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

Carlota Quintal

doi:10.1186/s12939-019-1044-9

Abstract

BackgroundCatastrophic 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.MethodsData 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.ResultsThe 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).ConclusionsThe 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.

Highlights

Catastrophic health expenditure (CHE) is well established as an indicator of financial protection on which there is extensive literature
When research on catastrophic health expenditure emerged in the literature [6, 8], the example of Portugal was highlighted as an Organisation for Economic Cooperation and Development (OECD) country with an unexpectedly high level of CHE
In what concerns the distribution of CHE across types of households, our results suggest that CHE is concentrated on households with elderly, which is in line with previous evidence that found that the presence of elderly in households increased the risk of CHE in Portugal [32, 33] and elsewhere [34, 35]

Summary

Introduction

Catastrophic health expenditure (CHE) is well established as an indicator of financial protection on which there is extensive literature. The financial protection of families, when using needed healthcare, has been long recognised as a core dimension of health system evaluation [1, 2], becoming part of the 17 Sustainable Development Goals promoted by the United Nations in 2015 [3]. In this context, catastrophic health expenditure (CHE) is an established indicator of the financial protection dimension. We further look at the distribution of the health expenditure of families incurring CHE across types of healthcare

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Methods

Results

Discussion

Conclusion