Disease-specific distress healthcare financing and catastrophic out-of-pocket expenditure for hospitalization care in Bangladesh

Despite universal health coverage, patients with chronic kidney disease (CKD) in middle-income nations still face financial hardship. Catastrophic health care expenditures (CHEs) serve as a valuable index of patient-derived financial hardship, but few studies have explored the connection of CHE with clinical correlates, especially in patients with CKD. This study aimed to assess the association between CHE and health-related quality of life (HRQoL) in a spectrum of patients with CKD in Thailand. A multicenter, nationwide cross-sectional study. Patients with CKD (stages 3-5 and dialysis) from 11 centers across Thailand. Catastrophic health expenditures. Health-related quality of life. Data on clinical, socioeconomic status, and out-of-pocket expenses were acquired via interviews. The CHE was defined ashealth care expenditures of at least 40% of the household's capacity to pay. The HRQoL wasassessed using the EuroQol-5 Dimensions (EQ5DL) questionnaire. Fractional and multivariable logistic regression models were used to determine the CHE's effect on EQ5DL composite utility scores and each HRQoL dimension. Of 1,224 patients with CKD, 20% experienced CHE. EuroQol-5 Dimensions utility scores were notably lower in those with CHE (CHE, 0.76 vs No CHE, 0.82, P<0.001) after adjustments for confounding factors. Differences between CHE and non-CHE appeared in mobility, self-care, and usual activity, with multivariable analysis showing more severe mobility and activity issues in CHE. (adjusted OR [95% CI] in CHE vs non-CHE: mobility: 1.89 [1.23-2.91], P=0.004; usual activity: 1.82 [1.10-3.02], P=0.020]. Cross-sectional design prevents causal inferences. Despite health coverage, patients with CKD with financial strain experience reduced quality of life, with pronounced effects on mobility and daily activity. Integrating the assessment of patient-derived financial burden is an essential step into CKD care plans in middle-income countries.

A look at catastrophic medical expenses and the poor.

Every health system needs to take action to shield households from the expense of medical costs. The Ethiopian government implemented community-based health insurance (CBHI) to protect households from catastrophic health care expenditure (CHE) and enhance the utilization of health care services. The impact of CBHI on CHE with total household expenditure and non-food expenditure measures hadn't been studied, so the study aimed to evaluate the impact of CBHI on CHE among households in Kutaber district, Ethiopia. A total of 472 households (225 insured and 247 uninsured) were selected by multistage sampling techniques. Households total out-of-pocket (OOP) health payments ≥10% threshold of total household expenditure or ≥40% threshold of household non-food expenditure categorized as CHE. The co-variants for participation in the CBHI scheme were estimated by using a probit regression model. A propensity score matching analysis was used to determine the impact of CBHI on CHE. A Chi-square (χ2) test was computed to compare CHE between insured and uninsured households. The magnitude of CHE was 39.1% with total household expenditure and 1.8% with non-food expenditure measures among insured households. Insured households were 46.3% protected from CHE when compared to uninsured households with total household expenditure measures and 24.2% to 25% with non-food expenditure measures. The magnitude of CHE was lower among CBHI-enrolled households. CBHI is an effective means of financial protection benefits for households as a share of total household expenditure and non-food expenditure measures. Therefore, increasing the upper limits of benefit packages, minimizing exclusions, and CBHI scale-up to uninsured households is essential.

BackgroundChina has been undergoing tremendous demographic and epidemiological transitions during the past three decades and increasing burden from non-communicable diseases and an ageing population have presented great health-care challenges for the country. Numerous studies examine catastrophic healthcare expenditures (CHE) worldwide on whole populations rather than specific vulnerable groups. As hypertension and other chronic conditions impose a growing share of the disease burden in China, they will become an increasingly important component of CHE. This study aims to estimate households with hypertension incurring CHE and its income-related inequality in the rural areas of Shaanxi Province.MethodsData were obtained from the National Household Health Service Surveys of Shaanxi Province conducted in 2013 and 13104 households were identified for analysis. The households were classified into three types: households with non-chronic diseases, households with hypertension only and households with hypertension plus other chronic diseases. CHE was measured according to the proportion of out-of-pocket health payments to non-food household expenditures and the concentration index was employed to measure the extent of income-related inequality in CHE. A decomposition method based on a probit model was used to decompose the concentration index into its determining components.ResultsThe incurring of CHE of households with hypertension is at a disconcerting level compared to households with non-chronic diseases. Households with hypertension only and households with hypertension plus other chronic diseases incurred CHE in 23.48% and 34.01% of cases respectively whereas households with non-chronic diseases incurred CHE in only 13.33%. The concentration index of households with non-chronic diseases is -0.4871. However, the concentration index of households with hypertension only and households with hypertension plus other chronic diseases is -0.4645 and -0.3410 respectively. The majority of observed inequalities in CHE were explained by household economic status and having elder members.ConclusionsThe proportion of households incurring CHE in the rural areas of Shaanxi Province was considerably high in all three types of households and households with hypertension were at a higher risk of incurring CHE. Furthermore, there existed a strong pro-poor inequality of CHE in all three types of households and the results implied more inequality in households with non-chronic diseases compared with two other groups. Our study suggests that more concern needs to be directed toward households with hypertension plus other chronic diseases and households having elder members.

Out-of-Pocket and Total Costs for Common Hand Procedures From 2008 to 2016: A Nationwide Claims Database Analysis

BackgroundOut-of-pocket (OOP) cost of cancer treatment has increased substantially globally. In low- and middle-income countries, many patients face financial distress due to cancer. For patients with cancers in Bangladesh, this study aimed to (1) estimate the annual OOP cost of cancers from households’ perspective, (2) assess the coping strategies and financial distress, and (3) examine factors associated with OOP cost.MethodsWe used data from a cross-sectional hospital-based survey conducted in three randomly selected hospitals in Bangladesh. A bottom-up micro-costing approach was used to estimate the OOP cost components. We used the logistic regression model and the generalized linear model to examine the determinants of distress financing and OOP cost, respectively.ResultsThe average annual OOP cost per cancer patient was US$ 6,504 (range, US$ 959 − 29,681), which was greater than 2 times the average annual household income. About 90% of households faced distress financing due to cancer. Having at least one comorbid condition, cancer stage 2 or higher, households having no elderly people, or having treatment abroad was significantly associated with a higher OOP cost compared to those without the condition.ConclusionOOP cost of cancer treatment and the proportions of patients with distress financing and financial catastrophe are alarmingly high in Bangladesh. Earlier cancer diagnosis and implementation of Government financial health protection schemes are crucial and urgent to alleviate the enormous economic burden and ensure equitable access to care for the patients.

BackgroundDental healthcare is the costliest and single most source of the financial barrier to seeking and use of needed healthcare. Hence, this study aims to analyses impact of out-of-pocket (OOP) payments for dental services on prevalence catastrophic healthcare expenditure (CHE) among Iranian households during 2018.MethodsWe performed a cross-sectional analysis to determine the prevalence rate of CHE due to use of dental healthcare services among 38,858 Iranian households using the 2018 Household Income and Expenditure Survey (HIES) survey data of Iran. The WHO approach was used to determine the CHE due to use of dental care services at the 40% of household capacity to pay (CTP). Multiple logistic regression models were used to obtain the odds of facing with CHE among households that paid for any dental healthcare services over the last month while adjusting for covariates included in the model. These findings were reported for urban, rural areas and also for low, middle and high human development index HDI across provinces.ResultsThe study indicated that the prevalence of CHE among households that used and did not used dental services over the last month was 16.5% (95% CI: 14.9 to 18.3) and 4.3% (95% CI: 4.1 to 4.6), respectively. The adjusted odds ratio (AOR) for the covariates revealed that the prevalence of CHE for the overall households that used dental healthcare service was 6.2 times (95% CI: 5.4 to 7.1) than those that did not use dental healthcare services. The urban households that used dental healthcare had 7.8 times (95%CI: 6.4–9.4) while the rural ones had 4.7 times (95% CI: 3.7–5.7) higher odds of facing CHE than the corresponding households that did not use dental healthcare services.ConclusionsThe study indicates that out-of-pocket costs for dental care services impose a substantial financial burden on household’s budgets at the national and subnational levels. Alternative health care financing strategies and policies targeted to the reduction in CHE in general and CHE due to dental services in particular are urgently required in low and middle income countries such as Iran.

Kidney replacement therapy in chronic kidney disease patients can result in catastrophic health costs, pushing them into poverty in lower middle-income countries. There are only limited studies from India focusing on the financial hardship of these patients. Data on direct nonmedical and indirect cost of hemodialysis (HD) are also limited. This study aims to find the different components of cost for HD and its association with quality of life (QOL) among HD patients. Primary objective was to find the cost of HD, which include direct medical, direct nonmedical and indirect cost. Secondary objective was to study whether the ratio of out-of-pocket (OOP) payments for HD to household income can affect the QOL. The QOL was assessed using EQ-5D-5L instrument. Catastrophic health care expenditure was defined as OOP health care expenditure exceeding 40% of the household income and distress financing as borrowing money or selling assets to meet the OOP expenditure for treatment. Of the 152 patients enrolled for the study, 103 (67.8%) were males. Mean age was 60.9 ± 12.5 years. Monthly OOP expenditure for dialysis was USD 478.4 (362.6-663.6) of which direct nonmedical and indirect expenses constitute USD 115.6 (88.4-292.4). Median percentage of household income spent for dialysis was 194.5 (IQR 128-297). One hundred and forty-two (93.4%) had catastrophic healthcare expenditure and 76 (50%) had distressing health care expenditure. On multivariable linear regression, proportion of total household income spend for dialysis was associated with poor QOL in patients undergoing HD; coefficient=-0.04 (95% CI -0.008 - 0.092), p=0.039. Nonmedical direct and indirect cost is substantial among patients undergoing HD. Nine of 10 patients had catastrophic health care expenditure, which pushed 50% of the patients to distress financing.

Rural‒urban disparity in catastrophic healthcare expenditure (CHE) is a well-documented challenge in low- and middle-income countries, including Bangladesh, limiting financial protection and hindering the achievement of the Universal Health Coverage target of the United Nations Sustainable Development Goals. However, the factors driving this divide remain poorly understood. Therefore, this study aims to identify the key determinants of the rural‒urban disparity in CHE incidence in Bangladesh and their changes over time. We used nationally representative data from the latest three rounds of the Bangladesh Household Income and Expenditure Survey (2005, 2010, and 2016). CHE incidence among households seeking healthcare was measured using the normative food, housing, and utilities method. To quantify covariate contributions to the rural‒urban CHE gap, we employed the Oaxaca-Blinder multivariate decomposition approach, adapted by Powers et al. for nonlinear response models. CHE incidence among rural households increased persistently during the study period (2005: 24.85%, 2010: 25.74%, 2016: 27.91%) along with a significant (p-value ≤ 0.01) rural‒urban gap (2005: 9.74%-points, 2010: 13.94%-points, 2016: 12.90%-points). Despite declining over time, substantial proportions of CHE disparities (2005: 87.93%, 2010: 60.44%, 2016: 61.33%) are significantly (p-value ≤ 0.01) attributable to endowment differences between rural and urban households. The leading (three) covariate categories consistently contributing significantly (p-value ≤ 0.01) to the CHE gaps were composition disparities in the lowest consumption quintile (2005: 49.82%, 2010: 36.16%, 2016: 33.61%), highest consumption quintile (2005: 32.35%, 2010: 15.32%, 2016: 18.39%), and exclusive reliance on informal healthcare sources (2005: -36.46%, 2010: -10.17%, 2016: -12.58%). Distinctively, the presence of chronic illnesses in households emerged as a significant factor in 2016 (9.14%, p-value ≤ 0.01), superseding the contributions of composition differences in household heads with no education (4.40%, p-value ≤ 0.01) and secondary or higher education (7.44%, p-value ≤ 0.01), which were the fourth and fifth significant contributors in 2005 and 2010. Rural‒urban differences in household economic status, educational attainment of household heads, and healthcare sources were the key contributors to the rural‒urban CHE disparity between 2005 and 2016 in Bangladesh, with chronic illness emerging as a significant factor in the latest period. Closing the rural‒urban CHE gap necessitates strategies that carefully address rural‒urban variations in the characteristics identified above.

Objective:Oral cancer causes a significant disease burden and financial distress, especially among disadvantaged groups. While Malaysia has achieved universal health coverage via its highly subsidized public healthcare, patient and family expenditure for treatment of oral potentially malignant disorders (OPMD) and oral cancer remains a concern in the equitability of care. This study thus aims to estimate household out-of-pocket (OOP) expenditures and the extent of catastrophic healthcare expenditure (CHE) while identifying its predictors. Methods:This three-part study consists of a cross-sectional survey to collect sociodemographic and health utilization data of patients, a retrospective medical record abstraction to identify resources consumed, and cost modeling to simulate expenditures in two tertiary public hospitals. Loss of productivity was calculated based on absenteeism related to disease management in the hospital. OOP payments for transport, care in public healthcare facilities, and other healthcare expenditures were tallied. A CHE was defined as OOP spendings of more than 10% from total annual household income. Multivariable logistic regression was further applied to identify the association between sociodemographic factors and the incidence of CHE. Results:A total of 52 patients with OPMD and 52 with oral cancer were surveyed and medical records were abstracted. A Kruskal-Wallis test showed a statistically significant difference in OOP share over household income between OPMD, early- and late-stage cancer, χ2(2)=51.05, p<0.001, with the mean percentage of 9%, 22%, and 65% respectively. This study found that the prevalence of CHE in the first year of diagnosis was 86.5% for oral cancer and 19.2% for OPMD. Indian ethnicity (OR=6.24, p=0.046) and monthly income group ‘less than USD 2,722’ (OR=14.32, p=0.023) were shown as significant predictors for CHE. Conclusions:Our study demonstrated the provision of subsidies may not be adequate to shield the more vulnerable group from CHE when they are diagnosed with OPMD and oral cancer.

Background: Out-of-pocket expenses (OOPE) are the primary means of funding healthcare costs in developing nations, and when the cost is too high, it leads to catastrophic healthcare expenditures (CHE). Aim &amp; Objective: This study aimed to assess the proportion of households that faced CHE and also examined the associated factors that determine CHE at the household level. Methods and Material: Between September 2020 and February 2021, a cross-sectional study covering a sample of 771 households was conducted in four districts of Assam. A multistage sampling design was employed to select the sample households. Statistical analysis used: Binary logistic regression analysis has been performed to ascertain the factors that could determine household CHE. Results: 23% households had experienced CHE, high dependence on the private healthcare system. Monthly household income, duration of illness, presence of children under five years of age and elderly members, education of household head, and health insurance were the significant factors influencing CHE. Conclusions: The study identified the growing use of private healthcare services as a major concern that contributes to the prevalence of CHE. To make all healthcare services accessible and affordable and to lower OOP on healthcare, it is also crucial to improve the infrastructure and quality of the public healthcare system in rural and remote locations.

IntroductionEthiopian households’ out-of-pocket healthcare payments constitute one-third of the national healthcare budget and are higher than the global and low-income countries average, and even the global target. Such out-of-pocket payments pose severe financial risks, can be catastrophic, impoverishing, and one of the causal barriers for low utilisation of healthcare services in Ethiopia. This study aimed to assess the financial risk of seeking maternal and neonatal healthcare in southern Ethiopia.MethodsA population-based cohort study was conducted among 794 pregnant women, 784 postpartum women, and their 772 neonates from 794 households in rural kebeles of the Wonago district, southern Ethiopia. The financial risk was estimated using the incidence of catastrophic healthcare expenditure, impoverishment, and depth of poverty. Annual catastrophic healthcare expenditure was determined if out-of-pocket payments exceeding 10% of total household or 40% of non-food expenditure. Impoverishment was analysed based on total household expenditure and the international poverty line of ≈ $1.9 per capita per day.ResultsApproximately 93% (735) of pregnant women, 31% (244) of postpartum women, and 48% (369) of their neonates experienced illness. However, only 56 households utilised healthcare services. The median total household expenditure was $527 per year (IQR = 390: 370,760). The median out-of-pocket healthcare payment was $46 per year (IQR = 46: 46, 92) with two episodes per household, and shared 19% of the household’s budget. The poorer households paid more than did the richer for healthcare, during pregnancy-related and neonatal illness. However, the richer paid more than did the poorer during postpartum illness. Forty-six percent of households faced catastrophic healthcare expenditure at the threshold of 10% of total household expenditure, or 74% at a 40% non-food expenditure, and associated with neonatal illness (aRR: 2.56, 95%CI: 1.02, 6.44). Moreover, 92% of households were pushed further into extreme poverty and the poverty gap among households was 45 Ethiopian Birr per day. The average household size among study households was 4.7 persons per household.ConclusionsThis study demonstrated that health inequity in the household’s budget share of total OOP healthcare payments in southern Ethiopia was high. Besides, utilisation of maternal and neonatal healthcare services is very low and seeking such healthcare poses a substantial financial risk during illness among rural households. Therefore, the issue of health inequity should be considered when setting priorities to address the lack of fairness in maternal and neonatal health.

Direct oral anticoagulants (DOACs) are used to prevent thrombosis in patients with nonvalvular atrial fibrillation (NVAF) and venous thromboembolism (VTE). Despite their clinical benefits, some patients abandon their DOAC prescription. To retrospectively evaluate the association between patient out-of-pocket (OOP) costs and abandonment of the first DOAC prescription among patients with NVAF or VTE in the United States. Data from Symphony Health, an ICON plc Company, PatientSource (April 1, 2017, to October 31, 2020) were used to select patients with NVAF or VTE with an approved or abandoned claim for a DOAC (apixaban, dabigatran, rivaroxaban). OOP costs (2021 US dollars) of the index claim were described by abandonment status, and multivariable logistic regression models were used to evaluate the association between OOP costs of the index DOAC claim and abandonment. Analyses were performed in patients with NVAF and VTE separately. Among 753,755 patients with NVAF, 88.5% had an approved index DOAC claim and 11.5% had an abandoned index DOAC claim. Among 308,429 patients with VTE, 91.5% had an approved index DOAC claim and 8.5% had an abandoned index DOAC claim. Mean OOP costs of the index DOAC claim were lower in those with an approved than abandoned claim (NVAF approved vs abandoned: $79 vs $175; VTE approved vs abandoned: $65 vs $133). Among patients with NVAF, 21.4% of those with an approved claim and 9.1% of those with an abandoned claim had no OOP costs, 58.7% (approved) and 49.0% (abandoned) had OOP costs greater than $0 to less than $100, and 19.9% (approved) and 41.9% (abandoned) had OOP costs greater than or equal to $100; among patients with VTE, 27.8% (approved) and 15.6% (abandoned) had no OOP costs, 58.4% (approved) and 54.8% (abandoned) had OOP costs greater than $0 to less than $100, and 13.8% (approved) and 29.6% (abandoned) had OOP costs greater than or equal to $100. In multivariable models, the risk of abandonment increased by 21% (NVAF) and 17% (VTE) for each $100 in OOP costs (both P < 0.001). Relative to patients with no OOP costs, patients with OOP costs greater than $0 to less than $50 were 86% (NVAF) and 55% (VTE) more likely to abandon their index DOAC, patients with OOP costs greater than $50 to less than $100 were 80% (NVAF) and 111% (VTE) more likely to abandon their index DOAC, and patients with OOP costs greater than or equal to $100 were 332% (NVAF) and 244% (VTE) more likely to abandon their index DOAC (all P < 0.001). Among patients with NVAF or VTE, OOP costs of the first DOAC claim greater than or equal to $100 were associated with the highest risk of abandoning the first DOAC prescription.

The aims of this study were to assess factors associated with catastrophic healthcare expenditure (CHE) and the burden of out-of-pocket (OOP) payments for specific healthcare services in Peru. We used data from 30,966 households that participated in the 2016 National Household Survey (Encuesta Nacional de Hogares, ENAHO). Participants reported household characteristics and expenditure on ten healthcare services. CHE was defined as healthcare spending equal to or higher than 40% of the household's capacity to pay. The associations of various household characteristics and OOP payments for specific healthcare services with CHE were assessed in logistic regression models. Poorer, rural and smaller households as well as those with older adults and individuals with chronic conditions had greater odds of facing CHE. According to the estimates from the adjusted regression model, healthcare services could be grouped into three groups. Medical tests, surgery and medication were in the first group with odds ratios (ORs) between 6.43 and 4.72. Hospitalisation, outpatient, dental and eye care were in the second group with ORs between 2.61 and 1.46. Child care, maternity care and other healthcare services (such as contraceptives, rehabilitation, etc.) were in the third group with non-significant ORs. Many Peruvian households are forced to finance their healthcare through OOP payments, burdening their finances to the extent of affecting their living standards.

Using a repeated cross-section data set from Ghana for 1991/1992, 1998/1999, 2005/2006, 2012/2013 and 2016/17, and a Two-Stage Least Squares estimator, this paper investigates the effect of agricultural income on remittances and consumption expenditure. It is found that households in Ghana use remittances to protect themselves from decline in agricultural income due to rainfall failure. The results suggest that a 100 Ghana Cedis decrease in agricultural income leads to a 30 Ghana Cedis increase in remittances. The results further posit that rainfall-induced agricultural income changes affect total consumption and food expenditures of rural households. A 100 Ghana Cedis decrease in agricultural income due to rainfall failure leads to a 60 Ghana Cedis fall in total consumption expenditure, and 36 Ghana Cedis fall in food expenditure of rural households. Very poor households in rural areas are found to be more vulnerable to such rainfall-driven agricultural income changes.