Abstract
BackgroundFinancial risk protection and equity are major components of universal health coverage (UHC), which is defined as ensuring access to health services for all citizens without any undue financial burden. We investigated progress towards UHC financial risk indicators and assessed variability of inequalities in financial risk protection indicators by wealth quintile. We further examined the determinants of different financial hardship indicators related to healthcare costs.MethodsA cross-sectional, three-stage probability survey was conducted in Bangladesh, which collected information from 1600 households from August to November 2011. Catastrophic health payments, impoverishment, and distress financing (borrowing or selling assets) were treated as financial hardship indicators in UHC. Poisson regression models were used to identify the determinants of catastrophic payment, impoverishment and distress financing separately. Slope, relative and concentration indices of inequalities were used to assess wealth-based inequalities in financial hardship indicators.ResultsThe study found that around 9% of households incurred catastrophic payments, 7% faced distress financing, and 6% experienced impoverishing health payments in Bangladesh. Slope index of inequality indicated that the incidence of catastrophic health payment and distress financing among the richest households were 12 and 9 percentage points lower than the poorest households respectively. Multivariable Poisson regression models revealed that all UHC financial hardship indicators were significantly higher among household that had members who received inpatient care or were in the poorest quintile. The presence of a member with chronic illness in a household increased the risk of impoverishment by nearly double.ConclusionThis study identified a greater inequality in UHC financial hardship indicators. Rich households in Bangladesh were facing disproportionately less financial hardship than the poor ones. Households can be protected from financial hardship associated with healthcare costs by implementing risk pooling mechanism, increasing GDP spending on health, and properly monitoring subsidized programs in public health facilities.
Highlights
Financial risk protection and equity are major components of universal health coverage (UHC), which is defined as ensuring access to health services for all citizens without any undue financial burden
Equity in financial hardship indicators Around 9.0% of households incurred catastrophic health payment, 5.6% of households experienced impoverishing health expenditure, and 7.0% faced distress financing to pay for health care costs (Fig. 1)
Significant differences in catastrophic payment and distress financing among poor and rich households were found in all three measures of inequality indices (Table 2)
Summary
Financial risk protection and equity are major components of universal health coverage (UHC), which is defined as ensuring access to health services for all citizens without any undue financial burden. There are two key targets in UHC plan: having at least 80% essential health service coverage, and 100% financial risk protection from catastrophic and impoverishing payment for health services by 2030 [2, 3]. Financial risk protection plan is accepted as a key mechanism to ensure affordable and equitable access to care for all citizens of a country irrespective of their socio-economic statuses [4]. Similar to other South Asian countries, Bangladesh is simultaneously experiencing a double burden of diseases, low health service coverage, and a lack of financial risk protection mechanism in their health system [5, 6]. There are a number of small scale NGO-based community insurance schemes, often operating in conjunction with micro-financing schemes, but these cover less than 1% of the total population and target mainly poor populations [9]
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