government funds to cover some costs to reduce out-of-pocket expenses. However, there are several challenges in reducing the financial burdens faced by TB patients. First, medical costs must be contained by reducing the profit-maximizing behaviors of hospitals. Second, treatment for TB and multi-drug resistant TB (MDR-TB) is only available at county hospitals and city or provincial hospitals, respectively, and these hospitals have low reimbursement rates and high co-payments. Third, many patients with TB and MDR-TB are at the edge of poverty, and therefore ineligible for medical assistance, which targets extremely poor individuals. In addition, the local governments of less developed provinces often face fiscal difficulties, making it challenging to use of local government funds to provide financial support for TB patients. We suggest that stakeholders at multiple sectors should engage in transparent and responsive communications, coordinate policy developments, and integrate resources to improve the integration of social protection schemes. Conclusions The Chinese government is examining the establishment of multi-source financing for TB treatment by mobilization of funds from the government and social protection schemes. These efforts require strengthening the cooperation of multiple sectors and improving the accountability of different government agencies. All key stakeholders must take concrete actions in the near future to assure significant progress toward the goal of alleviating the financial burden faced by TB and MDR-TB patients. Graphic abstract ![]()
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Affiliation(s)
- Qian Long
- Global Health Research Center, Duke Kunshan University, Jiangsu, China
| | - Wei-Xi Jiang
- Global Health Research Center, Duke Kunshan University, Jiangsu, China
| | - Hui Zhang
- National Center for Tuberculosis Control and Prevention, China CDC, Beijing, China
| | - Jun Cheng
- National Center for Tuberculosis Control and Prevention, China CDC, Beijing, China
| | - Sheng-Lan Tang
- Global Health Research Center, Duke Kunshan University, Jiangsu, China.,Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Wei-Bing Wang
- Department of Epidemiology, School of Public Health & Key Laboratory of Public Health Safety (Ministry of Education), Fudan University, 138 Yi Xue Yuan Road, Shanghai, 200032, China.
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Atake EH. Does the type of health insurance enrollment affect provider choice, utilization and health care expenditures? BMC Health Serv Res 2020; 20:1003. [PMID: 33143717 PMCID: PMC7607548 DOI: 10.1186/s12913-020-05862-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 10/25/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Two of the objectives of Universal Health Coverage are equity in access to health services and protection from financial risks. This paper seeks to examine whether the type of health insurance enrollment affects the utilization of health services, choice of provider and financial protection of households in Togo. METHODS Data were obtained from a cross-sectional, representative household survey involving 1180 insured households that had reported either illness in the household in the 4 weeks preceding the survey or hospitalization in the 12 months preceding the survey. A nested logit model was used to account for the utilization of health services and provider choice, and methods of assessing catastrophic health care expenditures were used to analyze the level of household financial protection. RESULTS Policyholders of private health insurance use private health care facilities more than policyholders of public health insurance. The main reasons for not using health centers among households with public insurance were out-of-pocket payments (49.19%), waiting time (36.80%), and distance to the nearest health center (36.76%). Furthermore, on average, households with public insurance spent a higher proportion of their total monthly nonfood expenditures on health care than those with private insurance. We find that the type of insurance, share of expenditures allocated to food, distance to the nearest health center, and waiting time significantly impact the choice of provider. Regardless of the type of health insurance, elderly individuals avoid using private health centers and referral hospitals due to the high cost. CONCLUSION We found that a multiple health insurance system results in a multilevel health system that is not equitable for everyone. The capacity of the health insurance system to provide equitable health care services and protect its members from catastrophic health care expenditures should be at the core of health care reform. This study recommends raising awareness of the criteria for the reimbursement of medical procedures within the framework of public insurance and promoting specific health insurance mechanisms for elderly individuals. Careful attention should be paid to ensuring universal education and literacy as a means of improving access to and the use of health care.
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Sriram S, Khan MM. Effect of health insurance program for the poor on out-of-pocket inpatient care cost in India: evidence from a nationally representative cross-sectional survey. BMC Health Serv Res 2020; 20:839. [PMID: 32894118 PMCID: PMC7487854 DOI: 10.1186/s12913-020-05692-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 08/31/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In India, Out-of-pocket expenses accounts for about 62.6% of total health expenditure - one of the highest in the world. Lack of health insurance coverage and inadequate coverage are important reasons for high out-of-pocket health expenditures. There are many Public Health Insurance Programs offered by the Government that cover the cost of hospitalization for the people below poverty line (BPL), but their coverage is still not complete. The objective of this research is to examine the effect of Public Health Insurance Programs for the Poor on hospitalizations and inpatient Out-of-Pocket costs. METHODS Data from the recent national survey by the National Sample Survey Organization, Social Consumption in Health 2014 are used. Propensity score matching was used to identify comparable non-enrolled individuals for individuals enrolled in health insurance programs. Binary logistic regression model, Tobit model, and a Two-part model were used to study the effects of enrolment under Public Health Insurance Programs for the Poor on the incidence of hospitalizations, length of hospitalization, and Out-of- Pocket payments for inpatient care. RESULTS There were 64,270 BPL people in the sample. Individuals enrolled in health insurance for the poor have 1.21 higher odds of incidence of hospitalization compared to matched poor individuals without the health insurance coverage. Enrollment under the poor people health insurance program did not have any effect on length of hospitalization and inpatient Out-of-Pocket health expenditures. Logistic regression model showed that chronic illness, household size, and age of the individual had significant effects on hospitalization incidence. Tobit model results showed that individuals who had chronic illnesses and belonging to other backward social group had significant effects on hospital length of stay. Tobit model showed that days of hospital stay, education and age of patient, using a private hospital for treatment, admission in a paying ward, and having some specific comorbidities had significant positive effect on out-of-pocket costs. CONCLUSIONS Enrolment in the public health insurance programs for the poor increased the utilization of inpatient health care. Health insurance coverage should be expanded to cover outpatient services to discourage overutilization of inpatient services. To reduce out-of-pocket costs, insurance needs to cover all family members rather than restricting coverage to a specific maximum defined.
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Affiliation(s)
- Shyamkumar Sriram
- Department of Health Services Policy and Management, University of South Carolina, Columbia, SC, USA.
| | - M Mahmud Khan
- Department of Health Services Policy and Management, University of South Carolina, Columbia, SC, USA
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Kwesiga B, Aliti T, Nabukhonzo P, Najuko S, Byawaka P, Hsu J, Ataguba JE, Kabaniha G. What has been the progress in addressing financial risk in Uganda? Analysis of catastrophe and impoverishment due to health payments. BMC Health Serv Res 2020; 20:741. [PMID: 32787844 PMCID: PMC7425531 DOI: 10.1186/s12913-020-05500-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 07/02/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Monitoring progress towards Universal Health Coverage (UHC) requires an assessment of progress in coverage of health services and protection of households from the impact of direct out-of-pocket payments (i.e. financial risk protection). Although Uganda has expressed aspirations for attaining UHC, out-of-pocket payments remain a major contributor to total health expenditure. The aim of this study is to monitor progress in financial risk protection in Uganda. METHODS This study uses data from the Uganda National Household Surveys for 2005/06, 2009/10, 2012/13 and 2016/17. We measure financial risk protection using catastrophic health care payments and impoverishment indicators. Health care payments are catastrophic if they exceed a set threshold (i.e. 10 and 25%) of the total household consumption expenditure. Health payments are impoverishing if they push the household below the poverty line (the US$1.90/day and Uganda's national poverty lines). A logistic regression model is used to assess the factors associated with household financial risk. RESULTS The results show that while progress has been made in reducing financial risk, this progress remains minimal, and there is still a risk of a reversal of this trend. We find that although catastrophic health payments at the 10% threshold decreased from 22.4% in 2005/06 to 13.8% in 2012/13, it increased to 14.2% in 2016/17. The percentage of Ugandans pushed below the national poverty line (US$1.90/day) has decreased from 5.2% in 2005/06 to 2.7% in 2016/17. The distribution of both catastrophic health payments and impoverishment varies across socio-economic status, location and residence. In addition, certain household characteristics (poverty, having a child below 5 years and an adult above 60 years) are more associated with the lack of financial risk protection. CONCLUSION There is need for targeted interventions to reduce OOP, especially among those affected so as to increase financial risk protection. In the short-term, it is important to ensure that public health services are funded adequately to enable effective coverage with quality health care. In the medium-term, increased reliance on mandatory prepayment will reduce the burden of OOP health spending further.
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Affiliation(s)
- Brendan Kwesiga
- World Health Organization, Health Systems Cluster, Nairobi, Kenya
| | - Tom Aliti
- Ministry of Health, Planning Department, Kampala, Uganda
| | | | - Susan Najuko
- Ministry of Health, Planning Department, Kampala, Uganda
| | | | - Justine Hsu
- World Health Organization, Economic Analysis Cluster, Geneva, Switzerland
| | - John E. Ataguba
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Grace Kabaniha
- World Health Organization, Health Systems Cluster India Country Office, New Delhi, India
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Garg S, Bebarta KK, Tripathi N. Performance of India's national publicly funded health insurance scheme, Pradhan Mantri Jan Arogaya Yojana (PMJAY), in improving access and financial protection for hospital care: findings from household surveys in Chhattisgarh state. BMC Public Health 2020; 20:949. [PMID: 32546221 PMCID: PMC7298746 DOI: 10.1186/s12889-020-09107-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 06/12/2020] [Indexed: 11/17/2022] Open
Abstract
Background A national Publicly Funded Health Insurance (PFHI) scheme called Pradhan Mantri Jan Arogaya Yojana (PMJAY) was launched by government of India in 2018. PMJAY seeks to cover 500 million persons with an annual cover of around 7000 USD per household. PMJAY claims to be the largest government funded health scheme globally and has attracted an international debate as a policy for Universal Health Coverage. India’s decade-long experience of the earlier national and state-specific PFHI schemes had shown poor effectiveness in financial protection. Most states in India have completed a year of implementation of PMJAY but no evaluations are available of this important scheme. Methods The study was designed to find out the effect of enrolment under PMJAY in improving utilisation of hospital services and financial protection in Chhattisgarh which has been a leading state in implementing PFHI in terms of enrolment and claims. The study analyses three repeated cross-sections. Two of the cross-sections are from National Sample Survey (NSS) health rounds – year 2004 when there was no PFHI and 2014 when the older PFHI scheme was in operation. Primary data was collected in 2019-end to cover the first year of PMJAY implementation and it formed the third cross-section. Multivariate analysis was carried out. In addition, Propensity Score Matching and Instrumental Variable method were applied to address the selection problem in insurance. Results Enrollment under PMJAY or other PFHI schemes did not increase utilisation of hospital-care in Chhattisgarh. Out of Pocket Expenditure (OOPE) and incidence of Catastrophic Health Expenditure did not decrease with enrollment under PMJAY or other PFHI schemes. The size of OOPE was significantly greater for utilisation in private sector, irrespective of enrollment under PMJAY. Conclusion PMJAY provided substantially larger vertical cover than earlier PFHI schemes in India but it has not been able to improve access or financial protection so far in the state. Though PMJAY is a relatively new scheme, the persistent failure of PFHI schemes over a decade raises doubts about suitability of publicly funded purchasing from private providers in the Indian context. Further research is recommended on such policies in LMIC contexts.
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Affiliation(s)
- Samir Garg
- State Health Resource Centre, Raipur, Chhattisgarh, India.
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Obse AG, Ataguba JE. Assessing medical impoverishment and associated factors in health care in Ethiopia. BMC Int Health Hum Rights 2020; 20:7. [PMID: 32228634 PMCID: PMC7106681 DOI: 10.1186/s12914-020-00227-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 03/19/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND About 5% of the global population, predominantly in low- and middle-income countries, is forced into poverty because of out-of-pocket (OOP) health spending. In most countries in sub-Saharan Africa, the share of OOP health spending in current health expenditure exceeds 35%, increasing the likelihood of impoverishment. In Ethiopia, OOP payments remained high at 37% of current health expenditure in 2016. This study assesses the impoverishment resulting from OOP health spending in Ethiopia and the associated factors. METHODS This paper uses data from the Ethiopian Household Consumption Expenditure Survey (HCES) 2010/11. The HCES covered 10,368 rural and 17,664 urban households. OOP health spending includes spending on various outpatient and inpatient services. Impoverishing impact of OOP health spending was estimated by comparing poverty estimates before and after OOP health spending. A probit model was used to assess factors that are associated with impoverishment. RESULTS Using the Ethiopian national poverty line of Birr 3781 per person per year (equivalent to US$2.10 per day), OOP health spending pushed about 1.19% of the population (i.e. over 957,169 individuals) into poverty. At the regional level, impoverishment ranged between 2.35% in Harari and 0.35% in Addis Ababa. Living in rural areas (highland, moderate, or lowland) increased the likelihood of impoverishment compared to residing in an urban area. Households headed by males and adults with formal education are less likely to be impoverished by OOP health spending, compared to their counterparts. CONCLUSION In Ethiopia, OOP health spending impoverishes a significant number of the population. Although the country had piloted and initiated many reforms, e.g. the fee waiver system and community-based health insurance, a significant proportion of the population still lacks financial protection. The estimates of impoverishment from out-of-pocket payments reported in this paper do not consider individuals that are already poor before paying out-of-pocket for health services. It is important to note that this population may either face deepening poverty or forgo healthcare services if a need arises. More is therefore required to provide financial protection to achieve universal health coverage in Ethiopia, where the informal sector is relatively large.
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Affiliation(s)
- Amarech G Obse
- Health Economics Unit, School of Public Health and Family Medicine, Health Sciences Faculty, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa.
| | - John E Ataguba
- Health Economics Unit, School of Public Health and Family Medicine, Health Sciences Faculty, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
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Bayati M, Mehrolhassani MH, Yazdi-Feyzabadi V. A paradoxical situation in regressivity or progressivity of out of pocket payment for health care: which one is a matter of the health policy maker's decision to intervention? Cost Eff Resour Alloc 2019; 17:28. [PMID: 31889916 PMCID: PMC6916433 DOI: 10.1186/s12962-019-0197-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 12/08/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Equity in health financing as one main aspect of health equity plays an essential role on the path toward universal health coverage. Out of pocket payment (OOP), a source with high share to total health expenditure, is an inequitable mechanism for health financing. MAIN BODY The OOP has been considered regressive (Kakwani index with a negative value) in nature. However, in some studies especially in developing countries, it is reported to be progressive (Kakwani index with a positive value). The main questions are: Is the progressive OOP equitable? What causes this contradiction? What can we do for the proper interpretation? And what are policy implications of this issue? In this commentary we briefly elaborate on these issues. We present several reasons for progressivity of OOP, and several methodological and policy issues for addressing it. CONCLUSIONS Even if the OOP is progressive and the share of poor people is low, this may financially limit their access to health services, increase their risk of incurring catastrophic health expenditure (CHE), and even pushing them more into poverty. In order to provide a comprehensive picture of equity in health financing, other financial protection indicators such as the redistributive effect, re-rating, exposure to CHE, and impoverishment due to health expenditure should also be estimated and reviewed.
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Affiliation(s)
- Mohsen Bayati
- Health Human Resources Research Center, School of Management & Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Hossein Mehrolhassani
- Social Determinants of Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Vahid Yazdi-Feyzabadi
- Health Services Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
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Ta Y, Zhu Y, Fu H. Trends in access to health services, financial protection and satisfaction between 2010 and 2016: Has China achieved the goals of its health system reform? Soc Sci Med 2019; 245:112715. [PMID: 31825797 DOI: 10.1016/j.socscimed.2019.112715] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 09/21/2019] [Accepted: 12/01/2019] [Indexed: 11/27/2022]
Abstract
Guided by the principle of universal health coverage, China began its complex health system reform in 2009. Using data from the China Family Panel Studies (CFPS), this study assesses trends in healthcare utilization, financial protection, and satisfaction between 2010 and 2016. We use difference-in-means tests and regression analysis to evaluate overall trends and compare subsample results by urban/rural residence and income quartiles to examine changes in inequity. Our results show that China has achieved substantial improvements in access to healthcare services and financial protection since the health system reform in 2009. First, China has experienced a substantial increase in both inpatient and outpatient care utilization between 2010 and 2016. Second, people receive better financial protection by measures of health insurance coverage, inpatient reimbursement rate, the likelihood of incurring catastrophic health expenditure, and the likelihood of medical impoverishment. Third, inequity in financial protection by income quartiles has significantly decreased, though poorer groups remain more vulnerable. However, we do not observe a concurrent increase in satisfaction towards the health system. We also find that people are more willing to seek medical services in hospitals rather than primary care institutions. All these results suggest that China's ongoing health system reform should pay more attention to establishing a tiered health delivery system, strengthening financial protection for the poor, and increasing responsiveness to rising expectations.
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Affiliation(s)
- Yuqi Ta
- National School of Development, Peking University, Beijing, 100871, China.
| | - Yishan Zhu
- National School of Development, Peking University, Beijing, 100871, China.
| | - Hongqiao Fu
- Department of Health Policy and Management, School of Public Health, Peking University Health Science Center, Beijing, 100191, China.
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Abstract
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.
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Affiliation(s)
- Carlota Quintal
- FEUC, CeBER, CEISUC, Faculty of Economics, University of Coimbra, Av. Dias da Silva, 165 |, 3004-512, Coimbra, Portugal.
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Abstract
BACKGROUND Rising health spending is associated with high out-of-pocket expenditure (OOPE), catastrophic health spending (CHS), increasing poverty, and impoverishment. Though studies have examined poverty and impoverishment effect of health spending in India, there is limited research on the regional patterns of health spending by type of health centers. This paper tests the hypothesis that the poor people from the poorer states of India pay significantly more for hospitalization in public health centers than those in the richer states of India. METHODS Data from the Social Consumption of Health Survey (71st round, 2014), carried out by the National Sample Survey (NSS) is used in the analyses. Descriptive statistics, log-linear regression model and tobit model were used to examine the determinants and variations in health spending. RESULTS Inter-state variations in the utilization of public health services and the OOPE on hospitalization are high in India. States with high levels of poverty make higher use of the public health centers and yet incur high OOPE. In 2014, the mean OOPE per episode of hospitalization in public health centers in India was ₹5688 and ₹4264 for the economically poor households. It was lowest in the economically developed state of Tamil Nadu and highest in the economically poorer state of Bihar. The OOPE per episode of hospitalization in public health centers among the poor in the poorer states was at least twice that in Tamil Nadu. Among the poor using public health centers, the share of direct cost account 24% in Tamil Nadu compared to over 80% in Bihar, Odisha and other poorer states. Adjusting for socio-economic correlates, the cost of hospitalization per episode (CHPE) among the poor using public health centers was 51% lower than for the non-poor using private health centers in India. CONCLUSION The poor people in the poorer states in India pay significantly more to avail hospitalization in public health centers than those in the developed states. Provision of free medicines, surgery and free diagnostic tests in public health centers may reduce the high OOPE and medical poverty in India.
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Affiliation(s)
- Anjali Dash
- International Institute for Population Sciences, Govandi Station Road, Deonar, Mumbai, Maharashtra, 400088, India.
| | - Sanjay K Mohanty
- Department of Fertility Studies, International Institute for Population Sciences, Govandi Station Road, Deonar, Mumbai, 400088, India
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Baine SO, Kakama A, Mugume M. Development of the Kisiizi hospital health insurance scheme: lessons learned and implications for universal health coverage. BMC Health Serv Res 2018; 18:455. [PMID: 29903016 PMCID: PMC6003105 DOI: 10.1186/s12913-018-3266-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 05/31/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Kisiizi Hospital Health Insurance scheme started in 1996 to; improve access to health services, and provide a stable source of funding and reduce bad debts to Kisiizi hospital. Objectives of this study were; to describe Kisiizi Hospital Health Insurance scheme and to document lessons learned and implications for universal health coverage. METHODS This was a descriptive cross-sectional study. Data from different sources were triangulated and thematically analysed. RESULTS Most households (96%) were organized in Engozi societies (e-Societies), met monthly, and made financial contributions. Cultural solidarity in e-Societies provided a platform for the Kisiizi hospital health insurance scheme establishment, operation and made it compulsory for members. e-Societies disciplinary measures and fear of high out-of-pocket payment for health care enforced enrolment, retention and increased membership. Community sensitisation and community participation in setting premiums and co-payments provided for better understanding of health insurance and rendered them acceptable, affordable and equitable. Membership increased from 330 in 1996 to 38,400 families in 2017. Kisiizi hospital health insurance scheme covered only health services obtained from Kisiizi hospital. Kisiizi hospital health insurance scheme offered no exemption, credit and referral facilities. e-Societies sometimes paid premiums for members from savings and offered them loans to. Kisiizi hospital provided good quality health services, which were easily accessed by insured members. Kisiizi hospital got a stable source of funding and reduced debt burden. CONCLUSIONS Kisiizi hospital health insurance scheme improved access to health services, provided a stable source of funding and reduced bad debts to the hospital. Internal and external factors to e-Society enforced enrolment and retention of members in Kisiizi hospital health insurance scheme. Good quality health services at Kisiizi hospital demonstrated value for money and offered incentives for enrolment and retention, and coverage expansion. Community sensitization and participation in setting premiums and co-payments rendered Kisiizi hospital health insurance scheme acceptable, affordable and catered for equity. Insured members enjoyed benefits; protection against catastrophic health spending, impoverishment, and easy access to quality health care.
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Affiliation(s)
- Sebastian Olikira Baine
- Department of Health Policy, Planning and Management, Makerere University College of Health Sciences, School of Public Health, P. O. Box 7072, Kampala, Uganda
| | - Alex Kakama
- Kisiizi Hospital Health Insurance Scheme, Kisiizi Hospital, P. O. Box 109, Kabale, Uganda
| | - Moses Mugume
- Kisiizi Hospital Health Insurance Scheme, Kisiizi Hospital, P. O. Box 109, Kabale, Uganda
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Hsu J, Flores G, Evans D, Mills A, Hanson K. Measuring financial protection against catastrophic health expenditures: methodological challenges for global monitoring. Int J Equity Health 2018; 17:69. [PMID: 29855334 PMCID: PMC5984475 DOI: 10.1186/s12939-018-0749-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 03/13/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Monitoring financial protection against catastrophic health expenditures is important to understand how health financing arrangements in a country protect its population against high costs associated with accessing health services. While catastrophic health expenditures are generally defined to be when household expenditures for health exceed a given threshold of household resources, there is no gold standard with several methods applied to define the threshold and household resources. These different approaches to constructing the indicator might give different pictures of a country's progress towards financial protection. In order for monitoring to effectively provide policy insight, it is critical to understand the sensitivity of measurement to these choices. METHODS This paper examines the impact of varying two methodological choices by analysing household expenditure data from a sample of 47 countries. We assess sensitivity of cross-country comparisons to a range of thresholds by testing for restricted dominance. We further assess sensitivity of comparisons to different methods for defining household resources (i.e. total expenditure, non-food expenditure and non-subsistence expenditure) by conducting correlation tests of country rankings. RESULTS We found country rankings are robust to the choice of threshold in a tenth to a quarter of comparisons within the 5-85% threshold range and this increases to half of comparisons if the threshold is restricted to 5-40%, following those commonly used in the literature. Furthermore, correlations of country rankings using different methods to define household resources were moderate to high; thus, this choice makes less difference from a measurement perspective than from an ethical perspective as different definitions of available household resources reflect varying concerns for equity. CONCLUSIONS Interpreting comparisons from global monitoring based on a single threshold should be done with caution as these may not provide reliable insight into relative country progress. We therefore recommend financial protection against catastrophic health expenditures be measured across a range of thresholds using a catastrophic incidence curve as shown in this paper. We further recommend evaluating financial protection in relation to a country's health financing system arrangements in order to better understand the extent of protection and better inform future policy changes.
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Affiliation(s)
- Justine Hsu
- Department of Health Systems Governance and Financing, World Health Organization, 20 Avenue Appia, 1211, Geneva, Switzerland.
| | - Gabriela Flores
- Department of Health Systems Governance and Financing, World Health Organization, 20 Avenue Appia, 1211, Geneva, Switzerland
| | - David Evans
- World Bank, 3 Chemin Louis-Dunant, 1202, Geneva, Switzerland
| | - Anne Mills
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom
| | - Kara Hanson
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom
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Ghiasvand H, Olyaeemanesh A, Majdzadeh R, Abdi Z, Mobinizadeh M. Has the Financial Protection Been Materialized in Iranian Health System? Analyzing Household Income and Expenditure Survey 2003-2014. J Res Health Sci 2018; 18:e00404. [PMID: 29445050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 12/24/2017] [Accepted: 12/26/2017] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND The financial protection against catastrophic and impoverishing health expenditures is one of the main aspects of the universal health coverage. This study aimed to present a clear picture of the financial protection situation in Iran from 2003-2014. STUDY DESIGN This is an analytical study on secondary data of Statistical Center of Iran (SCI). The study has some policy implications for policy makers; therefore, it is an applied one. METHODS Data related to the Iranian rural and urban household payments on health expenditures was obtained from annual surveys of the SCI. WHO researchers' approach was used to calculate the Fairness of Financial Contribution Indicator (FFCI), the headcount and overshoot ratios of catastrophic and impoverishing health expenditures. A logistic regression was conducted to identify the determinants of probability of occurrence of catastrophic health expenditure among Iranian households in 2014. RESULTS The mean of FFCI for rural and urban households was 0.854 (0.41) and 0.867 (0.32), respectively. The average headcount ratios of catastrophic and impoverishing health expenditures were 1.32% (0.24) and 0.33% (P=0.006) for rural households and 1.4% (0.6) and 0.28% (P=0.001) for urban households. Concerning rural households, the overshoot of catastrophic and impoverishing health expenditures was 14.94% (P=0.001) and 7.22% (0.53); it was 15.59% (1.54) and 7.76% (0.52) for urban households. CONCLUSIONS No significant and considerable change was found in the headcount ratios of catastrophic and impoverishing health expenditure and in their overshoot or gap amounts. This suggested a lack of well-designed and effective schemes for materializing the financial protection in Iran.
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Affiliation(s)
- Hesam Ghiasvand
- Social Determinants of Health Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Alireza Olyaeemanesh
- National Institute of Health Research and Health Equity Research Centre, Tehran University of Medical Sciences, Tehran, Iran.
| | - Reza Majdzadeh
- Community Based Participatory Research Centre and Knowledge Utilization Research Centre, Tehran University of Medical Sciences and Iran's National Institute of Health Research, Tehran, Iran
| | - Zhaleh Abdi
- National Institute of Health Research, Tehran University of Medical Sciences, Tehran, Iran
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Lee TJ, Cheong C. Has the Copayment Ceiling Improved Financial Protection in the Korean National Health Insurance System? Evidence From the 2009 Policy Change. J Prev Med Public Health 2017; 50:393-400. [PMID: 29207446 PMCID: PMC5717331 DOI: 10.3961/jpmph.17.151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 11/09/2017] [Indexed: 11/09/2022] Open
Abstract
Objectives To relieve the financial burden faced by households, the Korean National Health Insurance (NHI) system introduced a "copayment ceiling," which evolved into a differential ceiling in 2009, with the copayment ceiling depending on patients' income. This study aimed to examine the effect of the differential copayment ceiling on financial protection and healthcare utilization, particularly focusing on whether its effects varied across different income groups. Methods This study obtained data from the Korea Health Panel. The number of households included in the analysis was 6555 in 2008, 5859 in 2009, 5539 in 2010, and 5372 in 2011. To assess the effects of the differential copayment ceiling on utilization, out-of-pocket (OOP) payments, and catastrophic payments, various random-effects models were applied. Utilization was measured as treatment days, while catastrophic payments were defined as OOP payments exceeding 10% of household income. Among the right-hand side variables were the interaction terms of the new policy with income levels, as well as a set of household characteristics. Results The differential copayment ceiling contributed to increased utilization regardless of income levels both in all patients and in cancer patients. However, the new policy did not seem to reduce significantly the incidence of catastrophic payments among cancer patients, and even increased the incidence among all patients. Conclusions The limited effect of the differential ceiling can be attributed to a high proportion of direct payments for services not covered by the NHI, as well as the relatively small number of households benefiting from the differential ceilings; these considerations warrant a better policy design.
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Affiliation(s)
- Tae-Jin Lee
- Department of Public Health Science, Graduate School of Public Health, Seoul National University, Seoul, Korea
| | - Chelim Cheong
- Department of Public Health Science, Graduate School of Public Health, Seoul National University, Seoul, Korea
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Mao W, Tang S, Zhu Y, Xie Z, Chen W. Financial burden of healthcare for cancer patients with social medical insurance: a multi-centered study in urban China. Int J Equity Health 2017; 16:180. [PMID: 29017542 PMCID: PMC5635570 DOI: 10.1186/s12939-017-0675-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 09/28/2017] [Indexed: 11/10/2022] Open
Abstract
Background Cancer accounts for one-fifth of the total deaths in China and brings heavy financial burden to patients and their families. Chinese government has made strong commitment to develop three types of social medical insurance since 1997 and recently, more attempts were invested to provide better financial protection. To analyze health services utilization and financial burden of insured cancer patients, and identify the gaps of financial protection provided by insurance in urban China. Methods A random sampling, from Urban Employee's Basic Medical Insurance claim database, was performed in 4 cities in 2008 to obtain insurance claim records of cancer patients. Services utilization, medical expenses and out-of-pocket (OOP) payment were the metrics collected from the insurance claim database, and household non-subsistence expenditure were estimated from Health Statistics. Catastrophic health expenditure was defined as household’s total out-of-pocket payments exceed 40% of non-subsistence expenditure. Stratified analysis by age groups was performed on service use, expenditure and OOP payment. Results Data on 2091 insured cancer patients were collected. Reimbursement rates were over 80% for Shanghai and Beijing while Fuzhou and Chongqing only covered 60%–70% of total medical expenditure. Shanghai had the highest reimbursement rate (88.2%), high total expenditure ($1228) but lowest OOP payment ($170) among the four cities. Chongqing and Fuzhou's insured cancer patients exclusively preferred tertiary hospitals for outpatient services. Fuzhou led the annual total medical expense ($9963), followed by Chongqing, Beijing and Shanghai. The average OOP as proportion of household’s capacity to pay was 87.3% (Chongqing), 66.0% (Fuzhou), 33.7% (Beijing) and 19.6% (Shanghai). Elderly insured cancer patients utilized fewer outpatient services, had lower number of inpatient admissions but longer length of stay, and higher total expenditure. Conclusions Social economic development was not necessarily associated with total medical expense but determined the level of financial protection. The economic burden of insured cancer patients was reduced by insurance but it is still necessary to provide further financial protections and improve affordability of healthcare for cancer patients in China.
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Affiliation(s)
- Wenhui Mao
- School of Public Health, Fudan University, P.O. Box 187, 138 Yi Xue Yuan Road, Shanghai, 200032, China.,Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, 27710, USA
| | - Shenglan Tang
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, 27710, USA.,Duke Kunshan University, No. 8 Duke Avenue, Kunshan, Jiangsu Province, 215316, China
| | - Ying Zhu
- School of Public Health, Fudan University, P.O. Box 187, 138 Yi Xue Yuan Road, Shanghai, 200032, China
| | - Zening Xie
- School of Public Health, Fudan University, P.O. Box 187, 138 Yi Xue Yuan Road, Shanghai, 200032, China
| | - Wen Chen
- School of Public Health, Fudan University, P.O. Box 187, 138 Yi Xue Yuan Road, Shanghai, 200032, China.
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Koch KJ, Cid Pedraza C, Schmid A. Out-of-pocket expenditure and financial protection in the Chilean health care system-A systematic review. Health Policy 2017; 121:481-94. [PMID: 28359550 DOI: 10.1016/j.healthpol.2017.02.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 02/19/2017] [Accepted: 02/21/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Protection against financial risk due to medical spending is an explicit health guarantee within Chile's AUGE health reform. This paper seeks to analyze the degree to which out-of-pocket expenditure still expose Chilean households to financial catastrophe and impoverishment, and to explore inequalities in financial protection. METHODS A systematic literature review was conducted to identify empirical studies analyzing financial protection in Chile. The search included databases as well as grey literature, i.e. governmental and institutional webpages. The indicators are based on the conceptual framework of financial protection, as portrayed in the World Health Report 2013. RESULTS We identify n=16 studies that fulfill the inclusion criteria. Empirical studies indicate that 4% of Chilean households faced catastrophic health expenditure defined as out-of-pocket expenditure exceeding 30% of household's capacity to pay, while less than 1% were pushed into poverty in 2012. In contrast to prior studies, recent data report that even publicly insured who should be fully protected from co-payments were affected by catastrophic health expenditure. Also in the private insurance system financial catastrophe is a common risk. CONCLUSION Despite health reform efforts, financial protection is insufficient and varies to the disadvantage of the poor and vulnerable groups. More research is required to understand why current mechanisms are not as effective as expected and to enable according reforms of the insurance system.
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Mathauer I, Behrendt T. State budget transfers to Health Insurance to expand coverage to people outside formal sector work in Latin America. BMC Health Serv Res 2017; 17:145. [PMID: 28209145 PMCID: PMC5314689 DOI: 10.1186/s12913-017-2004-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 01/11/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Contributory social health insurance for formal sector employees only has proven challenging for moving towards universal health coverage (UHC). This is because the informally employed and the poor usually remain excluded. One way to expand UHC is to fully or partially subsidize health insurance contributions for excluded population groups through government budget transfers. This paper analyses the institutional design features of such government subsidization arrangements in Latin America and assesses their performance with respect to UHC progress. The aim is to identify UHC conducive institutional design features of such arrangements. METHODS A literature search provided the information to analyse institutional design features, with a focus on the following aspects: eligibility/enrolment rules, financing and pooling arrangements, and purchasing and benefit package design. Based on secondary data analysis, UHC progress is assessed in terms of improved population coverage, financial protection and access to needed health care services. RESULTS Such government subsidization arrangements currently exist in eight countries of Latin America (Bolivia, Chile, Colombia, Costa Rica, Dominican Republic, Mexico, Peru, Uruguay). Institutional design features and UHC related performance vary significantly. Notably, countries with a universalist approach or indirect targeting have higher population coverage rates. Separate pools for the subsidized maintain inequitable access. The relatively large scopes of the benefit packages had a positive impact on financial protection and access to care. DISCUSSION AND CONCLUSION In the long term, merging different schemes into one integrated health financing system without opt-out options for the better-off is desirable, while equally expanding eligibility to cover those so far excluded. In the short and medium term, the harmonization of benefit packages could be a priority. UHC progress also depends on substantial supply side investments to ensure the availability of quality services, particularly in rural areas. Future research should generate more evidence on the implementation process and impact of subsidization arrangements on UHC progress.
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Affiliation(s)
- Inke Mathauer
- Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia, 1211 Geneva, Switzerland
| | - Thorsten Behrendt
- Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Friedrich-Ebert-Allee 36, 53113 Bonn, Germany
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Vilcu I, Probst L, Dorjsuren B, Mathauer I. Subsidized health insurance coverage of people in the informal sector and vulnerable population groups: trends in institutional design in Asia. Int J Equity Health 2016; 15:165. [PMID: 27716301 PMCID: PMC5050723 DOI: 10.1186/s12939-016-0436-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 09/06/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Many low- and middle-income countries with a social health insurance system face challenges on their road towards universal health coverage (UHC), especially for people in the informal sector and vulnerable population groups or the informally employed. One way to address this is to subsidize their contributions through general government revenue transfers to the health insurance fund. This paper provides an overview of such health financing arrangements in Asian low- and middle-income countries. The purpose is to assess the institutional design features of government subsidized health insurance type arrangements for vulnerable and informally employed population groups and to explore how these features contribute to UHC progress. METHODS This regional study is based on a literature search to collect country information on the specific institutional design features of such subsidization arrangements and data related to UHC progress indicators, i.e. population coverage, financial protection and access to care. The institutional design analysis focuses on eligibility rules, targeting and enrolment procedures; financing arrangements; the pooling architecture; and benefit entitlements. RESULTS Such financing arrangements currently exist in 8 countries with a total of 14 subsidization schemes. The most frequent groups covered are the poor, older persons and children. Membership in these arrangements is mostly mandatory as is full subsidization. An integrated pool for both the subsidized and the contributors exists in half of the countries, which is one of the most decisive features for equitable access and financial protection. Nonetheless, in most schemes, utilization rates of the subsidized are higher compared to the uninsured, but still lower compared to insured formal sector employees. Total population coverage rates, as well as a higher share of the subsidized in the total insured population are related with broader eligibility criteria. CONCLUSIONS Overall, government subsidized health insurance type arrangements can be effective mechanism to help countries progress towards UHC, yet there is potential to improve on institutional design features as well as implementation.
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Affiliation(s)
- Ileana Vilcu
- Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia, Geneva, 1211 Switzerland
| | - Lilli Probst
- Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia, Geneva, 1211 Switzerland
| | - Bayarsaikhan Dorjsuren
- Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia, Geneva, 1211 Switzerland
| | - Inke Mathauer
- Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia, Geneva, 1211 Switzerland
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Liu X, Sun X, Zhao Y, Meng Q. Financial protection of rural health insurance for patients with hypertension and diabetes: repeated cross-sectional surveys in rural China. BMC Health Serv Res 2016; 16:481. [PMID: 27608976 PMCID: PMC5017002 DOI: 10.1186/s12913-016-1735-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 09/01/2016] [Indexed: 11/10/2022] Open
Abstract
Background The New Cooperative Medical Scheme (NCMS) in rural China has been expanding in both population coverage and benefit package. China has also established an essential medicine policy in recent years to further reduce patients’ medical expenditures and financial burden. This study aims to evaluate the impact of these policies on reducing medical expenditures and financial burden of patients diagnosed with hypertension and diabetes. Methods This study used repeated cross-sectional surveys in 2011 and 2012 in three counties of Shandong Province. Outpatient and inpatient service expenditures and catastrophic health expenditures (CHE) were measured and analyzed. Results Medical expenditures for outpatient services significantly increased for hypertensive and diabetic patients within a 1 year period, while inpatient service expenditures remained unchanged. Although NCMS increased its reimbursement rate, hypertensive and diabetic patients still heavily suffered CHE from both outpatient and inpatient services. Outpatient services were more important factors than inpatient services contributing to non-communicable chronic diseases (NCD) patients’ financial burden. Conclusions The effects of NCMS expansion have been offset by the rapid escalation of medical expenditures. More attention should be paid to the design of NCMS benefit package to cover NCD outpatient services. There is also an urgent need to reform the current Fee for Service to other provider payment methods in order to control the escalating NCD medical expenditures. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1735-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xiaoyun Liu
- China Center for Health Development Studies, Peking University, Beijing, China.
| | - Xiaojie Sun
- Center for Health Management and Policy, Shandong University, Jinan, China
| | - Yang Zhao
- China Center for Health Development Studies, Peking University, Beijing, China
| | - Qingyue Meng
- China Center for Health Development Studies, Peking University, Beijing, China
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Dorjdagva J, Batbaatar E, Svensson M, Dorjsuren B, Kauhanen J. Catastrophic health expenditure and impoverishment in Mongolia. Int J Equity Health 2016; 15:105. [PMID: 27401464 PMCID: PMC4939814 DOI: 10.1186/s12939-016-0395-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 07/04/2016] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The social health insurance coverage is relatively high in Mongolia; however, escalation of out-of-pocket payments for health care, which reached 41 % of the total health expenditure in 2011, is a policy concern. The aim of this study is to analyse the incidence of catastrophic health expenditures and to measure the rate of impoverishment from health care payments under the social health insurance scheme in Mongolia. METHODS We used the data from the Household Socio-Economic Survey 2012, conducted by the National Statistical Office of Mongolia. Catastrophic health expenditures are defined an excess of out-of-pocket payments for health care at the various thresholds for household total expenditure (capacity to pay). For an estimate of the impoverishment effect, the national and The Wold Bank poverty lines are used. RESULTS About 5.5 % of total households suffered from catastrophic health expenditures, when the threshold is 10 % of the total household expenditure. At the threshold of 40 % of capacity to pay, 1.1 % of the total household incurred catastrophic health expenditures. About 20,000 people were forced into poverty due to paying for health care. CONCLUSIONS Despite the high coverage of social health insurance, a significant proportion of the population incurred catastrophic health expenditures and was forced into poverty due to out-of-pocket payments for health care.
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Affiliation(s)
- Javkhlanbayar Dorjdagva
- />Department of Health Policy and Management, School of Public Health, Mongolian National University of Medical Sciences, Zorig Street, Ulaanbaatar, 14210 Mongolia
- />Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Enkhjargal Batbaatar
- />Department of Health Policy and Management, School of Public Health, Mongolian National University of Medical Sciences, Zorig Street, Ulaanbaatar, 14210 Mongolia
| | - Mikael Svensson
- />Health Metrics Unit, the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Jussi Kauhanen
- />Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
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Abstract
Precautionary saving is the additional saving done by individuals to protect them financially in situations of uncertainty and reduce their vulnerability for negative shocks that may affect their consumption levels. This paper investigates the existence and extent of savings motivated by precaution in Mexico for people aged between 50 and 75, using data from the Mexican Health and Ageing Study 2003. The empirical strategy is based on a test of the direct relationship between the accumulated wealth and the uncertainty generated by the social security status, in particular the availability of health insurance, accounting also for the expectation to receive a retirement pension. The endogeneity-corrected estimates do not yield results that unequivocally support the existence of private savings as a risk protection mechanism, implying that the public protection system has an important role in reducing the vulnerability of the population studied.
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Affiliation(s)
| | - Edwin van Gameren
- El Colegio de México, Centro de Estudios Económicos. Mexico City, Mexico.
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Mathauer I, Theisling M, Mathivet B, Vilcu I. State budget transfers to health insurance funds: extending universal health coverage in low- and middle-income countries of the WHO European Region. Int J Equity Health 2016; 15:57. [PMID: 27038787 PMCID: PMC4818884 DOI: 10.1186/s12939-016-0321-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 02/15/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many low-and middle-income countries (LMIC) of the World Health Organization (WHO) European Region have introduced social health insurance payroll taxes after the political transition in the late 1980s, combined with budget transfers to allow for exempting specific population groups from paying contributions, such as those outside formal sector work and in particular vulnerable groups. This paper assesses the institutional design aspects of such financing arrangements and their performance with respect to universal health coverage progress in LMIC of the European region. METHODS The study is based on a literature review and review of secondary databases for the performance assessment. RESULTS Such financing arrangements currently exist in 13 LMIC of that region, with strong commonalities in institutional design: This includes a wide range of different eligible population groups, mostly mandatory membership, integrated pools for both the exempted and contributors, and relatively comprehensive benefit packages. Performance is more varied. Enrolment rates range from about 65 % to above 95 %, and access to care and financial protection has improved in several countries. Yet, inequities between income quintiles persist. CONCLUSIONS Budget transfers to health insurance arrangements have helped to deepen UHC or maintain achievements with respect to UHC in these European LMICs by covering those outside formal sector work, and in particular vulnerable population groups. However, challenges remain: a comprehensive benefit package on paper is not enough as long as supply side constraints and quality gaps as well as informal payments prevail. A key policy question is how to reach those so far uncovered.
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Affiliation(s)
- Inke Mathauer
- />Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia, 1211 Geneva, Switzerland
| | - Mareike Theisling
- />Health, Population Policy, Social Security Division, Federal Ministry for Economic Cooperation and Development, Bonn, Germany
| | - Benoit Mathivet
- />Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia, 1211 Geneva, Switzerland
| | - Ileana Vilcu
- />Consultant with the World Health Organization at the time of writing from October 2014 to December 2015, Avenue Appia, 1211 Geneva, Switzerland
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Habib SS, Perveen S, Khuwaja HMA. The role of micro health insurance in providing financial risk protection in developing countries--a systematic review. BMC Public Health 2016; 16:281. [PMID: 27004824 PMCID: PMC4802630 DOI: 10.1186/s12889-016-2937-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 03/08/2016] [Indexed: 11/24/2022] Open
Abstract
Background Out of pocket payments are the predominant method of financing healthcare in many developing countries, which can result in impoverishment and financial catastrophe for those affected. In 2010, WHO estimated that approximately 100 million people are pushed below the poverty line each year by payments for healthcare. Micro health insurance (MHI) has been used in some countries as means of risk pooling and reducing out of pocket health expenditure. A systematic review was conducted to assess the extent to which MHI has contributed to providing financial risk protection to low-income households in developing countries, and suggest how the findings can be applied in the Pakistani setting. Methods We conducted a systematic search for published literature using the search terms “Community based health insurance AND developing countries”, “Micro health insurance AND developing countries”, “Mutual health insurance AND developing countries”, “mutual OR micro OR community based health insurance” “Health insurance AND impact AND poor” “Health insurance AND financial protection” and “mutual health organizations” on three databases, Pubmed, Google Scholar and Science Direct (Elsevier). Only those records that were published in the last ten years, in English language with their full texts available free of cost, were considered for inclusion in this review. Hand searching was carried out on the reference lists of the retrieved articles and webpages of international organizations like World Bank, World Health Organization and International Labour Organization. Results Twenty-three articles were eligible for inclusion in this systematic review (14 from Asia and 9 from Africa). Our analysis shows that MHI, in the majority of cases, has been found to contribute to the financial protection of its beneficiaries, by reducing out of pocket health expenditure, catastrophic health expenditure, total health expenditure, household borrowings and poverty. MHI also had a positive safeguarding effect on household savings, assets and consumption patterns. Conclusion Our review suggests that MHI, targeted at the low-income households and tailored to suit the cultural and geographical structures in the various areas of Pakistan, may contribute towards providing protection to the households from catastrophe and impoverishment resulting from health expenditures. This paper emphasizes the need for further research to fill the knowledge gap that exists about the impact of MHI, using robust study designs and impact indicators.
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Affiliation(s)
- Shifa Salman Habib
- Department of Community Health Sciences, The Aga Khan University, Stadium Road, 74800, Karachi, Pakistan.
| | - Shagufta Perveen
- Department of Community Health Sciences, The Aga Khan University, Stadium Road, 74800, Karachi, Pakistan
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Abstract
Background: Out of pocket expenditure (OOPE) for any illness is still a major problem in India. Several evidence is available regarding growing OOPE and its impact on household poverty. However, limited evidence is there regarding OOPE on multiple disease conditions in public hospitals. Aim: To estimate the OOPE for various hospitalized conditions at the secondary level of care in Odisha and find out various financial coping mechanisms adopted by the patients. Methods: The primary survey was done in the secondary care hospitals in the two districts of Odisha using a semi-structured interview schedule. Data were collected from 284 subjects (212 males, 72 females) in 2014 on the socioeconomic status and OOPE on multiple disease conditions. Descriptive statistics using Stata Version 11 were used to estimate the results. Results: The mean total OOPE was Indian Rupees (INR) 2107 (95% confidence interval [CI]: 1788–2426) for single episode of hospitalization out of which medical expenditure was INR 1530 (95% CI: 1238–1821) and nonmedical expenditure was INR 577 (95% CI: 501–653). The OOPE on surgical conditions was 1.7 times more than the nonsurgical conditions. Drugs and diagnostics were the major components of hospital expenditure, whereas the share of transportation expenditure was more in the nonmedical expenditure. Further, most of the patients had to face hardship financing due to limited financial protection measures. Conclusions: With the growing debate on the rolling out of universal health insurance scheme in India, this study assumes significance by providing critical information for designing public financing strategies to protect the interest of the poor in public health care institutions.
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Affiliation(s)
- Sarit Kumar Rout
- Indian Institute of Public Health, Bhubaneswar, Odisha, PHFI, India
| | | | - Subhashisa Swain
- Indian Institute of Public Health, Bhubaneswar, Odisha, PHFI, India
| | - Sanghamitra Pati
- Indian Institute of Public Health, Bhubaneswar, Odisha, PHFI, India
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Cylus J, Papanicolas I. An analysis of perceived access to health care in Europe: How universal is universal coverage? Health Policy 2015; 119:1133-44. [PMID: 26252959 DOI: 10.1016/j.healthpol.2015.07.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 05/07/2015] [Accepted: 07/13/2015] [Indexed: 10/23/2022]
Abstract
The objective of this paper is to examine variations in perceptions of access to health care across and within 29 European countries. Using data from the 2008 round of the European Social Survey, we investigate the likelihood of an individual perceiving that they will experience difficulties accessing health care in the next 12 months, should they need it (N=51,835). We find that despite most European countries having mandates for universal health coverage, individuals who are low income, in poor health, lack citizenship in the country where they reside, 20-30 years old, unemployed and/or female have systematically greater odds of feeling unable to access care. Focusing on the role of income, we find that while there is a strong association between low income and perceived access barriers across countries, within many countries, perceptions of difficulties accessing care are not concentrated uniquely among low-income groups. This implies that factors that affect all income groups, such as poor quality care and long waiting times may serve as important barriers to access in these countries. Despite commitments to move towards universal health coverage in Europe, our results suggest that there is still significant heterogeneity among individuals' perceptions of access and important barriers to accessing health care.
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Affiliation(s)
- Jonathan Cylus
- European Observatory on Health Systems and Policies, London School of Economics, Houghton Street, WC2A 2AE London, United Kingdom.
| | - Irene Papanicolas
- Department of Social Policy, London School of Economics, Houghton Street, WC2A AE London, United Kingdom.
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Savitha S, Kiran KB. Effectiveness of micro health insurance on financial protection: Evidence from India. Int J Health Econ Manag 2015; 15:53-71. [PMID: 27878668 DOI: 10.1007/s10754-014-9158-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 11/24/2014] [Indexed: 06/06/2023]
Abstract
Iatrogenic poverty caused by inadequate public expenditure on health, lack of social health insurance and low penetration of private health insurance can be mitigated by micro health insurance (MHI) schemes that provide financial protection. The empirical evidence on the impact of MHI on financial protection is limited in India. This paper elucidates the effect of Sampoorna Suraksha Programme (SSP), a MHI scheme in Karnataka on financial protection. Cross-sectional study was undertaken in Karnataka and the data was gathered from 416 insured, 366 newly insured and 364 uninsured households. The impact of SSP on out of pocket expenses (OOPE), catastrophic health expenditure (CHE), non-medical consumption expenditure, hardship financing and labour supply was analysed using linear and logistic regression methods. Results of the study demonstrate that insured members incurred lower OOPE, CHE and hardship finance. There was no effect on consumption expenditure and no direct impact on labour supply measured in terms of withdrawal from workforce and substitution of labour. We advocate a larger role of MHI in health financing in India since it curtails impoverishment of households in informal sector by reducing OOPE and hardship financing.
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Affiliation(s)
- S Savitha
- School of Management, Manipal University, Manipal, India.
| | - K B Kiran
- Department of Humanities, Social Sciences & Management, National Institute of Technology Karnataka, Surathkal, Karnataka, India
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Flores G, Ir P, Men CR, O'Donnell O, van Doorslaer E. Financial protection of patients through compensation of providers: the impact of Health Equity Funds in Cambodia. J Health Econ 2013; 32:1180-1193. [PMID: 24189447 DOI: 10.1016/j.jhealeco.2013.09.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Revised: 01/07/2013] [Accepted: 09/16/2013] [Indexed: 06/02/2023]
Abstract
Public providers have no financial incentive to respect their legal obligation to exempt the poor from user fees. Health Equity Funds (HEFs) aim to make exemptions effective by giving NGOs responsibility for assessing eligibility and compensating providers for lost revenue. We use the geographic spread of HEFs over time in Cambodia to identify their impact on out-of-pocket (OOP) payments. Among households with some OOP payment, HEFs reduce the amount paid by 35%, on average. The effect is larger for households that are poorer and mainly use public health care. Reimbursement of providers through a government operated scheme also reduces household OOP payments but the effect is not as well targeted on the poor. Both compensation models raise household non-medical consumption but have no impact on health-related debt. HEFs reduce the probability of primarily seeking care in the private sector.
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Affiliation(s)
- Gabriela Flores
- Institute of Health Economics and Management, University of Lausanne, Switzerland; Institute of Health Policy and Management, Erasmus University Rotterdam, The Netherlands
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Moghadam MN, Banshi M, Javar MA, Amiresmaili M, Ganjavi S. Iranian Household Financial Protection against Catastrophic Health Care Expenditures. Iran J Public Health 2012. [PMID: 23193508 PMCID: PMC3494217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Protecting households against financial risks is one of objectives of any health system. In this regard, Iran's fourth five year developmental plan act in its 90th article, articulated decreasing household's exposure to catastrophic health expenditure to one percent. Hence, this study aimed to measure percentage of Iranian households exposed to catastrophic health expenditures and to explore its determinants. METHODS The present descriptive-analytical study was carried out retrospectively. Households whose financial contributions to the health system exceeded 40% of disposable income were considered as exposed to catastrophic healthcare expenditures. Influential factors on catastrophic healthcare expenditures were examined by logistic regression and chi-square test. RESULTS Of 39,088 households, 80 were excluded due to absence of food expenditures. 2.8% of households were exposed to catastrophic health expenditures. Influential factors on catastrophic healthcare were utilizing ambulatory, hospital, and drug addiction cessation services as well as consuming pharmaceuticals. Socioeconomics characteristics such as health insurance coverage, household size, and economic status were other determinants of exposure to catastrophic healthcare expenditures. CONCLUSION Iranian health system has not achieved the objective of reducing catastrophic healthcare expenditure to one percent. Inefficient health insurance coverage, different fee schedules practiced by private and public providers, failure of referral system are considered as probable barriers toward decreasing households' exposure to catastrophic healthcare expenditures.
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Affiliation(s)
- M Nekoei Moghadam
- Research Centre for Health Services Management, Kerman University of Medical Sciences, Kerman, Iran
| | - M Banshi
- Research Center for Modeling in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - M Akbari Javar
- Students’ Research Committee, Kerman University of Medical Sciences, Kerman, Iran
| | - M Amiresmaili
- Medical Informatics Research Center, Kerman University of Medical Sciences, Haftbagh Highway, Kerman, Iran,Corresponding Author: Tel: 0098 341 3205158, E-mail address:
| | - S Ganjavi
- Students’ Research Committee, Kerman University of Medical Sciences, Kerman, Iran
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