Household Non-food Expenditure Research Articles

Association of Catastrophic Health Expenditure With the Risk of Depression in Chinese Adults: Population-Based Cohort Study.

Depression is one of the most common mental illnesses, and it may have a lasting effect on one's whole life. As a form of financial hardship, catastrophic health expenditure (CHE) may be associated with depression. However, current evidence about the relationship between CHE and the risk of depression is insufficient. This study aimed to explore the relationship between CHE and the risk of depression among Chinese adults. In this study, we used 3 waves of the China Family Panel Studies (CFPS) from 2012, 2016, and 2018. The CFPS are a nationally representative study covering 25 of 31 provinces in Chinese mainland and representing nearly 94.5% of the total population. We selected eligible household heads as participants, divided them into 2 groups by CHE events at baseline (exposed group: with CHE; unexposed group: without CHE), and followed them up. Households with CHE were defined as having out-of-pocket medical expenditures exceeding 40% of the total household nonfood expenditure, and people with depression were identified by the 8-item Centre for Epidemiological Studies Depression Scale (CES-D). We first described the baseline characteristics and used logistical regression to estimate their effects on CHE events. Then, we used Cox proportional hazard models to estimate adjusted hazard ratios and 95% CIs of depression among participants with CHE compared with those without CHE. Finally, we analyzed the subgroup difference in the association between CHE and depression. Of a total of 13,315 households, 9629 were eligible for analysis. Among them, 6824 (70.9%) were men. The mean age was 50.15 (SD 12.84) years. Only 987 (10.3%) participants had no medical insurance. The prevalence of CHE at baseline was 12.9% (1393/9629). Participants with a higher family economic level (adjusted odds ratio [aOR] 1.15, 95% CI 1.02-1.31) and with the highest socioeconomic development level (aOR 1.18, 95% CI 1.04-1.34) had a higher prevalence of CHE than reference groups. During a median of 71 (IQR 69-72) person-months of follow-up, the depression incidence of participants with CHE (1.41 per 1000 person-months) was higher than those without CHE (0.73 per 1000 person-months). Multivariable models revealed that the adjusted hazard ratio for the incidence of depression in participants with CHE was 1.33 (95% CI 1.08-1.64), and this association appeared to be greater in participants without outpatient services (for interaction, P=.048). CHE was significantly associated with increased risk of depression among Chinese adults. Concentrated work should be done to monitor CHE, and more efforts to ensure financial protection need to be made to prevent depression, especially for people with high health care needs.

Household Food Security of Cocoa Farmers (Theobroma Cacao L) on Former Coal Mine Land in Sawahlunto City

An overview of the food security vulnerability of cocoa farmer households on former mining lands is able to provide recommendations in efforts to increase the income that can support the welfare of farmer households and increase regional farmer food security. The purpose of this study was to determine the amount of cocoa farmer household income and cocoa farmer household expenditure and the level of food security of cocoa farmer households in ex-mining areas in Talawi District, Sawahlunto City. With a sample of 39 respondents selected by simple random sampling and data analysis using a quantitative approach. This study shows the results that the average household income of respondents is IDR 3,082,821 per month. Whereas for the average respondent household food expenditure is Rp.1,426,282.05 or 59.94% of total household expenditure, the respondent's household non-food expenditure is Rp.953,384.62 or 40.06% of total household expenditure ladder. Judging from the proportion of household expenditure to total expenditure, the results show that the level of household food security is 23.08% of households are food secure and 76.92% of households are food insecure. Households should improve food expenditure patterns by paying attention to and diversifying the amount and type of food they will consume.

The burden of catastrophic and impoverishing health expenditure in Armenia: An analysis of Integrated Living Conditions Surveys, 2014-2018.

Armenia's health spending is characterized by low public spending and high out-of-pocket expenditure (OOP), which not only poses a financial barrier to accessing healthcare for Armenians but can also impoverish them. We analyzed Armenia's Integrated Living Conditions Surveys 2014-2018 data to assess the incidence and correlates of catastrophic health expenditure (CHE) and impoverishment. Households were considered to have incurred CHE if their annual OOP exceeded 40 percent of the per capita annual household non-food expenditure. We assessed impoverishment using the US$1.90 per person per-day international poverty line and the US$5.50 per person per-day upper-middle-income country poverty line. Logistic regression models were fitted to assess the correlates of CHE and impoverishment. We found that the incidence of CHE peaked in 2017 before declining in 2018. Impoverishment decreased until 2017 before rising in 2018. After adjusting for sociodemographic factors, households were more likely to incur CHE if the household head was older than 34 years, located in urban areas, had at least one disabled member, and had at least one member with hypertension. Households with at least one hypertensive member or who resided in urban areas were more likely to be impoverished due to OOP. Paid employment and high socioeconomic status were protective against both CHE and impoverishment from OOP. This detailed analysis offers a nuanced insight into the trends in Armenia's financial risk protection against catastrophic and impoverishing health expenditures, and the groups predominantly affected. The incidence of CHE and impoverishment in Armenia remains high with a higher incidence among vulnerable groups, including those living with chronic disease, disability, and the unemployed. Armenia should consider different mechanisms such as subsidizing medication and hospitalization costs for the poorest to alleviate the burden of OOP.

Analisis struktur pengeluaran rumah tangga di Provinsi Jambi Tahun 2020

The purpose of this study was to determine the effect of household groups on the structure of household expenditures. The data used in this study is the March 2020 Susenas raw data, namely Susenas data on household scores in 11 districts and cities of Jambi Province. The data analysis method used is descriptive method. The analytical tool used is Multiple Linear Regression (multiple regression). The results showed that in the upper urban household group, the independent variables were: household income, number of household members, age of the head of the household, education level of the head of the household, gender of the head of the household, the status of the head of the household in the main occupation, and the status of the household head. marriage of the head of the household can explain household non-food competition by 94.3 percent and together the independent variables can have an influence on household non-food expenditure. In the lower urban household group, the independent variables cannot explain expenditures other than household food because they only have an R2 value of 2.7 and together the independent variables also cannot have an effect on expenditures other than household food. As well as in the upper rural household group, the independent variable can explain household non-food competition by 65.5 percent and the independent variable can have an influence on household non-food expenditure.

Catastrophic health expenditure in sub-Saharan Africa: systematic review and meta-analysis.

ObjectiveTo estimate the incidence of, and trends in, catastrophic health expenditure in sub-Saharan Africa.MethodsWe systematically reviewed the scientific and grey literature to identify population-based studies on catastrophic health expenditure in sub-Saharan Africa published between 2000 and 2021. We performed a meta-analysis using two definitions of catastrophic health expenditure: 10% of total household expenditure and 40% of household non-food expenditure. The results of individual studies were pooled by pairwise meta-analysis using the random-effects model.FindingsWe identified 111 publications covering a total of 1 040 620 households across 31 sub-Saharan African countries. Overall, the pooled annual incidence of catastrophic health expenditure was 16.5% (95% confidence interval, CI: 12.9–20.4; 50 datapoints; 462 151 households; I2 = 99.9%) for a threshold of 10% of total household expenditure and 8.7% (95% CI: 7.2–10.3; 84 datapoints; 795 355 households; I2 = 99.8%) for a threshold of 40% of household non-food expenditure. Countries in central and southern sub-Saharan Africa had the highest and lowest incidence, respectively. A trend analysis found that, after initially declining in the 2000s, the incidence of catastrophic health expenditure in sub-Saharan Africa increased between 2010 and 2020. The incidence among people affected by specific diseases, such as noncommunicable diseases, HIV/AIDS and tuberculosis, was generally higher.ConclusionAlthough data on catastrophic health expenditure for some countries were sparse, the data available suggest that a non-negligible share of households in sub-Saharan Africa experienced catastrophic expenditure when accessing health-care services. Stronger financial protection measures are needed.

Examining the incidence of catastrophic health expenditures and its determinants using multilevel logistic regression in Malawi.

BackgroundDespite a free access to public health services policy in most sub-Saharan African countries, households still contribute to total health expenditures through out-of-pocket expenditures. This reliance on out-of-pocket expenditures places households at a risk of catastrophic health expenditures and impoverishment. This study examined the incidence of catastrophic health expenditures, impoverishing effects of out-of-pocket expenditures on households and factors associated with catastrophic expenditures in Malawi.MethodsWe conducted a secondary analysis of the most recent nationally representative integrated household survey conducted by the National Statistical Office between April 2016 to 2017 in Malawi with a sample size of 12447 households. Catastrophic health expenditures were estimated based on household annual nonfood expenditures and total household annual expenditures. We estimated incidence of catastrophic health expenditures as the proportion of households whose out-of-pocket expenditures exceed 40% threshold level of non-food expenditures and 10% of total annual expenditures. Impoverishing effect of out-of-pocket health expenditures on households was estimated as the difference between poverty head count before and after accounting for household health payments. We used a multilevel binary logistic regression model to assess factors associated with catastrophic health expenditures.ResultsA total of 167 households (1.37%) incurred catastrophic health expenditures. These households on average spend over 52% of household nonfood expenditures on health care. 1.6% of Malawians are impoverished due to out-of-pocket health expenditures. Visiting a religious health facility (AOR = 2.27,95% CI:1.24–4.15), hospitalization (AOR = 6.03,95% CI:4.08–8.90), larger household size (AOR = 1.20,95% CI:1.24–1.34), higher socioeconomic status (AOR = 2.94,95% CI:1.39–6.19), living in central region (AOR = 3.54,95% CI:1.79–6.97) and rural areas (AOR = 5.13,95% CI:2.14–12.29) increased the odds of incurring catastrophic expenditures.ConclusionThe risk of catastrophic health expenditures and impoverishment persists in Malawi. This calls for government to improve the challenges faced by the free public health services and design better prepayment mechanisms to protect more vulnerable groups of the population from the burden of out-of-pocket payments.

The influence of integration of health-insurance schemes on catastrophic health expenditure in China: a cohort study

BackgroundFragmented health-insurance schemes led to inefficiency and inequality in financial protection for universal health-care coverage. The Chinese government proceeded to consolidate the urban and rural health-insurance schemes with a unified fund collection, pooling, and payment system in 2016. Our study aims to establish the effects of the integration policy on incidence and distribution of catastrophic health expenditure (CHE) in China. MethodsWe obtained nationally representative cohort data for analysis from five China Family Panel Studies from 2010 to 2018, which included 17 858 households from 23 provinces. Families were selected using a probability proportional to size sampling technique with implicit stratification from 25 provinces in mainland China. In this natural experimental design, the five provinces with integrated health-insurance schemes before 2016 were considered to be the treatment group, and the other 18 provinces were considered to be the control group. We used a differences-in-differences method to capture the effects of integration policy on CHE incidence, measured by whether the out-of-pocket health expenditure exceeded 25% of the total household non-food expenditure, controlling for both household characteristics and geographical fixed effects. Further, we used the concentration index to investigate changes in the distribution of CHE. FindingsThe incidence of CHE for total population decreased from 17·4% (95% CI 16·7–18·0, SE 0·0034) in 2010 to 13·0% (12·4–13·6, 0·0031) in 2018. The incidence of CHE in urban areas decreased from 14·1% (13·3–15·0, 0·0045) in 2010 to 9·6% (8·8–10·3, 0·0038) in 2018, whereas it declined from 20·3% (19·3–21·3, 0·0050) to 16·6% (15·7–17·6, 0·0049) in rural areas. The incidence of CHE in treatment groups reduced from 15·2% (14·0–16·5, 0·0063) in 2010 to 10·1% (9·0–11·2, 0·0057) in 2018, whereas it decreased from 18·1% (17·3–18·9, 0·0040) in 2010 to 14·0% (13·2–14·7, 0·0036) in 2018 in control groups. In addition, consolidation of health-insurance schemes decreased the incidence of CHE by 1·7% (0·68–2·73, p<0·0001) in the treatment group, compared with the control group. The concentration index for CHE was –0·26 (treatment vs control group, p<0·0001) in the total population in 2018, –0·24 (treatment vs control group, p<0·0001) in the unconsolidated provinces, and –0·34 (treatment vs control group, p<0·0001) in consolidated provinces. InterpretationThe integration of different public health-insurance schemes in China might have increased the financial protection of residents covered by these schemes. However, urban–rural disparity in health insurance and unequal distribution of CHE among poor households have not altered. This study suggests that bulk purchasing and payment reform can be implemented to contain health-care costs and to refrain out-of-pocket payments, particularly for rural and population with low incomes. FundingNHC Key Laboratory of Health Economics and Policy Research, Shandong University (grant NHC-HEPR2019017).

Estimating Catastrophic Health Expenditures from Household Surveys: Evidence from Living Standard Measurement Surveys (LSMS)-Integrated Surveys on Agriculture (ISA) from Sub-Saharan Africa.

BackgroundOut of pocket (OOP) payments for healthcare remain a significant health financing challenge in sub-Saharan Africa (SSA). Understanding the drivers and impacts of this financial health burden is both an economic and a public health priority.ObjectiveThis study examines how the burden of OOP health expenditures varies with different thresholds for financial catastrophe.MethodsThe analysis is based on Livings Standards Measurement Surveys (LSMS)-Integrated Surveys on Agriculture (ISA) for five SSA countries—Ethiopia, Malawi, Nigeria, Tanzania, and Uganda. We estimate the degree by which OOP payments as share of total household non-food expenditures exceed either the 15 or 25% threshold.ResultsFor the countries considered, the severity of OOP payments is substantial—the average positive overshoot (beyond the 25% threshold) is above 10%, except for Nigeria. This reflects a higher percentage of OOP in total household health expenditures—compared to taxes and contributions—especially among the poor in these specific countries. Regarding sensitivity of distribution of catastrophic health expenditures, we find that households with low non-food expenditures are more likely to incur catastrophic payments with the exception for Uganda where catastrophic payments increase with the increase of non-food household expenditures.ConclusionThe burden of catastrophic health expenditures remains large. In order to reduce this burden, public health expenditures need to be expanded as an alternative. This calls for renewed attention to expand public revenues as the most sustainable methods of financing health expenditures in Africa.

Divergent Cooperative Memberships. Exploring the Determinants. A Case Study of Poultry Farming Households in Southwest Nigeria

This study examines the determinants of differential cooperative membership among poultry farming households in Oyo State. A multistage sampling technique was employed to randomly select 210 poultry farmers; 101 Cooperators and 109 Non-cooperators, using well-structured questionnaires. Descriptive statistics, T-test, Variance inflation factor, and stepwise multivariate regression are employed in data analysis. The study reveals that an ample proportion of the farmers are still within their productive age. Also, Farmers age, credit access, output level, and household non-food expenditure positively determines cooperative membership but negatively determined by paid labour, and marriage. Regarding differential cooperative memberships; formal education, age, and farm expenditure positively influences multipurpose cooperative membership but negatively influenced by gender and output level. Primary occupation, food expenditure, and paid labour, positively determined producer cooperative membership but negatively determined by farm expenditure, formal education, age, and household size while, primary occupation, and non-food expenditure positively determines marketing cooperative membership but negatively determined by paid labour, and farm expenditure. Farmers age, primary occupation, Non-food, and farming expenditure negatively determines consumer cooperative membership but positively determined by household size. Finding based policy options are inferred.

Safety nets and natural disaster mitigation: evidence from cyclone Phailin in Odisha

To what degree can vulnerability to extreme weather events be mitigated by access to a rural livelihoods program, particularly with regard to the impacts on women? This paper addresses this question through a natural experiment arising from two independent but overlapping sources of variation: exposure to a devastating cyclone that occurred in the Bay of Bengal region of India and the staggered rollout of a rural livelihoods intervention. Comparisons from household surveys across communities more or less exposed to the storm before and after the introduction of the program reveal that the storm led to significant reductions in overall household expenditure, and that these reductions were indeed the largest for women, adding to the emerging evidence for the frequently-posed hypothesis that women bear the brunt of the effects of disasters on overall household consumption. Participation in the livelihoods program mitigated some of the reductions in household nonfood expenditure and women's consumption, but not on food expenditure. These results from a densely populated region whose topography makes it particularly vulnerable to storms can inform future policy approaches and aid in modeling the impact of these policies on the effects of climate change.

Exploring the determinants of catastrophic health expenditure and socioeconomic horizontal equity in relation to it: a rural community based longitudinal study in West Bengal

Background:Equity in health care is defined as equal access to available care for equal need. Out-of-pocket expenditures are the most inequitable means of health care financing. These payments become catastrophic health expenditure (CHE) if it exceeds the household’s ‘Capacity to Pay’. As fairness is one of the fundamental objectives of the health system, identification of the factors responsible for these expenditures is important. Hence this study was conducted to find out the determinants of CHE and to explore the socioeconomic horizontal equity in relation to it. Methods:Total 352 households from 9 villages of Amdanga block, North 24 Parganas, were studied for 12 months. Annual out-of-pocket healthcare expenditure exceeding 40% of annual household non-food expenditure was classified as CHE and determinants of the same were identified using logit-model. Equity was measured by Concentration index and modified Kakwani measure (MDK). Results:Overall prevalence of CHE was 20.7% and highest (39.3%) in the second income quintile. The odds of incurring CHE were highest (35.43) for the households with member/s requiring inpatient treatment followed by households having more than five members (12.81). Negative value of concentration index and MDK indicated that the probability of incurring CHE was disproportionately concentrated among the poor and the financing system was degressive, however some amount of equity was noted in the poorest quintile. Conclusions:Apart from the poorest section in the community the poorer and middle income sections are still exposed to healthcare expenditure shocks and the health care spending was diverse and less equitable.

User-fee-removal improves equity of children's health care utilization and reduces families' financial burden: evidence from Jamaica.

BackgroundThe impact of user–fee policies on the equity of health care utilization and households’ financial burdens has remained largely unexplored in Latin American and the Caribbean, as well as in upper–middle–income countries. This paper assesses the short– and long–term impacts of Jamaica’s user–fee–removal for children in 2007.MethodsThis study utilizes 14 rounds of data from the Jamaica Survey of Living Conditions (JSLC) for the periods 1996 to 2012. JSLC is a national household survey, which collects data on health care utilization and among other purposes for planning. Interrupted time series (ITS) analysis was used to examine the immediate impact of the user–fee–removal policy on children’s health care utilization and households’ financial burdens, as well as the impact in the medium– to long–term.ResultsImmediately following the implementation of user–fee–removal, the odds of seeking for health care if the children fell ill in the past 4 weeks increased by 97% (odds ratio 2.0, 95% confidence interval (CI) 1.1 to 3.5, P = 0.018). In the short–term (2007–2008), health care utilization increased at a faster rate among children not in poverty than children in poverty; while this gap narrowed after 2008. There was minimal difference in health care utilization across wealth groups in the medium– to long–term. The household’s financial burden (health expenditure as a share of household’s non–food expenditures) reduced by 6 percentage points (95% CI: –11 to –1, P = 0.020) right after the policy was implemented and kept at a low level. The difference in financial burden between children in poverty and children not in poverty shrunk rapidly after 2007 and remained small in subsequent years.ConclusionsUser–fee–removal had a positive impact on promoting health care utilization among children and reducing their household health expenditures in Jamaica. The short–term and the medium– to long–term results have different indications: In the short–term, the policy deteriorated the equity of access to health care for children, while the equity status improved fast in the medium– to long–term.

Does tax-based health financing offer protection from financial catastrophe? Findings from a household economic impact survey of ischaemic heart disease in Malaysia.

Malaysia is an upper-middle income country with a tax-based health financing system. Health care is relatively affordable, and safety nets are provided for the needy. The objectives of this study were to determine the out-of-pocket health spending, proportion of catastrophic health spending (out-of-pocket spending>40% of non-food expenditure), economic hardship and financial coping strategies among patients with ischaemic heart disease (IHD) in Malaysia under the present health financing system. A cross-sectional study was conducted at the National Heart Institute of Malaysia involving 503 patients who were hospitalized during the year prior to the survey. The mean annual out-of-pocket health spending for IHD was MYR3045 (at the time US$761). Almost 16% (79/503) suffered from catastrophic health spending (out-of-pocket health spending ≥40% of household non-food expenditures), 29.2% (147/503) were unable to pay for medical bills, 25.0% (126/503) withdrew savings to help meet living expenses, 16.5% (83/503) reduced their monthly food consumption, 12.5% (63/503) were unable to pay utility bills and 9.0% (45/503) borrowed money to help meet living expenses. Overall, the economic impact of IHD on patients in Malaysia was considerable and the prospect of economic hardship likely to persist over the years due to the long-standing nature of IHD. The findings highlight the need to evaluate the present health financing system in Malaysia and to expand its safety net coverage for vulnerable patients.

The economic burden of chronic non-communicable diseases in rural Malawi: an observational study.

BackgroundEvidence from population-based studies on the economic burden imposed by chronic non-communicable diseases (CNCDs) is still sparse in Sub-Saharan Africa. Our study aimed to fill this existing gap in knowledge by estimating both the household direct, indirect, and total costs incurred due to CNCDs and the economic burden households bear as a result of these costs in Malawi.MethodsThe study used data from the first round of a longitudinal household health survey conducted in 2012 in three rural districts in Malawi. A cost-of-illness method was applied to estimate the economic burden of CNCDs. Indicators of catastrophic spending and impoverishment were used to estimate the economic burden imposed by CNCDs on households.ResultsA total 475 out of 5643 interviewed individuals reported suffering from CNCDs. Mean total costs of all reported CNCDs were 1,040.82 MWK, of which 56.8 % was contributed by direct costs. Individuals affected by chronic cardiovascular conditions and chronic neuropsychiatric conditions bore the highest levels of direct, indirect, and total costs. Using a threshold of 10 % of household non-food expenditure, 21.3 % of all households with at least one household member reporting a CNCD and seeking care for such a condition incurred catastrophic spending due to CNCDs. The poorest households were more likely to incur catastrophic spending due to CNCDs. An additional 1.7 % of households reporting a CNCD fell under the international poverty line once considering direct costs due to CNCDs.ConclusionOur study showed that the economic burden of CNCDs is high, causes catastrophic spending, and aggravates poverty in rural Malawi, a country where in principle basic care for CNCDs should be offered free of charge at point of use through the provision of an Essential Health Package (EHP). Our findings further indicated that particularly high direct, indirect, and total costs were linked to specific diagnoses, although costs were high even for conditions targeted by the EHP. Our findings point at clear gaps in coverage in the current Malawian health system and call for further investments to ensure adequate affordable care for people suffering from CNCDs.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1716-8) contains supplementary material, which is available to authorized users.

Refusal to enrol in Ghana's National Health Insurance Scheme: is affordability the problem?

BackgroundAccess to health insurance is expected to have positive effect in improving access to healthcare and offer financial risk protection to households. Ghana began the implementation of a National Health Insurance Scheme (NHIS) in 2004 as a way to ensure equitable access to basic healthcare for all residents. After a decade of its implementation, national coverage is just about 34% of the national population. Affordability of the NHIS contribution is often cited by households as a major barrier to enrolment in the NHIS without any rigorous analysis of this claim. In light of the global interest in achieving universal health insurance coverage, this study seeks to examine the extent to which affordability of the NHIS contribution is a barrier to full insurance for households and a burden on their resources.MethodsThe study uses data from a cross-sectional household survey involving 2,430 households from three districts in Ghana conducted between January-April, 2011. Affordability of the NHIS contribution is analysed using the household budget-based approach based on the normative definition of affordability. The burden of the NHIS contributions to households is assessed by relating the expected annual NHIS contribution to household non-food expenditure and total consumption expenditure. Households which cannot afford full insurance were identified.ResultsResults show that 66% of uninsured households and 70% of partially insured households could afford full insurance for their members. Enroling all household members in the NHIS would account for 5.9% of household non-food expenditure or 2.0% of total expenditure but higher for households in the first (11.4%) and second (7.0%) socio-economic quintiles. All the households (29%) identified as unable to afford full insurance were in the two lower socio-economic quintiles and had large household sizes. Non-financial factors relating to attributes of the insurer and health system problems also affect enrolment in the NHIS.ConclusionAffordability of full insurance would be a burden on households with low socio-economic status and large household size. Innovative measures are needed to encourage abled households to enrol. Policy should aim at abolishing the registration fee for children, pricing insurance according to socio-economic status of households and addressing the inimical non-financial factors to increase NHIS coverage.

Whether New Cooperative Medical Schemes Reduce the Economic Burden of Chronic Disease in Rural China

BackgroundThe New Cooperative Medical Scheme (NCMS) provides health insurance coverage for rural populations in China. This study aimed to evaluate changes in household catastrophic health expenditure (CHE) due to chronic disease before and after the reimbursement policies for services of chronic disease were implemented to provide additional financial support.MethodsThe study used data from the household surveys conducted in Shandong Province and Ningxia Hui Autonomous Region in 2006 and 2008. The study sample in village-level units was divided into two groups: 36 villages which implemented the NCMS reimbursement policies for chronic diseases as the intervention group, and 72 villages which did not as the control group. Health care expenditure of more than 40% of household’s non-food expenditure was defined as a household with CHE (i.e., impoverishment). The conceptual framework was established based on the Andersen socio-behavioral model of health care utilization to explore how the NCMS reimbursement policies impacted health expenditures. A difference-in-difference model was employed to compare the change in the proportion of households incurring CHE due to chronic disease between the two groups over time.ResultsThe households that participated in the NCMS were less likely to become impoverished (P<0.05). In addition, the households with both male household head and higher income level were protective factors to prevent CHE (P<0.05). Young households with preschool children suffered less from CHE (P<0.05). The effect of the NCMS reimbursement policies for chronic disease on the CHE was negative, yet not statistically significant (p = 0.814).ConclusionsThe NCMS coverage showed financial protection for households with chronic disease. However, the NCMS reimbursement policies should be strengthened in the future.

Socio-economic determinants of household out-of-pocket payments on healthcare in Pakistan.

BackgroundOut-of-pocket (OOP) payment on healthcare is dominant mode of financing in developing countries. In Pakistan it is 67% of total expenditure on healthcare. Analysis of determinants of OOP health expenditure is a key aspect of equity in healthcare financing. It helps to formulate an effective health policy. Evidence on OOP in Pakistan is sparse. This paper attempts to fill this research gap.MethodsWe estimated determinants of OOP payments on healthcare in Pakistan. We used data sets of Pakistan Household Integrated Economic Survey (HIES) and Pakistan Standard of Living Measurement (PSLM) Survey for the year 2004-05. We developed a multiple regression model for the determinants of OOP payments using methods of Ordinary Least Square (OLS). We mainly used social, economic, demographic and health variables in our analysis.ResultsMedian household OOP healthcare in the year 2004-05 was Pakistani Rupees (PKR) 2500 (US$ 41.99) in 2004-05. Household non-food expenditure was the single highest significant predictor of household OOP health expenditure. Household features like literate head and spouse, at least one obstetric delivery in last three years, unsafe water, unhygienic toilet and household belonging to Khyber Pukhtonkhwa (KPK) province were significant positive predictors of OOP payments. Households with male head, bricks used in housing construction, household with at least one child and no elderly, and head of household in a white collar profession were negative predictors of OOP payments.ConclusionOur analysis confirms earlier findings that economic status and number of old aged members are significant positive predictors of OOP payments. This association can direct government to enhance allocations to healthcare and to include program focusing on non-communicable diseases. Our findings suggest further research to explore beneficiaries of government healthcare programs and determinants of high OOP payments by household residing in KPK province than other province. The interaction between white collar profession and their economic status in predicting OOP payments is also an area for further research.

BASIS FOR EFFECTIVE COMMUNITY-BASED HEALTH INSURANCE SCHEMES: INVESTIGATING INEQUITIES IN CATASTROPHIC OUT-OF-POCKET HEALTH EXPENDITURES, AFFORDABILITY AND ALTRUISM

Background: Community-based health insurance (CBHI) schemes should be designed so that they are affordable,provide financial risk protection against catastrophic costs and harness community solidarity in form of altruism so as to ensure high levels of enrollment and use of the services. This paper presents information about the socio-economic status (SES) and geographic differences in affordability, catastrophic costs and altruism within the context of instituting effective CBHI schemes. Methods: The study took place in a rural, urban and semi-urban community in two states in Nigeria. Aquestionnaire was used to collect information from 3070 randomly selected householders. Contingent valuation method was used to elicit altruistic willingness to pay. Catastrophic health expenditures were examined at 40%, 10% and 5% thresholds based on household non - food expenditures. Affordability was measured as proportion of total household expenditure that will be consumed by the existing per capita monthly premium for CBHI, which is 500 Naira. Data was examined for links between affordability, catastrophic costs and altruistic WTP with SES and geographic area of residence. Results: Households are currently spending between 1139.6 Naira (US$ 9.5) and 3846.5 Naira (US$ 32.1) monthly on healthcare, and this was mainly as out-of-pocket expenditure. At the 40% household non-food expenditure threshold, 28.7% of households incurred catastrophic healthcare costs. Incidence of catastrophic costs was least in the urban area and amongst the highest quartile. A monthly premium of 500 naira (US$ 4.2) was found to be less that 3% of households’ monthly expenditures. The mean altruistic WTP was 202.7 Naira (US$1.7) per year. Conclusion: There were high levels of catastrophic costs, but with appreciable levels of affordability and altruistic WTP for CBHI, coverage can be increased and financial risk protection assured for most people that need CBHI

Evaluating the financial protection of patients with chronic disease by health insurance in rural China

BackgroundA growing number of developing countries are developing health insurance schemes that aim to protect households, particularly the poor, from financial catastrophe and impoverishment caused by unaffordable medical care. This paper investigates the extent to which patients suffering from chronic disease in rural China face catastrophic expenditure on healthcare, and how far the New Co-operative Medical Insurance Scheme (NCMS) offers them financial protection against this.MethodsA household survey was conducted in six counties in Ningxia Autonomous Region and Shandong Province, with a total of 6,147 rural households, including 3944 individual chronic disease patients. Structured questionnaires were used with chronic disease patients to investigate: their basic social and economic characteristics, including income and expenditure levels and NCMS membership; and their health care utilization, associated healthcare costs and levels of reimbursement by NCMS. 'Catastrophic' expenditure was defined as healthcare expenditure of more than 40% of household non-food expenditure.ResultsExpenditure for chronic diseases accounted for an average of 27% of annual non-food per capita expenditure amongst NCMS members in Shandong and 35% in Ningxia. 14-15% of families in both provinces spent more than 40% of their non-food expenditure on chronic healthcare costs. Between 8 and 11% of non NCMS members and 13% of NCMS members did not seek any medical care for chronic illness. A greater proportion of NCMS members in the poorest quintile faced catastrophic expenditure as compared to those in the richest quintile in both study sites. A slightly higher proportion of non-NCMS members than NCMS member households faced catastrophic expenditure, but the difference was not statistically significant.ConclusionA significant proportion of patients with chronic diseases face catastrophic healthcare costs and these are especially heavy for the poor. The NCMS offers only a limited degree of financial protection. The heavy financial burden of healthcare for chronic disease poses an urgent challenge to the NCMS. There is an urgent need for a clear policy on how to offer financial protection to those with chronic disease.

Are malaria treatment expenditures catastrophic to different socio-economic and geographic groups and how do they cope with payment? A study in southeast Nigeria

To determine the inequities in the household income depletion resulting from malaria treatment expenditures, the sacrifice of basic household needs (catastrophe) and the differences in payment strategies among different socio-economic and geographic groups in southeast Nigeria. Data were gathered through pre-tested, structured questionnaires from a random sample of 2 250 householders in rural and urban parts of southeast Nigeria. The level of catastrophic malaria treatment expenditure was computed as the percentage of average monthly malaria treatment expenditure divided by the average monthly non-food household expenditure, using a threshold of 5%. Socio-economic inequity was established using a socio-economic status (SES) index, while a rural-urban comparison examined geographic disparities. The average cost to treat a case of malaria was 796.5 Naira ($6.64) for adults and 789.0 Naira ($6.58) for children. The monthly malaria treatment expenditure as a proportion of monthly household non-food expenditure was 7.8%, 8.5%, 5.5% and 3.9% for the most poor, very poor, poor and least poor SES groups respectively. Malaria treatment accounted for 7.1% and 5.0% of non-food expenditures for rural and urban dwellers, respectively. More than 95% of the people financed their treatment through out-of-pocket payment (OOP), with no SES and rural-urban variance, as opposed to insurance payment mechanisms and fee exemptions. There were socio-economic and geographic inequities in the financial burden resulting from malaria treatment. The treatment expenditure depleted more of the aggregate income of the two worse-off SES (Q1 and Q2) and of the rural dwellers. Government and donor agencies should institute the abolition of user fees for malaria, the transition from OOP to pre-payment mechanisms and the improvement of physical access to appropriate malaria treatment services, as well as subsidies and deferrals in order to engender financial risk protection from malaria treatment.