Financial Risk Protection Research Articles

Catastrophic health expenditures in hospitalized patients with delta variant of COVID-19: A cross-sectional study.

Background: Financial protection of populations against healthcare costs is one of the fundamental responsibilities of governments. This study aimed to investigate the incidence of catastrophic health expenditures (CHE) and it's affecting factors in hospitalized patients with delta variant of COVID-19. Methods: In this cross-sectional study, we included 400 hospitalized COVID-19 patients at Kosar Hospital of Semnan in 2022, using a researcher-made checklist. Based on qualitative nature of the variables, chi-square test was used to investigate the statistical associations between the demographic/background characteristics and the incidence of CHE. Results: On average, COVID-19 imposed 1833.43 USD direct medical costs per one hospitalized patient. The ratio of direct-medical costs to household's non-food expenses was 2.35, and 61% (CI:±4.78%) of the patients were subject to CHE. Besides, residence place, basic insurance type, benefitting from supplementary insurance, suffering from underlying diseases, hospitalization in ICU, falling into a coma, facing pulmonary failure, and performing hemoperfusion had significant associations with CHE (P<0.05). Conclusion: The incidence of CHE in hospitalized COVID-19 patients was undesirable, which may be due to geographical, economical, and occupational inequalities apart from the factors related to the severity of the disease. So, health policymakers should pay attention to the provision of proper financial risk protection policies to make the health insurance system more efficient and appropriate.

The extent of financial risk protection among households enrolled under national health insurance schemes in West Africa

The extent of financial risk protection among households enrolled under national health insurance schemes in West Africa

Calculating care: the valuation of medical routes while health seeking in Vietnam

ABSTRACT Vietnam has implemented reforms in how health care is financed to provide patient financial risk protection. However, out-of-pocket payments remain high and insurance use is low relative to the country’s high population coverage rate. In this article, I argue that health insurance was not a pre-requisite for obtaining health care in Vietnam; rather, paying for care through health insurance was but one among many ‘medical routes’ for obtaining treatment. I develop the notion of 'calculative practices of care,' which I define as the repertoires of value scales patients employ as they navigate Vietnam's increasingly stratified public-private health system. The findings contribute to ethnographic research on health financing, particularly how patients practice valuation while health seeking.

Out-of-pocket Expenditure on Medicines and Financial Risk Protection in India: Is the Sustainable Development Goal in Sight?

Out-of-pocket expenditures on medicines (ME) form a large share of the total out-of-pocket expenditure (OOPE) and pose financial risks for Indian households. Using repeated cross-section analysis of national health surveys for 2014 and 2017–2018, change in financial risk due to ME is examined. Logit regression is used to look at the factors associated with financial risk due to medicine expenditure. Households incurring ME declined by 7%. Per capita monthly ME declined to ₹80 (US$1.25, 95% CI: 78–82) from ₹111 (US$1.74, 95% CI: 108–114). Catastrophic headcount declined to 8.6% from 13.5%, but the mean positive overshoot remained constant at ₹9.5 at the 10% threshold. Impoverishment headcount also declined to 1.4% from 2.2%, and 6.1% persons were immiserated in 2017–2018. Distribution of ME and catastrophe continued to be pro-rich, but impoverishment was greater in poorer households. Among states, the headcount of catastrophe was highest in Kerala, and Odisha had the greatest impoverishment in 2017–2018. Cancer patients faced the largest catastrophe, and tuberculosis patients faced the largest impoverishment due to ME. The odds ratio of financial vulnerability was 2.91 (95% CI: 2.5–3.3) for households with more than one member incurring ME, 1.82 (95% CI: 1.6–2.1) for households with chronic disease patients, and 1.6 (95% CI: 1.4–1.8) for private care utilisation. We conclude that declining OOPE led to a decline in financial risk due to ME.

Achieving Universal Health Coverage in Low- and Middle-Income Countries: Challenges for Policy Post-Pandemic and Beyond.

Achieving universal health coverage (UHC) is critical for ensuring equity, improving health, and protecting households from financial catastrophe. The COVID-19 pandemic derailed the progress made across primary health targets. This article aims to review the policy challenges to achieve UHC in a post-pandemic world. A narrative review of 118 peer reviewed and grey literature was conducted. A total of 77 published articles were identified using an electronic search in PubMed and Scopus and a bibliographic search of relevant literature. Another 41 Reports, websites, blogs, news articles, and data were manually sourced from international agencies (WHO, World Bank, IMF, FAO, etc.), government agencies, and non-government organizations. The challenges were identified and discussed under five broad findings: i) weak public health care systems ii) challenges to building resilient health systems, iii) health care financing and financial risk protection, iv) epidemiological and demographic challenges, and v) governance and leadership. LMICs in Africa and South Asia face significant challenges to achieving UHC by 2030. As countries recover from the pandemic's aftermath, significant investments and innovations are needed to ensure progress toward UHC. Efficient resource mobilization through internal accruals, international cooperation, and resource sharing is needed.

Financial model construction of a cross-border e-commerce platform based on machine learning

With the development of informatization, traditional industries have been seriously impacted by cross-border e-commerce (CBEC), and the financial management mode no longer meets the needs of CBEC users. As cross-border electronic trading platforms face enormous financial data challenges, they need financial supervision and effective network risk protection. Artificial intelligence (AI) can effectively improve the financial accounting ability and resource integration of platforms. However, at present, the underdeveloped financial management system of CBEC platforms and problems, such as the running records of platform funds have seriously hindered the development of the financial standardization of platforms because the financial management system affects managers’ statistical analysis of financial data. Therefore, this paper analyzes the financial risks, the management problems and the causes of these problems of CBEC platforms and then uses AI to study the financial operation of CBEC platforms. Subsequently, this paper uses a machine learning (ML) algorithm to analyze the financial data clustering center and the security factor of the financial model. Finally, this paper proposes some corresponding strategies for financial model optimization and construction that can improve the information security and capital management of CBEC finance and promote the long-term development of CBEC platforms. The experimental results show that the classifier value and the safety factor of the financial model of CBEC platforms gradually increase under the ML algorithm. The mean value of the classifier value is approximately 1.14, and the mean value of the safety factor is approximately 1.37. Overall, the initial value of the classifier value of the platform financial model is 0.85, which increases to 1.41 on the seventh day, while the whole process increases by 0.56. The initial value of the safety factor of the platform financial model is 1.10, which increases to 1.64 on the seventh day, while the whole process increases by 0.54. The transaction information security and financial accounting accuracy of the CBEC platform financial model is better than that of the original financial model. The transaction information security is 10.4% higher than that of the original financial model, and the financial accounting accuracy is 10% higher than that of the original financial model. In other words, both AI and ML can promote the financial accounting standards and long-term development of CBEC platforms.

Navigating health systems for burn care: Patient journeys and delays in Uttar Pradesh, India

BackgroundIndia has one of the highest burden of burns. The health systems response to burn care is sometimes patchy and highly influenced by social determinants. Delay in access to acute care and rehabilitation adversely affects recovery outcomes. Evidence on underlying factors for delays in care are limited. In this study, we aim to explore patients’ journeys to analyse their experiences in accessing burn care in Uttar Pradesh, India. MethodsWe conducted qualitative inquiry using the patient journey mapping approach and in-depth interviews (IDI). We purposively selected a referral burn centre in Uttar Pradesh, India and included a diverse group of patients. A chronological plot of the patient’s journey was drawn and confirmed with respondents at the end of the interview. A detailed patient journey map was drawn for each patient based on interview transcripts and notes. Further analysis was done in NVivo 12 using a combination of inductive and deductive coding. Similar codes were categorised into sub-themes, which were distributed to one of the major themes of the ‘three delays’ framework. ResultsSix major burns patients (4 female and 2 males) aged between 2 and 43 years were included in the study. Two patients had flame burns, and one had chemical, electric, hot liquid, and blast injury, respectively. Delay in seeking care (delay 1) was less common for acute care but was a concern for rehabilitation. Accessibility and availability of services, costs of care and lack of financial support influenced delay (1) for rehabilitation. Delay in reaching an appropriate facility (delay 2) was common due to multiple referrals before reaching an appropriate burn facility. Lack of clarity on referral systems and proper triaging influenced this delay. Delay in getting adequate care (delay 3) was mainly due to inadequate infrastructure at various levels of health facilities, shortage of skilled health providers, and high costs of care. COVID-19-related protocols and restrictions influenced all three delays. ConclusionsBurn care pathways are adversely affected by barriers to timely access. We propose using the modified 3-delays framework to analyse delays in burns care. There is a need to strengthen referral linkage systems, ensure financial risk protection, and integrate burn care at all levels of health care delivery systems.

Predicting health services utilization using a score of perceived barriers to medical care: evidence from rural Senegal

BackgroundEnsuring access to healthcare services is a key element to achieving the Sustainable Development Goal 3 of “promoting healthy lives and well-being for all” through Universal Health Coverage (UHC). However, in the context of low- and middle-income countries, most studies focused on financial protection measured through catastrophic health expenditures (CHE), or on health services utilization among specific populations exhibiting health needs (such as pregnancy or recent sickness).MethodsThis study aims at building an individual score of perceived barriers to medical care (PBMC) in order to predict primary care utilization (or non-utilization). We estimate the score on six items: (1) knowing where to go, (2) getting permission, (3) having money, (4) distance to the facility, (5) finding transport, and (6) not wanting to go alone, using individual data from 1787 adult participants living in rural Senegal. We build the score via a stepwise descendent explanatory factor analysis (EFA), and assess its internal consistency. Finally, we assess the construct validity of the factor-based score by testing its association (univariate regressions) with a wide range of variables on determinants of healthcare-seeking, and evaluate its predictive validity for primary care utilization.ResultsEFA yields a one-dimensional score combining four items with a 0.7 Cronbach’s alpha indicating good internal consistency. The score is strongly associated—p-values significant at the 5% level—with determinants of healthcare-seeking (including, but not limited to, sex, education, marital status, poverty, and distance to the health facility). Additionally, the score can predict non-utilization of primary care at the household level, utilization and non-utilization of primary care following an individual’s episode of illness, and utilization of primary care during pregnancy and birth. These results are robust to the use of a different dataset.ConclusionAs a valid, sensitive, and easily documented individual-level indicator, the PBMC score can be a complement to regional or national level health services coverage to measure health services access and predict utilization. At the individual or household level, the PBMC score can also be combined with conventional metrics of financial risk protection such as CHE to comprehensively document deficits in, and progress towards UHC.

Effects of public financing of essential maternal and child health interventions across wealth quintiles in Nigeria: an extended cost-effectiveness analysis

Maternal and newborn mortality rates in Nigeria are among the highest globally, and large socioeconomic inequalities exist in access to maternal, newborn, and child health (MNCH) services in the country. Inequalities also exist in catastrophic health expenditure among households in Nigeria. We aimed to estimate the health and financial risk protection benefits across different wealth groups in Nigeria if a policy of public financing of MNCH interventions were to be introduced. We did an extended cost-effectiveness analysis to estimate the health and financial risk protection benefits, across different household wealth quintiles, of a public-financing policy that assumes zero out-of-pocket costs to patients at the point of care for 18 essential MNCH services. We projected health outcomes (deaths in children aged <5 years [under-5 deaths] and maternal deaths) and private expenditure averted using the Lives Saved Tool with data extracted from national surveys. We modelled three scenarios: 1) coverage expansion at a rate equal to the trend observed between 2013 and 2018 (status quo); 2) annual coverage expansion by 5% compared with the status quo (uniform scale-up scenario); and 3) annual coverage expansion by 10%, 8%, 6%, 4%, and 2% compared with the status quo from the poorest to the wealthiest quintiles, respectively (pro-poor scale-up scenario). Our analysis shows that, if an additional 5% increase in coverage was provided for all wealth quintiles between 2019 and 2030, this uniform scale-up policy would prevent more than 0·11 million maternal deaths and 1·05 million under-5 deaths, avert US$1·8 billion in private expenditure, and avert 3266 cases of catastrophic health expenditure. The incremental cost effectiveness ratio would be $44 per life-year gained, which is highly cost-effective when compared with the gross domestic product per capita of Nigeria for 2018 ($2028). The policy would prevent a higher number of under-5 deaths and catastrophic health expenditure cases in poorer quintiles, but would prevent more maternal deaths and private expenditure in wealthier quintiles. If poorer populations experienced a greater increase in service coverage (ie, the pro-poor scale-up scenario), more maternal and under-5 deaths would be prevented in the poorer quintiles and more private expenditure would be averted than would be under previous scenarios. Public financing of essential MNCH interventions in Nigeria would provide substantial health and financial risk protection benefits to Nigerian households. These benefits would accrue preferentially to the poorest quintiles and would contribute towards reduction of health and socioeconomic inequalities in Nigeria. The distribution would be more pro-poor if public financing of MNCH interventions could target poor households. WHO Partnership for Maternal, Newborn, and Child Health.

Leaving no one behind in health: Financial hardship to access health care in Ethiopia.

Financial hardship (of health care) is a global and a national priority area. All people should be protected from financial hardship to ensure inclusive better health outcome. However, financial hardship of healthcare has not been well studied in Ethiopia in general and in Debre Tabor town in particular. Therefore, this study aimed to assess the incidence of financial hardship of healthcare and associated factors among households in Debre Tabor town. Community based cross sectional study was conducted, from May 24/2022 to June 17/2022, on 423 (selected through simple random sampling) households. Financial hardship was measured through catastrophic (using 10% threshold level) and impoverishing (using $1.90 poverty line) health expenditures. Patient perspective bottom up and prevalence based costing approach were used. Indirect cost was estimated through human capital approach. Bi-variable and multiple logistic regressions were used. The response rate was 95%. The mean household annual healthcare expenditure was Ethiopian birr 12050.64 ($227.37). About 37.1% (95%CI: 32, 42%) of the households spend catastrophic health expenditure with a 10% threshold level and 10.4% of households were impoverished with $1.90 per day poverty line. Being old, with age above 60, (AOR: 4.21, CI: 1.23, 14.45), being non-insured (AOR: 2.19, CI: 1.04, 4.62), chronically ill (AOR: 7.20, CI: 3.64, 14.26), seeking traditional healthcare (AOR: 2.63, CI: 1.37. 5.05) and being socially unsupported (AOR: 2.77, CI: 1.25, 6.17) were statistically significant factors for catastrophic health expenditure. The study showed that significant number of households was not yet protected from financial hardship of healthcare. The financial hardship of health care is stronger among the less privileged populations: non-insured, the chronically diseased, the elder and socially unsupported. Therefore, financial risk protection strategies should be strengthened by the concerned bodies.

Equity-Informative Economic Evaluations of Vaccines: A Systematic Literature Review.

The Immunization Agenda 2030 prioritizes the populations without access to vaccines. Health equity has been increasingly incorporated into economic evaluations of vaccines to foster equitable access. Robust and standardized methods are needed to evaluate the health equity impact of vaccination programs to ensure monitoring and effective addressing of inequities. However, methods currently in place vary and potentially affect the application of findings to inform policy decision-making. We performed a systematic review by searching PubMed, Embase, Econlit, and the CEA Registry up to 15 December 2022 to identify equity-informative economic evaluations of vaccines. Twenty-one studies were included that performed health equity impact analysis to estimate the distributional impact of vaccines, such as deaths averted and financial risk protection, across equity-relevant subgroups. These studies showed that the introduction of vaccines or improved vaccination coverage resulted in fewer deaths and higher financial risk benefits in subpopulations with higher disease burdens and lower vaccination coverage-particularly poorer income groups and those living in rural areas. In conclusion, methods to incorporate equity have been evolving progressively. Vaccination programs can enhance equity if their design and implementation address existing inequities in order to provide equitable vaccination coverage and achieve health equity.

Catastrophic health expenditure and associated factors among households of non community based health insurance districts, Ilubabor zone, Oromia regional state, southwest Ethiopia

BackgroundOut-of-pocket health expenditure is the proportion of total health expenditure that is paid by individuals and households at the time of health service. Hence, the objective of this study is to assess the incidence and intensity of catastrophic health expenditure and associated factors among households in non-community-based health insurance districts in the Ilubabor zone, Oromia National Regional State, Ethiopia.MethodA community-based cross-sectional study design was employed in the Ilubabor zone on non-community-based health insurance scheme districts from August 13 to September 2, 2020, and 633 households participated in the study. A multistage one cluster sampling method was used to select three districts out of seven districts. Data was collected by using a structured mix of open and close-ended pre -tested questionnaires by face-to-face interviewing. A micro-costing/bottom up approach was used for all household expenditure. After checking its completeness, all household consumption expenditure was done by mathematical analysis using Microsoft Excel. Binary and multiple logistic were done using 95%CI and significance was declared at P < 0.05.ResultsThe number of households that participated in the study was 633, with a response rate of 99.7%. Out of 633 households surveyed, 110 (17.4%) were in catastrophe, which exceeds 10% of total household expenditure. After medical care expenses, about 5% of the households moved downward from the middle poverty line to extreme poverty. Out-of-pocket payment AOR: 31.201: 95% CI (12.965–49.673), daily income less than 1.90 USD AOR: 2.081: 95% CI (1.010–3.670), living a medium distance from a health facility AOR: 6.219: 95% CI (1.632–15.418), and chronic disease AOR: 5.647: 95% CI (1.764–18.075.ConclusionIn this study, family size, average daily income, out of pocket payment and chronic diseases were statistically significant and independent predictors for household catastrophic health expenditure. Therefore, to overcome financial risk, the Federal Ministry of Health should develop different guidelines and modalities by considering household per capita and income to improve the enrolment of community-based health insurance. Also, the regional health bureau should improve their budget share of 10% to increase the coverage of poor households. Strengthening financial risk protection mechanisms, such as community-based health insurance, could help to improve healthcare equity and quality.

Catastrophic Health Expenditure and Poverty Impact Due to Mental Illness in India

Majority of people in low- and middle-income countries with mental illness do not receive healthcare, leading to chronicity, suffering and increased costs of care. This study estimated the out-of-pocket expenditure (OOPE), catastrophic health expenditure (CHE), and poverty impact due to mental illness in India. Data was acquired from the 76th round data of the National Sample Survey (NSS) on the theme ‘Persons with Disabilities in India Survey’, July–December 2018. Data of 6,679 persons who reported mental illness during the survey was included for analysis. OOPE, CHE, poverty impact and state differentials of healthcare expenditure on mental illness were analysed using standard methods. In total, 18.1% of the household’s monthly consumption expenditure was spent on healthcare on mental illness. About 59.5% and 32.5% of the households were exposed to CHE based on 10% and 20% thresholds, respectively. About 20.7% of the households were forced to become poor from non-poor due to treatment care expenditure on mental illness. Our study suggests the critical need to accelerate on various measures for early diagnosis and management of mental health issues along with financial risk protection for reducing financial impact of healthcare expenditure on mental illness among households in India.

Impact of health insurance coverage on health care utilization during COVID-19 pandemic: A propensity score matched survey analysis in a target region in India.

Health insurance is considered as a mechanism to accelerate the progress towards universal health coverage and ensure financial risk protection for households throughout the country. There is a growing body of evidence reporting that the health insurance coverage can significantly improve the access and utilization of healthcare services. Hence, we attempted to determine the impact of health insurance on the utilization of healthcare services during COVID-19 pandemic. A community-based cross-sectional study was conducted in rural Tamil Nadu. The primary data collection was conducted during November 2021. We employed a multi-stage stratified random sampling technique. Propensity score matching analysis was performed using radius matching method at 0.05 calliper to estimate the following parameters: average treatment effect (ATE), average treatment effect on treated (ATT), and average treatment effect on untreated (ATU). In total, 2390 participants were included. Almost two-third belonged to 18-45years with almost equal distribution of males and females. Only 13.6% were covered by health insurance. Healthcare utilization was significantly higher among participants with health insurance (55.2%) compared to participants without coverage (42.5%). The ATT values in intervention and control group were 0.55 and 0.46 (p<0.001). Similarly, the ATU values in intervention and control group were 0.42 and 0.51. The ATE value was 0.08. Our study shows that the health insurance coverage had significant impact on utilization of healthcare services during COVID-19 pandemic. Further longitudinal research exploring the effect of different forms of health insurance for improving access and utilization of healthcare services can be undertaken.

Long Covid: A call for global action

AbstractThe COVID‐19 pandemic has resulted in another global health crisis with millions of individuals with Long Covid experiencing disability, worse health‐related quality of life, and productivity and income losses. Despite its impact on population health outcomes, health systems, and the economy, there remains a need for a global consensus on its standard definition, diagnostic approaches, and treatment plans to manage symptoms. In many low‐ and middle‐income countries (LMICs), there are limited published estimates on Long Covid, limited studies on its diagnostics and therapeutics, and limited media and news coverage. We advocate for a global action plan and necessary investments on Long Covid research and treatment, meaningful involvement of patients and cooperation between high‐income countries and LMICs, stronger and more effective public health communication surrounding the risks of Long Covid, and support toward financial risk protection as advocated by Universal Health Care.

High Deductibles are Associated With Severe Disease, Catastrophic Out-of-Pocket Payments for Emergency Surgical Conditions.

Out-of-pocket spending has risen for individuals with private health insurance, yet little is known about the unintended consequences that high levels of cost-sharing may have on delayed clinical presentation and financial outcomes for common emergency surgical conditions. In this retrospective analysis of claims data from a large commercial insurer (2016-2019), we identified adult inpatient admissions following emergency department presentation for common emergency surgical conditions (eg, appendicitis, cholecystitis, diverticulitis, and intestinal obstruction). Primary exposure of interest was enrollment in a high-deductible health insurance plan (HDHP). Our primary outcome was disease severity at presentation-determined using ICD-10-CM diagnoses codes and based on validated measures of anatomic severity (eg, perforation, abscess, diffuse peritonitis). Our secondary outcome was catastrophic out-of-pocket spending, defined by the World Health Organization as out-of-pocket spending >10% of annual income. Among 43,516 patients [mean age 48.4 (SD: 11.9) years; 51% female], 41% were enrolled HDHPs. Despite being younger, healthier, wealthier, and more educated, HDHP enrollees were more likely to present with more severe disease (28.5% vs 21.3%, P <0.001; odds ratio (OR): 1.34, 95% CI: 1.28-1.42]); even after adjusting for relevant demographics (adjusted OR: 1.23, 95% CI: 1.18-1.31). HDHP enrollees were also more likely to incur 30-day out-of-pocket spending that exceeded 10% of annual income (20.8% vs 6.4%, adjusted OR: 3.93, 95% CI: 3.65-4.24). Lower-income patients, Black patients, and Hispanic patients were at highest risk of financial strain. For privately insured patients presenting with common surgical emergencies, high-deductible health plans are associated with increased disease severity at admission and a greater financial burden after discharge-especially for vulnerable populations. Strategies are needed to improve financial risk protection for common surgical emergencies.

“It is like an umbrella covering you, yet it does not protect you from the rain”: a mixed methods study of insurance affordability, coverage, and financial protection in rural western Kenya

Countries in Sub-Saharan Africa are increasingly adopting mandatory social health insurance programs. In Kenya, mandatory social health insurance is being implemented through the national health insurer, the National Hospital Insurance Fund (NHIF), but the level of coverage, affordability and financial risk protection provided by health insurance, especially for rural informal households, is unclear. This study provides as assessment of affordability of NHIF premiums, the need for financial risk protection, and the extent of financial protection provided by NHIF among rural informal workers in western Kenya.Methods We conducted a mixed methods study with a cross-sectional household survey (n = 1773), in-depth household interviews (n = 36), and 6 focus group discussions (FGDs) with community stakeholders in rural western Kenya. Health insurance status was self-reported and households were categorized into insured and uninsured. Using survey data, we calculated the affordability of health insurance (unaffordability was defined as the monthly premium being > 5% of total household expenditures), out of pocket expenditures (OOP) on healthcare and its impact on impoverishment, and incidence of catastrophic health expenditures (CHE). Logistic regression was used to assess household characteristics associated with CHE.Results Only 12% of households reported having health insurance and was unaffordable for the majority of households, both insured (60%) and uninsured (80%). Rural households spent an average of 12% of their household budget on OOP, with both insured and uninsured households reporting high OOP spending and similar levels of impoverishment due to OOP. Overall, 12% of households experienced CHE, with uninsured households more likely to experience CHE. Participants expressed concerns about value of health insurance given its cost, availability and quality of services, and financial protection relative to other social and economic household needs. Households resulted to borrowing, fundraising, taking short term loans and selling family assets to meet healthcare costs.Conclusion Health insurance coverage was low among rural informal sector households in western Kenya, with health insurance premiums being unaffordable to most households. Even among insured households, we found high levels of OOP and CHE. Our results suggest that significant reforms of NHIF and health system are required to provide adequate health services and financial risk protection for rural informal households in Kenya.

Illnesses and hardship financing in India: an evaluation of inpatient and outpatient cases, 2014-18

BackgroundProgress towards universal health coverage requires strengthening the country's health system. In developing countries, the increasing disease burden puts a lot of stress on scarce household finances. However, this burden is not the same for everyone. The economic burden varies across the disease groups and care levels. Government intervention is vital in formulating policies in addressing financial distress at the household level. In India, even when outpatient care forms a significant proportion of out-of-pocket expenditure, government schemes focus on reducing household expenditure on inpatient care alone. Thus, people resort to hardship financing practices like informal borrowing or selling of assets in the event of health shocks. In this context, the present study aims to identify the disease(s) that correlates with maximum hardship financing for outpatients and inpatients and to understand the change in hardship financing over time.MethodsWe used two waves of National Sample Survey Organisation’s data on social consumption on health- the 71st and the 75th rounds. Descriptive statistics are reported, and logistic regression is carried out to explain the adjusted impact of illness on hardship financing. Pooled logistic regression of the two rounds is estimated for inpatients and outpatients. Marginal effects are reported to study the changes in hardship financing over time.ResultsThe results suggest that cancer had the maximum likelihood of causing hardship financing in India for both inpatients (Odds ratio 2.41; 95% Confidence Interval (CI): 2.03 - 2.86 (71st round), 2.54; 95% CI: 2.21 - 2.93 (75th round)) and outpatients (Odds ratio 6.11; 95% CI: 2.95 - 12.64 (71st round), 3.07; 95% CI: 2.14 - 4.40 (75th round)). In 2018, for outpatients, the hardship financing for health care needs was higher at public health facilities, compared to private health facilities (Odds ratio 0.72; 95% CI: 0.62 - 0.83 (75th round). The marginal effects model of pooled cross-section analysis reveals that from 2014 to 2018, the hardship financing had decreased for inpatients (Odds ratio 0.747; 95% CI:0.80 - -0.70), whereas it had increased for outpatients (Odds ratio 0.0126; 95% CI: 0.01 - 0.02). Our results also show that the likelihood of resorting to hardship financing for illness among women was lesser than that of men.ConclusionGovernment intervention is quintessential to decrease the hardship financing caused by cancer. The intra-household inequalities play an important role in explaining their hardship financing strategies. We suggest the need for more financial risk protection for outpatient care to address hardship financing.

Occupational and geographical differentials in financial protection against healthcare out-of-pocket payments in Nepal: Evidence for universal health coverage.

The low-and middle-income countries, including Nepal, aim to address the financial hardship against healthcare out-of-pocket (OOP) payments through various health financing reforms, for example, risk-pooling arrangements that cover different occupations. World Health Organization (WHO) has recommended member states to establish pooling arrangements so that the financial risks owing to health uncertainty can be spread across population. This study aims to analyse the situation of financial protection across occupations and geography using nationally representative annual household survey (AHS) in Nepal. We measured catastrophic health expenditure (CHE) due to OOP using two popular approaches-budget share and capacity-to-pay, and impoverishment impact at absolute and relative poverty lines. This study is the first of its kind from south-east Asia to analyse disaggregated estimates of financial protection across occupations and geography. The inequality in financial risk protection was measured using concentration index. Data were extracted from AHS 2014-15 -a cross-sectional survey that used standard consumption measurement tool (COICOP) and International Standard Classification of Occupations (ISCO). We found a CHE of 10.7% at 10% threshold and 5.2% at 40% threshold among households belonging to agricultural workers. The corresponding figures were 10% and 4.8% among 'plant operators and craft workers'. Impoverishment impact was also higher among these households at all poverty lines. In addition, CHE was higher among unemployed households. A negative concentration index was observed for CHE and impoverishment impact among agricultural workers and 'plant operators and craft workers'. In rural areas, we found a CHE of 11.5% at 10% threshold and a high impoverishment impact. Across provinces, CHE was 12% in Madhesh and 14.3% in Lumbini at 10% threshold, and impoverishment impact was 1.9% in Madhesh, Karnali and Sudurpachim at US $1.90 a day poverty line. Households belonging to informal occupations were more prone to CHE and impoverishment impact due to healthcare OOP payments. Impoverishment impact was disproportionately higher among elementary occupations, agricultural workers, and 'plant operators and craft workers'. Similarly, the study found a wide urban/rural and provincial gap in financial protection. The results can be useful to policymakers engaged in designing health-financing reforms to make progress toward UHC.

The impact of community-based health insurance on health service utilization and financial risk protection in Ethiopia

BackgroundEvidence on the effectiveness of community-based health insurance (CBHI) in low-income countries is inconclusive. This study assessed the impact of CBHI on health service utilization and financial risk protection in Ethiopia.MethodsWe conducted a comparative cross-sectional study nested within a larger national household survey in 2020. Data was collected from three groups of households—CBHI member households (n = 1586), non-member households from CBHI implementing woredas (n = 1863), and non-member households from non-CBHI implementing woredas (n = 789). Indicators of health service utilization, out-of-pocket health spending, catastrophic health expenditure, and impoverishment due to health spending among CBHI members were compared with non-members from CBHI implementing woredas and households from non-CBHI implementing woredas. Propensity score matching (PSM) was used to account for possible selection bias.ResultsThe annual number of OPD visits per capita among CBHI member households was 2.09, compared to 1.53 among non-member households from CBHI woredas and 1.75 among households from non-CBHI woredas. PSM estimates indicated that CBHI members had 0.36 (95% CI: 0.25, 0.44) and 0.17 (95% CI: -0.04, 0.19) more outpatient department (OPD) visits per capita per year than their matched non-member households from CBHI-implementing and non-CBHI implementing woredas, respectively. CBHI membership resulted in a 28–43% reduction in annual OOP payments as compared to non-member households. CBHI member households were significantly less likely to incur catastrophic health expenditures (measured as annual OOP payments of more than 10% of the household’s total expenditure) compared to non-members (p < 0.01).ConclusionCBHI membership increases health service utilization and financial protection. CBHI proves to be an important strategy for promoting universal health coverage. Implementing CBHI in all woredas and increasing membership among households in woredas that are already implementing CBHI will further expand its benefits.