Catastrophic Payments Research Articles

New evidence on household financial protection against out-of-pocket payments for health in Poland

Abstract Background Protecting households against financial hardship when using health care is an integral element of universal health coverage. Previous analysis showed that in Poland, catastrophic spending on health is more common than in many European countries. Over the last decade, several measures were undertaken to reduce the burden of out-of-pocket payments for households in Poland. Methods The study aimed to assess financial protection in Poland using the indicators of catastrophic and impoverishing health spending. It relies on the methodology developed by the WHO Region Office for Europe. Catastrophic expenditure is defined as out-of-pocket payments that are greater than 40% of household capacity to pay. The study uses data from the Polish household budget surveys in 2013-2021. Results The incidence of catastrophic health spending remained relatively constant over the years analyzed, with 9% of households affected. Only in the first year of the COVID-19 pandemic (2020) it reached nearly 10%, although overall household out-of-pocket expenditure declined that year. The share of households impoverished or further impoverished due to out-of-pocket payments decreased from 4% in 2013 to 3% in 2021. Payments on medicines are the main driver of catastrophic spending, particularly among poorer households, although their role has diminished over time. Household’s available resources, gender, age, education, disability status, residence place, number of children, and household’s main source of income are significantly associated with catastrophic health payments. Conclusions Despite the implemented policies, household financial protection against out-of-pocket payments in Poland did not improve significantly between 2013 and 2021. Available evidence should be used to design well-tailored measures to reduce the burden of out-of-pocket payments, targeting the most vulnerable population groups and specific healthcare areas. Key messages • Household financial protection against out-of-pocket payments in Poland did not improve significantly between 2013 and 2021. • Out-of-pocket payments for medicines are the main cause of financial hardship for Polish households.

Burden of out-of-pocket payment for maternal healthcare and its catastrophic effects in the era of free maternal and child health policy in Ghana

BackgroundGhana introduced a free maternal healthcare policy within its national health insurance program in 2008. Despite this, there are reports of significant out-of-pocket (OOP) payments for maternal healthcare in Ghana. This study examines OOP payments for maternal healthcare services and their catastrophic effects, including the correlates of catastrophic OOP payments. MethodsCross-sectional quantitative data were collected from 414 mothers through health facility exit interviews in two regions of Ghana. Catastrophic OOP payments were computed by expressing total health expenditure as a percentage of household total expenditure and non-food expenditure at various thresholds (5 %, 10 %, 20 % and 25 %). The correlates of catastrophic OOP payments were assessed using logistic regression models. ResultsThe median OOP payments for maternal healthcare was GH₵866.5(US$109.3). The median non-medical OOP cost (GH₵479[US$ 59.9]) was higher than the median medical OOP cost (GH₵296.5[US$ 37.1]). The median OOP cost was higher for delivery (GH₵454[US$56.8]) compared to ANC (GH₵356.5[US$44.5]) and PNC (GH₵21.5[US$2.6]). Non-medical supplies comprise 58 % of the total OOP payments. About 73 % and 90 % of respondents spent more than 5 % of their annual household total and non-food expenditure on maternal healthcare, respectively. Rural areas and care at private facilities were significantly associated (AORs<1; p-values<0.05) with lower probabilities of incurring catastrophic OOP expenditure. Tertiary education was associated (AORs> 1; p-values<0.05) with a higher probability of incurring catastrophic OOP payments. ConclusionOOP payments for maternal care are still prevalent in Ghana. We call for a reform of Ghana’s free maternal healthcare policy to include non-medical supplies within its benefit package.

Provincial inequality of China's progress towards universal health coverage: An empirical analysis in 2016-21.

Achieving universal health coverage (UHC) is a crucial target shared by the Sustainable Development Goals (SDGs). As UHC levels are influenced by factors such as the regional economy and resource allocation, subnational evidence in China is urgently needed. This study aimed to monitor provincial progress from 2016 to 2021, thereby informing the development of region-specific strategies. Based on the UHC monitoring framework proposed by the World Health Organization, a UHC index was constructed comprising the service coverage dimension (16 indicators) and financial protection dimension (four indicators). In this observational study, routinely collected health data from 25 provinces (autonomous regions and municipalities) in mainland China were obtained from statistical yearbooks, relevant literature, and nationally representative surveys. The indices were calculated using geometric means. Socioeconomic inequalities among provinces were quantified using the slope index of inequality (SII) and relative index of inequality (RII). From 2016 to 2021, China made laudable progress towards achieving UHC, with the index rising from 56.94 in 2016 to 63.03 in 2021. Most provinces demonstrated better performance in service coverage. Western provinces generally presented faster rates of progress, which were attributed to more substantial increases in financial protection. Despite significant disparities, with the UHC index ranging from 77.94 in Shanghai to 54.61 in Fujian in 2021, the overall equity of UHC has improved across the 25 provinces. SII decreased from 17.78 (95% confidence interval (CI) = 11.64, 23.93) to 12.25 (95% CI = 5.86, 18.63) and RII from 1.38 (95% CI = 1.29, 1.46) to 1.22 (95% CI = 1.16, 1.29). However, the non-communicable disease (NCD) domain experienced a drop in both index score and equity, underscoring the need for prioritised attention. In the context of SDGs and the 'Healthy China 2030' initiative, China has made commendable progress towards UHC, and inter-provincial equity has improved. However, substantial differences persisted. The equitable realisation of UHC necessitates prioritising the enhancement of service capacity and financial protection in less developed regions, particularly by addressing shortages in the general practitioner workforce and mitigating catastrophic payments. Developed regions should focus on preventing NCDs through effective interventions targeting key risk factors. This study provides insights for other countries to adopt comprehensive monitoring frameworks, identify subnational disparities, and introduce targeted policy initiatives.

Non-Communicable Diseases Impact Low-Income Households in Malaysia.

Non-communicable diseases (NCDs) have a vast and rising impact on households at all income levels across the globe, particularly with poorer people bearing the burden. Hence, this study examines NCDs' effects on Malaysia's B40 group (low-income earners). This study used the 2015 National Health and Morbidity Survey, a population-based cross-sectional survey with 18,616 respondents from B40 households in Malaysia. Logistic regression analysis is used to assess NCDs' influence on poverty. In 2015, more than 20% of the B40 households lived below the poverty level. In addition, the B40 households had a greater prevalence of NCDs, with almost half of them diagnosed with at least one NCD (47.32%); hypertension (9.90%), diabetes mellitus (17.12%) and hypercholesterolemia (22.89%). Households with a member having an NCD are more likely to experience poverty than those without NCDs. The results also suggested that B40 households with catastrophic payments were at a 25% threshold; the elderly, individuals without formal education and unpaid workers were more likely to experience poverty. The findings suggest that NCDs increase the likelihood of B40 households falling into poverty. These facts highlight the necessity of safeguarding B40 households from the financial burden of NCDs by creating more effective financial protection plans for Malaysia's low-income earners.

Financial protection in health revisited: Is catastrophic health spending underestimated for service- or disease-specific analysis?

Economists originally developed methods to assess financial catastrophe using total or aggregate out-of-pocket health spending. Aggregate out-of-pocket health spending is financially catastrophic when it exceeds a fixed proportion (i.e., threshold) of a household's total income or expenditure in a given period. However, these methods are now applied to assess financial catastrophe in disease- or service-specific rather than aggregate out-of-pocket health spending without using disease- or service-specific thresholds. This paper argues that not using disease- or service-specific thresholds for such assessments is misleading and underestimates the burden of financial catastrophe, especially among households from poorer backgrounds. It then proposed disease- or service-specific catastrophic payment thresholds, applied them to Nigeria and found that financial catastrophe was underestimated for the five service groups considered. The paper stresses the importance of using disease- or service-specific thresholds and avoiding unadjusted thresholds, which may leave poorer households behind as financially protected.

The economic burden of leprosy treatment to households in Ghana: A cross-sectional study in the Volta Region of Ghana.

Despite the known detrimental socio-economic consequences of leprosy morbidity, disability and social exclusion at the household level, research investigating the precise economic burden of leprosy remains scarce. This study aims to address this gap by examining the socio-economic burden of leprosy in Ho municipality in the Volta Region of Ghana. This was a cross-sectional cost of illness study, and quantitative data were collected from leprosy patients between October and December 2023. Data collected included socio-demographic characteristics, direct and indirect costs related to treatment of leprosy from the patient's perspective. Stata version 14 was used for the analysis. A total of 35 respondents participated in the study, comprising 51.43% females and 48.57% males. All respondents (100%) reported having a valid National Health Insurance Scheme membership. The average total cost of leprosy treatment per patient, encompassing both direct and indirect expenses, was US$361.54 (SD ± 286.87). Disaggregating this cost further revealed a medical cost of US$44.30, a non-medical cost of US$47.07 and an indirect cost of US$290.16. The estimated annual household income of respondents was US$446.4 and 60% of respondents incurred expenditure that was more than 10% of their annual income and were deemed to have experienced catastrophic payment. Patients with sequelae incurred additional costs of US$46 (range: US$8.3-US$166.7) per case. The costs of treating leprosy were considerably high leading to catastrophic health payments. This highlights the need for an all-encompassing strategy that addresses medical, non-medical and indirect costs. Implementing targeted support programs and ensuring medication affordability are key steps towards mitigating the economic susceptibility of leprosy patients and facilitating successful treatment outcomes.

Risk and determinants of catastrophic health expenditure among rural households in rivers state

Background: Concerns about how the expense of healthcare impacts rural families' ability to pay their bills are rising, especially in environments where prepayment systems are inadequate and people pay cash while using health services. This research evaluated the method of payment, frequency, and contributing factors of catastrophic health expenditure (CHE) among rural inhabitants of Rivers State. Methods: This retrospective longitudinal study was conducted among 450 inhabitants in six rural communities in Rivers State. The participants were chosen using a multistage sampling process. A validated semi-structured questionnaire which was interviewer administered was used to obtain the data. IBM statistical package for the social sciences version 25 was used to analyze the data. Data were summarized using means, frequency, and proportions while bivariate and multivariate binary logistic regression were used to explore determinants of CHE with p≤0.05 considered statistically significant. Results: The result showed that 94.9% of rural households pay for health care via out-of-pocket payment and 88.4% rural residents experience catastrophic health payment. Household income of less than N100,000 (AOR=2.8, 95% C.I.=1.4-5.4, p=0.002) and having two or more dependents (AOR=3.3, 95% C.I.=1.3-8.0 p=0.002) were determinants of CHE. Conclusions: There is need to increase public funding for healthcare as well as expand the coverage of the NHIS to mitigate the effect of health care cost on rural residents in Rivers State.

Catastrophic Out-of-Pocket Expenditure on Health: Evidence from the Regions in the Philippines

This study estimates Filipino’s catastrophic and impoverishing out-of-pocket (OOP) healthcare expenditures on a regional perspective to measure the effectiveness and progress of Philippines’ healthcare financing system in ensuring population protection from excessive and unequal healthcare costs. Observations are drawn from the most recent household-based survey in the Philippines, 2018 and 2021 Family Income and Expenditure Survey, and grouped by four major regions: National Capital Region, the rest of Luzon, Visayas, and Mindanao region. From 2018 to 2021, results showed that the distribution of catastrophic OOP healthcare expenditures decreases while depth of these payments increases across the four major regions. The highest incidences of these catastrophic payments were found in the rest of Luzon and Visayas regions, while the highest intensities were found in Mindanao region. Despite medicines and pharmaceuticals products dominance on OOP healthcare expenditures, payment on inpatient medical services drives the catastrophic expenditures of households. Aside, deepening poverty caused by healthcare payments were more evident in households residing in Mindanao regions, thus exposing this Filipino families to financial risk and poverty threats. Logistic regression analysis showed that aging households head, employment, and socio-economic status are significant and common factors affecting the likelihood of incurring excessive health expenditures across the regions. The risk of catastrophic and impoverishing effects of healthcare expenditures persists in the country. Low levels of catastrophic OOP healthcare expenditures may indicate that disadvantaged households focused on spending on basic necessities and struggle to afford healthcare due to high costs amid COVID 19, leading to foregone treatment. Thus, continuous implementation of fair and innovative ways of financing the healthcare system to reduce the financial burden of OOP payments on Filipino households is recommended.

Investigating household catastrophic health expenditure and coping mechanisms in patients with Chronic Kidney Disease in Enugu, Nigeria: a single center experience

The methods of financing healthcare expenditure for any country are vital in determining the health status of the country. To meet the rising costs of seeking health care, many poor households in managing chronic disease conditions like Chronic Kidney Disease (CKD) often resort to coping strategies that are further detrimental to their well-being. CKD is the 12th highest cause of death and 17th highest cause of disability worldwide. This study assessed the incidence of household catastrophic health expenditure and payment coping mechanism of patients with CKD. It was a descriptive cross-sectional study involving 100 patients with various stages of CKD attending the Nephrology clinics of University of Nigeria Teaching Hospital Enugu, South eastern Nigeria. They were recruited using a systematic sampling technique. A questionnaire was used to collect data. Data were collected using pre-tested semi-structured questionnaires and analyzed using descriptive statistics of frequencies, percentages, mean, standard deviation and interquartile range. Chi-square was used to test for association between payment coping mechanisms used by patients across socioeconomic groups. The study demonstrated uniformly high incidence of catastrophic expenditure for all the respondents both at 10% and 40% threshold (100% and 97%) respectively, with cost of treatment uniformly distributed among the various socioeconomic classes. Most of the patients assessed their treatment by paying out of pocket without reimbursement (88%), with money from personal bank savings being the commonest coping mechanism especially among the poorest Socioeconomic Status (SES) class, and borrowing among the least poor SES class. The study concluded that the prevalence of catastrophic expenditure was very high across all the socioeconomic status. It is recommended that the Nigerian Health Insurance program should be expanded to cover at least dialysis treatment of CKD, if not all aspects of CKD management in order to protect these patients and their household from ill-health mediated catastrophic expenditure.

Situation Analysis of a New Effort of Community-Based Health Planning and Services (CHPS) for Maternal Health in Upper West Region in Rural Ghana.

A free maternal health policy started in Ghana in 2008, however, health facility utilization is still low, and out-of-pocket payments (OOPPs) are putting households at risk of catastrophic expenditure. To improve this situation, some rural communities have assigned a midwife to a health post called community-based health planning and services (CHPS), where only assistant nurses are allocated. This study explored the effectiveness of the new approach in Upper West Region, Ghana. We conducted a cross-sectional study and interviewed women who gave birth in the last year. We systematically selected communities matched into four criteria: communities near CHPS (functional CHPS), communities near CHPS with a midwife (advanced CHPS), communities near a health centre, and communities without a health facility in their neighbourhood. In total, 534 women were interviewed: functional CHPS 104, advanced CHPS 131, near health centre 173, and no facility 126. About 78% of the women were 20 to 34 years old. About half of the women incurred OOPP, however, catastrophic payment (household spending > 5% of annual income) was significantly lower in advanced CHPS communities for normal delivery compared with the other three communities. The new local approach of assigning a midwife to CHPS functioned well, improving access to healthcare facilities for childbirth.

The financial burden of out of pocket payments on medicines among households in Ethiopia: analysis of trends and contributing factors

BackgroundIn Ethiopia, out-of-pocket (OOP) payment is the key means of healthcare financing, and expenses on medicines are a crucial component of such payment. This study aims to investigate the financial implications of OOP payments on medicines for Ethiopian households.MethodsThe study involved a secondary data analysis of the national household consumption and expenditure surveys of 2010/11 and 2015/16. The "capacity-to-pay" method was used to calculate catastrophic OOP medicine expenditures. The extent of economic status related to catastrophic medicine payment inequity was calculated using concentration index estimation. The impoverishment consequences of OOP payment on medicine were estimated using poverty headcount and poverty gap analysis methods. Logistic regression models were used to identify the variables that predict catastrophic medicine payments.ResultsMedicines accounted for the majority of healthcare spending (> 65%) across the surveys. From 2010 to 2016, the total percentage of households facing catastrophic medicine payments decreased from 1% to 0.73%. However, the actual number of people expected to have experienced catastrophic medicine payments increased from 399,174 to 401,519 people. Payment for medicines pushed 11,132 households into poverty in 2015/16. The majority of disparities were explained by economic status, place of residence, and type of health services.ConclusionOOP payment on medicine accounted for the majority of total health expenses in Ethiopia. A high medicine OOP payment continued to push households into catastrophic payments and impoverishment. Household seeking inpatient care, those with lower economic status and urban residents were among the most affected. Hence, innovative approaches to improve the supply of medicines in public facilities especially those in urban settings and risk protection mechanisms for medicine expenditures particularly for inpatient care are recommended.

The Association Between Household Financial Burden and Patient Mobility and Their Impact on Loss to Follow-Up Among Multidrug-Resistant Tuberculosis Patients in Guizhou, China.

We aimed to assess the household financial burden due to multidrug-resistant tuberculosis (MDR-TB) treatment and its predictors, examine its association with patient mobility, and test their impact on patient loss to follow-up (LTFU). A cross-sectional study combining follow-up data collection was conducted at the largest designated MDR-TB hospital in Guizhou. Data were collected from medical records and questionnaires. Household financial burden was measured by the incidence of 2 indicators: catastrophic total costs (CTC) and catastrophic health expenditure (CHE). Mobility was classified as mover or non-mover after the patient's address was verified twice. A multivariate logistic regression model was used to identify associations between variables. Model I and Model II were separated by CHE and CTC. Out of 180 households, the incidence of CHE and CTC was 51.7% and 80.6%, respectively. Families with low income and patients who were primary income earners were significantly associated with catastrophic costs. 42.8% of patients were movers. Patients from households with CHE (ORadj=2.2, 95% CI: 1.1-4.1) or with CTC (ORadj=2.6, 95% CI: 1.1-6.3) were more likely to move. Finding a job against financial difficulty (58.4%) was the top reason for movers. 20.0% of patients experienced LTFU. Patients from households with catastrophic payments (CHE: ORadj=4.1, 95% CI 1.6-10.5 in Model I; CTC: ORadj=4.8, 95% CI 1.0-22.9 in Model II), patients who were movers (ORadj=6.1, 95% CI 2.5-14.8 in Model I; ORadj=7.4, 95% CI 3.0-18.7 in Model II) and primary income earners (ORadj=2.5, 95% CI: 1.0-5.9 in Model I; ORadj=2.7, 95% CI 1.1-6.6 in Model II) had an increased risk of LTFU. There is a significant association between household financial burden due to MDR-TB treatment and patient mobility in Guizhou. They impact patients' treatment adherence and cause LTFU. Being a primary breadwinner increases the risk for catastrophic household payments and LTFU.

Informal employment and catastrophic health expenditures: Evidence from Pakistan.

Workers in informal employment suffered significant out-of-pocket healthcare expenditures (OOPHEs) due to their low earnings and a lack of a social safety net or health insurance. There is little or no evidence of impoverishment caused by OOPHEs in the context of labor market categorization. Therefore, this study examines the economic burden of OOPHEs and its associated consequences on households, whose members are in informal employment. This study estimates the incidence of catastrophic health expenditures (CHEs) and impoverishment across the households in formal and informal employment and their key determinants in Pakistan by employing the data from the two rounds of the Household Integrated Economic Survey (2015-16, 2018-19). For measuring CHEs and impoverishment, the budget share and capacity-to-pay approaches are applied. Various thresholds are used to demonstrate the sensitivity of catastrophic measures. We found a higher incidence of catastrophic healthcare payments among the informal workers, that is, 4.03% and 7.11% for 2015-16 and 2018-19, respectively, at a 10% threshold, while at a 40% threshold, the incidence of CHEs is found to be 0.40% and 2.34% for 2015-16 and 2018-19, respectively. These OOPHEs caused 1.53% and 3.66% of households who are in informal employment to become impoverished, compared with their formal counterparts. The study demonstrates that the probability of incurring CHEs and becoming impoverished is high among informal workers, compared with their formal counterparts. This result has clear policy implications, in which to protect the informal workers, it is necessary to expand the insurance coverage, particularly during the COVID-19 response and recovery efforts.

Catastrophic health-care payments and multidimensional poverty: Are they related?

The negative impact of health-related out-of-pocket (OOP) payments is a well-known problem in low and middle-income countries (LMICs). Cross-sectional analysis reveals that households use different coping mechanisms to mitigate or overcome the effect of OOP payments, but little is known from a longitudinal perspective. We explore this link using panel data for Colombia, Mexico, India, Malawi, Nigeria, Uganda, and Tanzania. Using a fixed-effect model, we computed the association between multidimensional poverty (MP) and facing catastrophic health payments (CHP) using a capacity-to-pay approach. We estimated different heterogeneous effects, including variables such as area of residence, facing CHP, being poor in the first wave, and facing CHP in period two. While using cross-sectional data, we found that the association between CHP and MP is present for six of the seven countries; it is not the case for the time variation in most of them. The results provide evidence that OOP induce a long-term impact on MP only in Colombia, India and Nigeria. In the last two countries, the levels of poverty and CHP were the highest of all seven, and the association between both situations was found by using different poverty cutoffs and thresholds to define CHP.

Catastrophic Costs among Tuberculosis-Affected Households in Egypt: Magnitude, Cost Drivers, and Coping Strategies.

Despite national programs covering the cost of treatment for tuberculosis (TB) in many countries, TB patients still face substantial costs. The end TB strategy, set by the World Health Organization (WHO), calls for "zero" TB households to be affected by catastrophic payments by 2025. This study aimed to measure the catastrophic healthcare payments among TB patients in Egypt, to determine its cost drivers and determinants and to describe the coping strategies. The study utilized an Arabic-validated version of the TB cost tool developed by the WHO for estimating catastrophic healthcare expenditure using the cluster-based sample survey with stratification in seven administrative regions in Alexandria. TB payments were considered catastrophic if the total cost exceeded 20% of the household's annual income. A total of 276 patients were interviewed: 76.4% were males, 50.0% were in the age group 18-35, and 8.3% had multidrug-resistant TB. Using the human capital approach, 17.0% of households encountered catastrophic costs compared to 59.1% when using the output approach. The cost calculation was carried out using the Egyptian pound converted to the United States dollars based on 2021 currency values. Total TB cost was United States dollars (USD) 280.28 ± 29.9 with a total direct cost of USD 103 ± 10.9 and a total indirect cost of USD 194.15 ± 25.5. The direct medical cost was the main cost driver in the pre-diagnosis period (USD 150.23 ± 26.89 pre diagnosis compared to USD 77.25 ± 9.91 post diagnosis, p = 0.013). The indirect costs (costs due to lost productivity) were the main cost driver in the post-diagnosis period (USD 4.68 ± 1.18 pre diagnosis compared to USD 192.84 ± 25.32 post diagnosis, p < 0.001). The households drew on multiple financial strategies to cope with TB costs where 66.7% borrowed and 25.4% sold household property. About two-thirds lost their jobs and another two-thirds lowered their food intake. Being female, delay in diagnosis and being in the intensive phase were significant predictors of catastrophic payment. Catastrophic costs were high among TB households in Alexandria and showed wide variation according to the method used for indirect cost estimation. The main cost driver before diagnosis was the direct medical costs, while it was the indirect costs, post diagnosis.

Disparity in Catastrophic Healthcare Expenditures Across Households’ Income Groups in Nigeria: The Lens of Foster-Greer-Thorbecke Poverty Indices

The Nigeria health care system seems to have continue in the downturn trend as a result of the decay in public health care system and this have continued to drive the rising health care financed by out-of-pocket expenditure health hence, the study examined the disparity in Catastrophic Healthcare expenditures across Households income groups in Nigeria using the Nigeria Health and Demographic Survey 2018. The study employed the Foster-Greer-Thorbecke indices and the logit model. Findings from the study showed that some household and individual characteristics are associated with catastrophic health expenditure in Nigeria. Many households experience catastrophic health payments due to factors such as age, education of household head, health insurance status, geo- political zone, type of health facilities visited, and type of illness suffered. Governments are yet to find fair and innovative ways of financing the health system so as to reduce the financial burden of out-of-pocket payments on households and individuals in Nigeria. There is also urgent need for increased financial protection as well as insurance coverage through small credit and rural households’ contribution scheme as an alternative to the National Health Insurance Scheme to enhance health financing option that could reduce the huge private health cost of out-of-pocket expenditure. There is need for pressure on the legislature to provide a bill that disallow health care tourism for public office holders abroad as way of checkmating the better health care system in Nigeria. Keywords: Health care, Inequality, Income groups, private health cost, households DOI: 10.7176/JESD/13-20-03 Publication date: October 31 st 2022

Multimorbidity, healthcare use and catastrophic health expenditure by households in India: a cross-section analysis of self-reported morbidity from national sample survey data 2017–18

BackgroundThe purpose of this research is to generate new evidence on the economic consequences of multimorbidity on households in terms of out-of-pocket (OOP) expenditures and their implications for catastrophic OOP expenditure.MethodsWe analyzed Social Consumption Health data from National Sample Survey Organization (NSSO) 75th round conducted in the year 2017–2018 in India. The sample included 1,13,823 households (64,552 rural and 49,271 urban) through a multistage stratified random sampling process. Prevalence of multimorbidity and related OOP expenditure were estimated. Using Coarsened Exact Matching (CEM) we estimated the mean OOP expenditure for individuals reporting multimorbidity and single morbidity for each episode of outpatient visits and hospital admission. We also estimated implications in terms of catastrophic OOP expenditure for households.ResultsResults suggest that outpatient OOP expenditure is invariably lower in the presence of multimorbidity as compared with single conditions of the selected Non-Communicable Diseases(NCDs) (overall, INR 720 [USD 11.3] for multimorbidity vs. INR 880 [USD 14.8] for single). In the case of hospitalization, the OOP expenditures were mostly higher for the same NCD conditions in the presence of multimorbidity as compared with single conditions, except for cancers and cardiovascular diseases. For cancers and cardiovascular, OOP expenditures in the presence of multimorbidity were lower by 39% and 14% respectively). Furthermore, around 46.7% (46.674—46.676) households reported incurring catastrophic spending (10% threshold) because of any NCD in the standalone disease scenario which rose to 63.3% (63.359–63.361) under the multimorbidity scenario. The catastrophic implications of cancer among individual diseases was the highest.ConclusionsMultimorbidity leads to high and catastrophic OOP payments by households and treatment of high expenditure diseases like cancers and cardiovascular are under-financed by households in the presence of competing multimorbidity conditions. Multimorbidity should be considered as an integrated treatment strategy under the existing financial risk protection measures (Ayushman Bharat) to reduce the burden of household OOP expenditure at the country level.

Cost of childbirth in Upper West Region of Ghana: a cross-sectional study

BackgroundOut-of-pocket payment (OOPP) is reported to be a major barrier to seeking maternal health care especially among the poor and can expose households to a risk of catastrophic expenditure and impoverishment.This study examined the OOPPs women made during childbirth in the Upper West region of Ghana.MethodsWe carried out a cross-sectional study and interviewed women who gave birth between January 2013 and December 2017. Data on socio-demographic characteristics, place of childbirth, as well as direct cost (medical and non-medical) were collected from respondents. The costs of childbirth were estimated from the patient perspective. Logistics regression was used to assess the factors associated with catastrophic payments cost. All analyses were done using STATA 16.0.ResultsOut of the 574 women interviewed, about 71% (406/574) reported OOPPs on their childbirth. The overall average direct medical and non-medical expenditure women made on childbirth was USD 7.5. Cost of drugs (USD 8.0) and informal payments (UDD 5.7) were the main cost drivers for medical and non-medical costs respectively. Women who were enrolled into the National Health Insurance Scheme (NHIS) spent a little less (USD 7.5) than the uninsured women (USD 7.9). Also, household childbirth expenditure increased from primary health facilities level (community-based health planning and services compound = USD7.2; health centre = USD 6.0) to secondary health facilities level (hospital = USD11.0); while home childbirth was USD 4.8. Overall, at a 10% threshold, 21% of the respondents incurred catastrophic health expenditure. Regression analysis showed that place of childbirth and household wealth were statistically significant factors associated with catastrophic payment.ConclusionsThe costs of childbirth were considerably high with a fifth of households spending more than one-tenth of their monthly income on childbirth and therefore faced the risk of catastrophic payments and impoverishment. Given the positive effect of NHIS on cost of childbirth, there is a need to intensify efforts to improve enrolment to reduce direct medical costs as well as sensitization and monitoring to reduce informal payment. Also, the identified factors that influence cost of childbirth should be considered in strategies to reduce cost of childbirth.

An Analysis of Catastrophic Out-of-Pocket Health Expenditures in Ghana.

Ghana implemented a universal health coverage scheme aimed at attaining financial risk protection against catastrophic out-of-pocket health expenditures. The effort has yielded mixed benefits for the different socio-economic profiles of the population. The present study estimates the incidence of catastrophic payments among Ghanaian households. The study analyzed the round seven dataset of the Ghana Living Standards Survey collected between 2016 and 2017. We estimated the incidence and intensity of catastrophic payments for total household consumption and non-food consumption for a range of thresholds. The analysis further weighted the measures of catastrophic payments to determine the distribution sensitivity. As the threshold increased from 10 to 25% of total household consumption, the incidence of catastrophic payments dropped from 1.0 to 0.1%. At the 40% threshold of non-food consumption, the estimated incidence was 0.2%. For both total household consumption and non-food consumption, the concentration indices were negative at all the thresholds. The results were indicative of a higher concentration of financial catastrophe among the poorest households and significant inequalities in the incidence between the poorest and richest households. The study confirmed the declining trend in the general incidence of catastrophic health expenditures in Ghana. However, the incidence and risk of financial catastrophe remained disproportionately higher among the poorest households, which is instructive of gaps in financial risk protection coverage. The Ghana National Health Insurance Scheme must therefore strengthen its targeting and enrolment of this sub-population group to reduce their vulnerability to catastrophic payments.

A Tale of Two Social Insurance Systems in South Korea and Taiwan: A Financial Risk Protection Perspective

ABSTRACT Universal Health Coverage (UHC) is a widespread policy goal in the 21st century. The aim is to protect people from financial risk while promoting their access to good-quality care. This study examined the social insurance systems of South Korea and Taiwan to explore the critical challenges of achieving effective UHC. By assessing the impact of UHC on financial risk protection (measured by out-of-pocket payment share and catastrophic payment headcount), we found that when South Korea inaugurated its National Health Insurance (NHI) program with a limited benefits package and high cost sharing, it did not reduce the financial burden. Meanwhile, we observed a drop of 5 to 6 percentage points in the catastrophic payment headcount in Taiwan, which offered a universal and rather comprehensive benefits package with a modest cost-sharing design under its single-payer NHI system. The political-economic context of the UHC policy evolution was further explored through an in-depth discussion. We conclude that to provide sufficient financial risk protection against unexpected medical expenses, the design of the insurance scheme, in particular the risk-sharing mechanism, not only matters but is also the key to success.