Catastrophic Health Spending Research Articles

Persistent low adherence to hypertension treatment in Kyrgyzstan: How can we understand the role of drug affordability?

It is well known that cardiovascular diseases (CVD) are a growing cause of mortality and morbidity in low-and middle-income countries (LMIC). While hypertension (HTN), a leading risk factor for CVD, can be easily managed with widely available medicines, there is a huge gap in treatment for HTN in many LMIC. One such country is Kyrgyzstan, where HTN is a major public health concern and adherence to medication is low. The reasons for low adherence in Kyrgyzstan are not well understood, but some evidence suggests that HTN medicines may be unaffordable for low-income families, resulting in inequitable access to HTN treatment. With data from the 2010 Kyrgyzstan Integrated Household Survey, we estimate the prevalence and factors associated with adherence to HTN medication in Kyrgyzstan. We then investigate the hypothesis that affordability may be an important factor in adherence to HTN medication. Using the coarsened exact matching approach, we estimate the economic burden faced by households with at least one member with elevated blood pressure (EBP) in Kyrgyzstan and their risk of catastrophic spending on health care. We find that EBP households have significantly higher total expenditure on health, as well as on medicines, and are more likely to experience catastrophic health spending, suggesting that out-of-pocket expenditure for EBP may be prohibitively expensive for the poorest in Kyrgyzstan. Our findings also reveal a high prevalence of self-medication (i.e. purchasing and using medication without a doctor's prescription), and increased expenditure due to self-medication, among those with EBP. Our research suggests that affordability of HTN medicines may be an important factor in low adherence to treatment in Kyrgyzstan. Low affordability may be due partly to the prescription of medicines that are not reimbursable under the national drug benefit plan, but more research is needed to identify solutions to the affordability problem.

Coping with the economic burden of Diabetes, TB and co-prevalence: evidence from Bishkek, Kyrgyzstan.

BackgroundThe increasing number of patients co-affected with Diabetes and TB may place individuals with low socio-economic status at particular risk of persistent poverty. Kyrgyz health sector reforms aim at reducing this burden, with the provision of essential health services free at the point of use through a State-Guaranteed Benefit Package (SGBP). However, despite a declining trend in out-of-pocket expenditure, there is still a considerable funding gap in the SGBP. Using data from Bishkek, Kyrgyzstan, this study aims to explore how households cope with the economic burden of Diabetes, TB and co-prevalence.MethodsThis study uses cross-sectional data collected in 2010 from Diabetes and TB patients in Bishkek, Kyrgyzstan. Quantitative questionnaires were administered to 309 individuals capturing information on patients’ socioeconomic status and a range of coping strategies. Coarsened exact matching (CEM) is used to generate socio-economically balanced patient groups. Descriptive statistics and logistic regression are used for data analysis.ResultsTB patients are much younger than Diabetes and co-affected patients. Old age affects not only the health of the patients, but also the patient’s socio-economic context. TB patients are more likely to be employed and to have higher incomes while Diabetes patients are more likely to be retired. Co-affected patients, despite being in the same age group as Diabetes patients, are less likely to receive pensions but often earn income in informal arrangements. Out-of-pocket (OOP) payments are higher for Diabetes care than for TB care. Diabetes patients cope with the economic burden by using social welfare support. TB patients are most often in a position to draw on income or savings. Co-affected patients are less likely to receive social welfare support than Diabetes patients. Catastrophic health spending is more likely in Diabetes and co-affected patients than in TB patients.ConclusionsThis study shows that while OOP are moderate for TB affected patients, there are severe consequences for Diabetes affected patients. As a result of the underfunding of the SGBP, Diabetes and co-affected patients are challenged by OOP. Especially those who belong to lower socio-economic groups are challenged in coping with the economic burden.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1369-7) contains supplementary material, which is available to authorized users.

Impact of Micro Health Insurance Plans on Protecting Households Against Catastrophic Health Spending in Tanzania

AbstractThe paper analyses the impact of households’ membership in micro health insurance plans on the protection against catastrophic health spending, in the episodes of illness. The analysis considers the groups of poor and non-poor members of micro health insurance schemes and non-members in both urban and rural areas in Tanzania.Matching estimator method was used to analyse the effect of membership in the micro health insurance on the protection against catastrophic health spending, in the episodes of illness among the members of micro health insurance scheme and non-members for the different income groups. Data used in the analysis involved those on the 10,300 households involved in Tanzania Demographic and Health Survey of 2011.The estimation results revealed that insurance schemes enabled households to get protection against catastrophic health spending, in the episodes of illness to members of insurance schemes compared to non-members. Thus, it is recommended that households be encouraged to enroll in the micro health insurance schemes. The insurance scheme also needs to be close to the would be customers. This will also contribute to poverty reduction in the country as well.

Investigating determinants of catastrophic health spending among poorly insured elderly households in urban Nigeria.

BackgroundIn the absence of functional social security mechanisms for elderly people in Nigeria, elderly households are solely responsible for geriatric healthcare costs, which can lead to catastrophic health expenditures (CHE) – particularly among the poor. This study investigates the key determinants of CHE among poorly insured elderly households in Nigeria. We also offer some policy options for reducing the risk of CHE.MethodsData on out-of pocket payments and self-reported health status were sourced from the Nigerian General Household Panel Survey (NGHPS) in Nigeria, conducted by the National Bureau of Statistics in 2010, with technical support from the World Bank. CHE was defined at the 10 % of total consumption expenditure threshold. The determinants of CHE and their marginal effects were investigated using probit regressions. An elderly household is defined as a household with at least one elderly member ≥ 50 years old.ResultsThe proportion of elderly households with CHE is 9.6 %. Poorer and smaller elderly households were most at risk of CHE. Female-headed households were less likely to incur CHE compared to male-headed households (p < 0.01). Conversely, households with informal health financing arrangements were less likely to incur CHE (p < 0.001). Education and utilising a health promoting tool, such as treated bednets increased the probability of incurring CHE in Urban Nigeria.ConclusionFindings from this paper should prompt policy action to financially support poor elderly households at risk of CHE in Urban Nigeria. The Nigerian government should enhance the national health insurance scheme to provide better coverage for elderly people, thereby protecting elderly households from incurring CHE.

Impact of Micro Health Insurance Plans on Protecting Households Against Catastrophic Health Spending in Tanzania

Impact of Micro Health Insurance Plans on Protecting Households Against Catastrophic Health Spending in Tanzania

The economic burden of overseas medical treatment: a cross sectional study of Maldivian medical travelers

BackgroundAccess to tertiary care is a problem common to many small states, especially island ones. Although medical treatment overseas (MTO) may result in cost savings to high income countries, it can be a relatively high cost for low and middle income source countries. The purpose of this study was to estimate the costs of overseas medical treatment incurred by the households of medical travelers from Maldives and assess the burden of medical treatment overseas on the government and on households.MethodsA survey was conducted of inbound Maldivian medical travelers who traveled during the period June – December 2013. Participants were stratified by the source of funds used for treatment abroad. Three hundred and forty four government-subsidized and 471 privately funded Maldivians were interviewed. Self-reported data on the utilization and expenses incurred during the last visit abroad, including both expenses covered by the government and borne by the household, were collected using a researcher administered structured questionnaire.ResultsThe median per capita total cost of a medical travel episode amounted to $1,470. Forty eight percent of the cost was spent on travel. Twenty six percent was spent on direct medical costs, which were markedly higher among patients subsidized by the government than self-funded patients (p = <0.001). The two highest areas of spending for public funds were neoplasms and diseases of the circulatory system in contrast to diseases of the musculoskeletal system and nervous system for privately funded patients. Medical treatment overseas imposed a considerable burden on households as 43 % of the households of medical travelers suffered from catastrophic health spending. Annually, an estimated $68.9 million was spent to obtain treatment for Maldivians in overseas health facilities ($204 per capita), representing 4.8 % of the country’s GDP.ConclusionsOverseas medical treatment represents a substantial economic burden to the Maldives in terms of lost consumer spending in the local economy and catastrophic health spending by households. Geographical inequality in access to public funds for MTO and the disproportionate travel cost borne by travelers from rural areas need to be addressed in the existing Universal Health Care programme to minimize the burden of MTO. Increased investment to create more capacity in the domestic health infrastructure either through government, private or by foreign direct investment can help divert the outflow on MTO.

The economic burden of maternal mortality on households: evidence from three sub-counties in rural western Kenya

BackgroundThis study explores the consequences of a maternal death to households in rural Western Kenya focusing particularly on the immediate financial and economic impacts.MethodsBetween September 2011 and March 2013 all households in the study area with a maternal death were surveyed. Data were collected on the demographic characteristics of the deceased woman; household socio-economic status; a history of the pregnancy and health care access and utilization; and disruption to household functioning due to the maternal death. These data were supplemented by in-depth and focus group discussions.ResultsThe health service utilization costs associated with maternal deaths were significantly higher, due to more frequent service utilization as well as due to the higher cost of each visit suggesting more involved treatments and interventions were sought with these women. The already high costs incurred by cases during pregnancy were further increased during delivery and postpartum mainly a result of higher facility-based fees and expenses. Households who experienced a maternal death spent about one-third of their annual per capita consumption expenditure on healthcare access and use as opposed to at most 12% among households who had a health pregnancy and delivery. Funeral costs were often higher than the healthcare costs and altogether forced households to dis-save, liquidate assets and borrow money. What is more, the surviving members of the households had significant redistribution of labor and responsibilities to make up for the lost contributions of the deceased women.ConclusionKenya is in the process of instituting free maternity services in all public facilities. Effectively implemented, this policy can lift a major economic burden experienced by a very large number of household who seek maternal health services which can be catastrophic in complicated cases that result in maternal death. There needs to be further emphasis on insurance schemes that can support households through catastrophic health spending.

Achieving universal health coverage goals in Thailand: the vital role of strategic purchasing.

Strategic purchasing is one of the key policy instruments to achieve the universal health coverage (UHC) goals of improved and equitable access and financial risk protection. Given favourable outcomes of Universal Coverage Scheme (UCS), this study synthesized strategic purchasing experiences in the National Health Security Office (NHSO) responsible for the UCS in contributing to achieving UHC goals. The UCS applied the purchaser–provider split concept where NHSO, as a purchaser, is in a good position to enforce accountability by public and private providers to the UCS beneficiaries, through active purchasing. A comprehensive benefit package resulted in high level of financial risk protection as reflected by low incidence of catastrophic health spending and impoverished households. The NHSO contracted the District Health System (DHS) network, to provide outpatient, health promotion and disease prevention services to the whole district population, based on an annual age-adjusted capitation payment. In most cases, the DHS was the only provider in a district without competitors. Geographical monopoly hampered the NHSO to introduce a competitive contractual agreement, but a durable, mutually dependent relationship based on trust was gradually evolved, while accreditation is an important channel for quality improvement. Strategic purchasing services from DHS achieved a pro-poor utilization due to geographical proximity, where travel time and costs were minimal. Inpatient services paid by Diagnostic Related Group within a global budget ceiling, which is estimated based on unit costs, admission rates and admission profiles, contained cost effectively. To prevent potential under-provisions of the services, some high cost interventions were unbundled from closed end payment and paid on an agreed fee schedule. Executing monopsonistic purchasing power by NHSO brought down price of services given assured quality. Cost saving resulted in more patients served within a finite annual budget.

Universal health coverage for elderly people with non-communicable diseases in low-income and middle-income countries: a cross-sectional analysis

BackgroundPopulation ageing and the growing burden of non-communicable diseases are crucial challenges for low-income and middle-income countries, especially because of their effects on the economy and on development and competitiveness indicators. In 2005, WHO urged countries to establish financing insurance mechanisms ensuring equitable universal health coverage. We assessed health coverage for elderly people with non-communicable diseases. MethodsWe did this cross-sectional analysis of people aged older than 50 years who had non-communicable diseases in six low-income and middle-income countries (China, Ghana, India, Mexico, Russia, and South Africa) from the WHO Study on global AGEing and adult health (SAGE) Wave1 (2007–10). We analysed individual and household data for 17 752 participants with regards to doctor visits, treatment, supervision, effectiveness of care, catastrophic health spending, and equitable distribution of health coverage across socioeconomic groups. We estimated weighted population means, and fitted logistic regression models and standardised concentration curves. FindingsEffective coverage ranged from 20·7% (95% CI 15·2–27·5) of patients in Mexico to 48·2% (43·9–52·5) in South Africa. Insured patients were significantly more likely to have effective coverage than were uninsured patients in Ghana (odds ratio 1·8, 95% CI 1·4–2·5), India (3·1, 1·9–4·9), and Mexico (3·0, 1·7–5·3). The effect of social determinants on effective coverage varied across countries. Catastrophic health spending ranged from 8·1% (95% CI 5·9–11·2) in South Africa to 45·7% (42·0–49·4) in India, even among people with insurance. Pro-rich inequities existed for effective coverage (except in South Africa) and catastrophic health spending (except in Russia). InterpretationHealth insurance is associated with health coverage in all the countries studied, but it is insufficient to ensure universal health coverage. Differences in effectiveness and equity within and between low-income and middle-income countries relate to the social circumstances in each country, which determine the challenges of achieving universal health coverage. FundingNone.

Analysis of the Impact of Rural Households Membership in the Micro Health Insurance on the Utilization of Health Services in Tanzania

This paper analyses the utilization of health services among the members of micro health insurance schemes in rural areas in Tanzania. Most literature on health insurance in rural areas in developing countries, including Tanzania, had analyzed socio-economic determinants of the households’ demand for health insurance plans. Little attention has been given to the outcomes of purchasing the health insurance plans as the determinants of membership in the schemes. This is the research knowledge gap that this study seeks to fill. In order to examine the effect of households’ membership in the micro health insurance schemes, on the utilization of health services, the matching estimator method has been adopted. In addition, the data from Tanzania Demographic and Health Survey of 2011 were used to analyse the outcome of households’ membership in the health insurance schemes on the utilization of health services. The findings revealed that the membership in the micro health insurance plans increased the utilization of the health services among the poor households, but not for the non-poor. Moreover, the insurance schemes did not provide protection against catastrophic health spending among the rural households in the episodes of illness. The reasons are that the households had to incur additional expenditures when visiting the health facilities in episodes of illness and that the plans provide limited range of benefits to households. Thus, it is recommended that poor households should be encouraged to enrol in the micro health insurance schemes. Moreover, the health facilities should provide adequate supplies so as to minimize out of pocket spending for households in the episode of illness.

Financial catastrophe and poverty impacts of out-of-pocket health payments in Turkey

To determine the prevalence of catastrophic health payments, examine the determinants of catastrophic expenditures, and assess the poverty impact of out-of-pocket (OOP) payments. Data came from the 2004 to 2010 Household Budget Survey. Catastrophic health spending was defined by health payments as percentage of household consumption expenditures and capacity to pay at a set of thresholds. The poverty impact was evaluated by poverty head counts and poverty gaps before and after OOP health payments. The percentage of households that catastrophically spent their consumption expenditure and capacity to pay increased from 2004 to 2010, regardless of the threshold used. Households with a share of more than 40% health spending in both consumption expenditure and capacity to pay accounted for less than 1% across years. However, when a series of potential confounders were taken into account, the study found statistically significantly increased risk for the lowest threshold and decreased risk for the highest threshold in 2010 relative to the base year. Household income, size, education, senior and under 5-year-old members, health insurance, disabled members, payment for inpatient care and settlement were also statistically significant predictors of catastrophic health spending. Overall, poverty head counts were below 1%. Poverty gaps reached a maximum of 0.098%, with an overall increase in 2010 compared to 2004. Catastrophe and poverty increased from 2004 to 2010. However, given that the realization of some recent policies will affect the financial burden of OOP payments on households, the findings of this study need to be replicated.

Treatment seeking and health financing in selected poor urban neighbourhoods in India, Indonesia and Thailand

This article presents a comparative analysis of socio-economic disparities in relation to treatment-seeking strategies and healthcare expenditures in poor neighbourhoods within larger health systems in four cities in India, Indonesia and Thailand. About 200 households in New Delhi, Bhubaneswar, Jogjakarta and Phitsanulok were repeatedly interviewed over 12 months to relate health problems with health seeking and health financing at household level. Quantitative data were complemented with ethnographic studies involving the same neighbourhoods and a number of private practitioners at each site. Within each site, the higher and lower income groups among the poor were compared. The lower income group was more likely than the higher income group to seek care from less qualified health providers and incur catastrophic health spending. The study recommends linking quality control mechanisms with universal health coverage (UHC) policies; to monitor the impact of UHC among the poorest; intervention research to reach the poorest with UHC; and inclusion of private providers without formal medical qualification in basic healthcare.

Household Health Spending in India: a Comparative Study of Demographically Advanced and Transitive States

Using the unit data from 61 st and 66 th rounds of consumption expenditure surveys carried out by National Sample Survey Organisation, this paper examines the change in household health spending of demographically advanced and transitive states of India. Descriptive and multivariate analyses are used to understand the differentials and change in health spending. Results suggest that during 2004-2010 the household health expenditure at constant prices has increased by 25 per cent in India, 32 per cent in Kerala, 33 per cent in Maharashtra and eight per cent in Uttar Pradesh. The institutional health spending in India has increased by 53 per cent compared with 15 per cent for non-institutional health spending. The increase in household health spending is higher among the poor, less educated, labourer households and among elderly households. Results of multivariate analyses suggest that households with elderly members are more likely to incur catastrophic health expenditure compared with households without any elderly member. Based on the findings, the paper suggests an increase in public spending on health to protect the poor, marginalised and elderly households from catastrophic health spending.

Catastrophic health care spending and impoverishment in Kenya.

BackgroundMany health systems in Africa are funded primarily through out-of-pocket payments. Out-of-pocket payments prevent people from seeking care, can result to catastrophic health spending and lead to impoverishment. This paper estimates the burden of out-of-pocket payments in Kenya; the incidence and intensity of catastrophic health care expenditure and the effect of health spending on national poverty estimates.MethodsData were drawn from a nationally representative health expenditure and utilization survey (n = 8414) conducted in 2007. The survey provided detailed information on out-of-pocket payments and consumption expenditure. Standard data analytical techniques were applied to estimate the incidence and intensity of catastrophic health expenditure. Various thresholds were applied to demonstrate the sensitivity of catastrophic measures.ResultsEach year, Kenyan households spend over a tenth of their budget on health care payments. The burden of out-of-pocket payments is highest among the poor. The poorest households spent a third of their resources on health care payments each year compared to only 8% spent by the richest households. About 1.48 million Kenyans are pushed below the national poverty line due to health care payments.ConclusionsKenyans are becoming poorer due to health care payments. The need to protect individuals from health care related impoverishment calls for urgent reforms in the Kenyan health system. An important policy question remains what health system reforms are needed in Kenya to ensure that financial risk protection for all is achieved.

Examining inequities in incidence of catastrophic health expenditures on different healthcare services and health facilities in Nigeria.

ObjectiveThere is limited evidence about levels of socio-economic and other differences in catastrophic health spending in Nigeria and in many sub-Saharan African countries. The study estimated the level of catastrophic healthcare expenditures for different healthcare services and facilities and their distribution across socioeconomic status (SES) groups.MethodsThe study took place in four Local Government Areas in southeast Nigeria. Data were collected using interviewer-administered questionnaires administered to 4873 households. Catastrophic health expenditures (CHE) were measured using a threshold of 40% of monthly non-food expenditure. We examined both total monthly health expenditure and disaggregated expenditure by source and type of care.ResultsThe average total household health expenditure per month was 2354 Naira ($19.6). For outpatient services, average monthly expenditure was 1809 Naira ($15.1), whilst for inpatient services it was 610 Naira ($5.1). Higher health expenditures were incurred by urban residents and the better-off SES groups. Overall, 27% of households incurred CHE, higher for poorer socioeconomic groups and for rural residents. Only 1.0% of households had a member that was enrolled in a health insurance scheme.ConclusionThe worse-off households (the poorest SES and rural dwellers) experienced the highest burden of health expenditure. There was almost a complete lack of financial risk protection. Health reform mechanisms are needed to ensure universal coverage with financial risk protection mechanisms.

Towards Universal Health Coverage: An Evaluation of Rwanda Mutuelles in Its First Eight Years

Background Mutuelles is a community-based health insurance program, established since 1999 by the Government of Rwanda as a key component of the national health strategy on providing universal health care. The objective of the study was to evaluate the impact of Mutuelles on achieving universal coverage of medical services and financial risk protection in its first eight years of implementation.Methods and FindingsWe conducted a quantitative impact evaluation of Mutuelles between 2000 and 2008 using nationally-representative surveys. At the national and provincial levels, we traced the evolution of Mutuelles coverage and its impact on child and maternal care coverage from 2000 to 2008, as well as household catastrophic health payments from 2000 to 2006. At the individual level, we investigated the impact of Mutuelles' coverage on enrollees' medical care utilization using logistic regression. We focused on three target populations: the general population, under-five children, and women with delivery. At the household level, we used logistic regression to study the relationship between Mutuelles coverage and the probability of incurring catastrophic health spending. The main limitation was that due to insufficient data, we are not able to study the impact of Mutuelles on health outcomes, such as child and maternal mortalities, directly.The findings show that Mutuelles improved medical care utilization and protected households from catastrophic health spending. Among Mutuelles enrollees, those in the poorest expenditure quintile had a significantly lower rate of utilization and higher rate of catastrophic health spending. The findings are robust to various estimation methods and datasets.ConclusionsRwanda's experience suggests that community-based health insurance schemes can be effective tools for achieving universal health coverage even in the poorest settings. We suggest a future study on how eliminating Mutuelles copayments for the poorest will improve their healthcare utilization, lower their catastrophic health spending, and affect the finances of health care providers.

Out-of-pocket expenditures for hospital care in Iran: who is at risk of incurring catastrophic payments?

Since the beginning of 1980s, the Iranian health care system has undergone several reforms designed to increase accessibility of health services. Notwithstanding these reforms, out-of-pocket payments which create a barrier to access health services contribute almost half of total health are financing in Iran. This study aimed to provide a greater understanding about the inequality and determinants of the out-of-pocket expenditure (OOPE) and the related catastrophic expenditure (CE) for hospital services in Iran using a nationwide survey data, the 2003 Utilisation of Health Services Survey (UHSS). The concentration index and the Heckman selection model were used to assess inequality and factors associated with these expenditures. Inequality analysis suggests that the CE is concentrated among households in lower socioeconomic levels. The results of the Heckman selection model indicate that factors such as length of stay, admission to a hospital owned by private sector or Ministry of Health and Medical Education, and living in remote areas are positively associated with higher OOPE. Results of the ordered-probit selection model demonstrate that length of stay, lower household wealth index, and admission to a private hospital are major factors contributing to the increase in the probability of CE. Also, we find that households living in East Azarbaijan, Kordestan and Sistan and Balochestan face a higher level of CE. Based on our findings, the current employer-sponsored health insurance system does not offer equal protection against hospital expenditure in Iran. It seems that a single universal health insurance scheme that covers health services for all Iranian-regardless of their employment status-can better protect households from catastrophic health spending.

A Cross-Sectional Study of the Microeconomic Impact of Cardiovascular Disease Hospitalization in Four Low- and Middle-Income Countries

ObjectiveTo estimate individual and household economic impact of cardiovascular disease (CVD) in selected low- and middle-income countries (LMIC).BackgroundEmpirical evidence on the microeconomic consequences of CVD in LMIC is scarce.Methods and FindingsWe surveyed 1,657 recently hospitalized CVD patients (66% male; mean age 55.8 years) from Argentina, China, India, and Tanzania to evaluate the microeconomic and functional/productivity impact of CVD hospitalization. Respondents were stratified into three income groups. Median out-of-pocket expenditures for CVD treatment over 15 month follow-up ranged from 354 international dollars (2007 INT$, Tanzania, low-income) to INT$2,917 (India, high-income). Catastrophic health spending (CHS) was present in >50% of respondents in China, India, and Tanzania. Distress financing (DF) and lost income were more common in low-income respondents. After adjustment, lack of health insurance was associated with CHS in Argentina (OR 4.73 [2.56, 8.76], India (OR 3.93 [2.23, 6.90], and Tanzania (OR 3.68 [1.86, 7.26] with a marginal association in China (OR 2.05 [0.82, 5.11]). These economic effects were accompanied by substantial decreases in individual functional health and productivity.ConclusionsIndividuals in selected LMIC bear significant financial burdens following CVD hospitalization, yet with substantial variation across and within countries. Lack of insurance may drive much of the financial stress of CVD in LMIC patients and their families.

Maternal and neonatal health expenditure in mumbai slums (India): A cross sectional study

BackgroundThe cost of maternity care can be a barrier to access that may increase maternal and neonatal mortality risk. We analyzed spending on maternity care in urban slum communities in Mumbai to better understand the equity of spending and the impact of spending on household poverty.MethodsWe used expenditure data for maternal and neonatal care, collected during post-partum interviews. Interviews were conducted in 2005-2006, with a sample of 1200 slum residents in Mumbai (India). We analysed expenditure by socio-economic status (SES), calculating a Kakwani Index for a range of spending categories. We also calculated catastrophic health spending both with and without adjustment for coping strategies. This identified the level of catastrophic payments incurred by a household and the prevalence of catastrophic payments in this population. The analysis also gave an understanding of the protection from medical poverty afforded by coping strategies (for example saving and borrowing).ResultsA high proportion of respondents spent catastrophically on care. Lower SES was associated with a higher proportion of informal payments. Indirect health expenditure was found to be (weakly) regressive as the poorest were more likely to use wage income to meet health expenses, while the less poor were more likely to use savings. Overall, the incidence of catastrophic maternity expenditure was 41%, or 15% when controlling for coping strategies. We found no significant difference in the incidence of catastrophic spending across wealth quintiles, nor could we conclude that total expenditure is regressive.ConclusionsHigh expenditure as a proportion of household resources should alert policymakers to the burden of maternal spending in this context. Differences in informal payments, significantly regressive indirect spending and the use of savings versus wages to finance spending, all highlight the heavier burden borne by the most poor. If a policy objective is to increase institutional deliveries without forcing households deeper into poverty, these inequities will need to be addressed. Reducing out-of-pocket payments and better regulating informal payments should have direct benefits for the most poor. Alternatively, targeted schemes aimed at assisting the most poor in coping with maternal spending (including indirect spending) could reduce the household impact of high costs.

Determining factors of catastrophic health spending in Bogota, Colombia

This study tests whether the low-income population in Bogota not insured under the General Social Security Health System is able to economically handle unexpected health problems or not. It used data from the Health Services Use and Expenditure Study conducted in Colombia in 2001, for which each household recorded its monthly out-of-pocket health expenditure during the year and the household income was measured as the sum of each member's contribution to the household. Payment capacity or available income and catastrophic health spending were based on the latest methodology proposed by the World Health Organization (WHO) in 2005. A probit model was adjusted to determine the factors that significantly influence the likelihood of a household having catastrophic health spending. The percentage of households with catastrophic health spending in Bogota was 4.9%; incidence was higher in low-income households where none of the members were affiliated to social security, where there had been an in-patient event, and where the heads of household were over 60years of age. There is no statistical evidence for rejecting the hypothesis under study, which states that low-income households that have no health insurance are more likely to have catastrophic health spending than higher-income households with health insurance.