Inequality In Catastrophic Health Expenditure Research Articles

Socioeconomic Inequalities in Catastrophic Health Expenditure in Sindh Province of Pakistan

This study aims to examines the socio-economic inequality in Catastrophic Health Expenditure(CHE) by using the data from the Household Integrated Economic Surveys. Catastrophic Health Expenditure(CHE) was computed using the ability-to-pay-approach. To assess socioeconomic inequality in CHE for the years 2018, both generalized and standard concentration Indices were used. The results of concentration index revealed that Catastrophic Health Expenditure(CHE) concentrated among the poor in Sindh. The inequality decomposition analysis reveals that wealth status was the main cause of the inequality. The upper wealth quantiles had larger contribution, while the lower quantiles showed smaller contribution to inequality in CHE. Further, employed head of the household, Educated head of household, private provision of healthcare, and inpatient access of healthcare were negative contributors to CHE inequality in Sindh.

Evaluating the effectiveness of the National Health Insurance Fund in providing financial protection to households with hypertension and diabetes patients in Kenya

BackgroundNon-communicable diseases (NCDs) can impose a substantial financial burden to households in the absence of an effective financial risk protection mechanism. The national health insurance fund (NHIF) has included NCD services in its national scheme. We evaluated the effectiveness of NHIF in providing financial risk protection to households with persons living with hypertension and/or diabetes in Kenya.MethodsWe carried out a prospective cohort study, following 888 households with at least one individual living with hypertension and/or diabetes for 12 months. The exposure arm comprised households that are enrolled in the NHIF national scheme, while the control arm comprised households that were not enrolled in the NHIF. Study participants were drawn from two counties in Kenya. We used the incidence of catastrophic health expenditure (CHE) as the outcome of interest. We used coarsened exact matching and a conditional logistic regression model to analyse the odds of CHE among households enrolled in the NHIF compared with unenrolled households. Socioeconomic inequality in CHE was examined using concentration curves and indices.ResultsWe found strong evidence that NHIF-enrolled households spent a lower share (12.4%) of their household budget on healthcare compared with unenrolled households (23.2%) (p = 0.004). While households that were enrolled in NHIF were less likely to incur CHE, we did not find strong evidence that they are better protected from CHE compared with households without NHIF (OR = 0.67; p = 0.47). The concentration index (CI) for CHE showed a pro-poor distribution (CI: -0.190, p < 0.001). Almost half (46.9%) of households reported active NHIF enrolment at baseline but this reduced to 10.9% after one year, indicating an NHIF attrition rate of 76.7%. The depth of NHIF cover (i.e., the share of out-of-pocket healthcare costs paid by NHIF) among households with active NHIF was 29.6%.ConclusionWe did not find strong evidence that the NHIF national scheme is effective in providing financial risk protection to households with individuals living with hypertension and/diabetes in Kenya. This could partly be explained by the low depth of cover of the NHIF national scheme, and the high attrition rate. To enhance NHIF effectiveness, there is a need to revise the NHIF benefit package to include essential hypertension and/diabetes services, review existing provider payment mechanisms to explicitly reimburse these services, and extend the existing insurance subsidy programme to include individuals in the informal labour market.

Examining the level and distribution of catastrophic health expenditure from 2013 to 2018: A province-level study in China

Since 2018, 96.8% of China's population has received universal health coverage; however, changes in the general population's level and distribution of catastrophic health expenditure (CHE) remain unclear. This study aims to quantify the incidence and intensity of CHE by adopting a multistage stratified random sampling procedure that used a threshold of 25% of non-food household expenditures. We use the concentration index to measure the extent of inequality in CHE. Furthermore, logistic regression was applied to identify the sociodemographic and economic determinants of CHE, thereby revealing that the incidence and intensity of CHE increased between 2013 and 2018. A greater concentration of CHE was identified in low-income households. Our results imply that expanding the existing public health insurance benefit packages and introducing universal supplementary private insurance to more population segments is necessary.

Old-age dependency and catastrophic health expenditure: Evidence from Longitudinal Ageing Study in India.

Out-of-pocket (OOP) payments and catastrophic health expenditure (CHE) have a strong age gradient. Though studies have examined the socio-demographic and geographic inequality in OOP payments and CHE in India, the role of old-age dependency in financial catastrophe remains unclear. Disaggregated estimates of CHE by the level of old-age dependency of households may help identify the most vulnerable sub-group and provide evidence for specific policies for the financial protection and health care of the elderly. The present study aims to estimate the incidence and intensity of CHE by the old-age dependency of households among middle-aged adults and the elderly in India. A total of 42,949 households from the Longitudinal Aging Study in India (LASI), 2017-18, covering households with at least one-member aged 45+ years, were included in the analysis. Households were classified into three mutually exclusive groups: no old-age dependency, low old-age dependency, and high old-age dependency. The incidence and intensity of CHE were estimated using the capacity-to-pay (CTP) approach. Concentration indices and concentration curves examine the extent of socioeconomic inequality in CHE. Binary logistic regression helps to understand the potential predictors of CHE across each type of old-age-dependent household. We estimated the overall incidence of CHE at 24.6% (95% CI: 23.3-25.8) among middle-aged adults and the elderly in India. The incidence was 33.2% (95% CI: 31.4-35.1) among households with high old-age dependency, 23.1% (95% CI: 20.8-25.5) among those with low old-age dependency, and 20.4% (95% CI: 19.0-21.7) among no old-age dependency households. CHE intensity was highest among households with low old-age dependency compared to those no old-age dependents. Catastrophic health expenditure was higher among the poorer households in each type of old-age dependency. Among all households, the odds of incurring CHE were higher among households with high old-age dependency (AOR: 1.52; 95% CI: 1.36-1.69) than those with no old-age dependency. Lower-income households, households with pensions as the main source of income, households belonging to scheduled castes, and households residing in rural areas had higher odds of incurring CHE. The co-variates of CHE varied significantly across the type of old-age dependency households. A household's enrolment into a health insurance scheme did not necessarily lower its CHE. Households with high old-age dependency had a higher probability of incurring CHE in India. Providing preventive and curative geriatric care in primary health centres (PHC) is recommended.

A 25-Year Trend of Catastrophic Health Expenditure and Its Inequality in China: Evidence from Longitudinal Data.

PurposeThe Chinese government has carried out two major cycles of reform to improve the health system and reduce the disease burden on residents. This study aims to comprehensively track the trends in the occurrence of catastrophic health expenditure (CHE) and its inequality in the past 25 years, which may help better understand the influence of health system reforms on CHE and its inequality.MethodsThe study employed the subset of data from China Health and Nutrition Survey conducted from 1991 to 2015. Health payments and net household income were used to calculate CHE. Concentration index and decomposition analysis were used to measure the magnitude of income-related inequality in CHE and decompose it into determinants, respectively.ResultsThe incidence of CHE in China increased from 3.10% in 1993 to 8.90% in 2004 and still maintained at a high level in the following years. The incidence gap of CHE between the richest and poorest became increasingly wider over year. Moreover, the values of adjusted concentration indexes were all negative in each year, decreasing from −0.202 in 1991 to −0.613 in 2015. Income was consistently the largest contributor to the inequality in CHE. The basic medical insurance did not decrease the incidence of CHE and showed the second largest contribution on its inequality before 2004. However, this contribution began to decline after 2006.ConclusionAfter the New Health Care Reform, despite many measures taken by the Chinese government, there was still a high incidence of CHE and an increasing inequality from 1991 to 2015. The basic medical insurance in China was not enough to protect households from CHE. The use of big data tools and techniques to effectively screen the poor households, and strengthening the social medical aid system would be helpful to decrease the inequality in CHE.

Decomposing socio-economic inequality in catastrophic out-of-pocket health expenditures in Malawi.

Reducing health inequalities and inequities is one of the key goals that health systems aspire to achieve as it ensures improvement in health outcomes among all population groups. Addressing the factors contributing to inequality in catastrophic health expenditures is important to reducing inequality in the burden of health expenditures. However, there are limited studies to explain the factors contributing to inequalities in catastrophic health expenditures. The study aimed to measure and decompose socio-economic inequality in catastrophic health into its determinants. Data for the analysis come from the fourth integrated household survey. Data for 12447 households in Malawi were collected from April 2016 to April 2017 by the National Statistical Office. The secondary analysis was conducted from June 2021 to October 2021. Catastrophic health expenditure was estimated as a proportion of households whose out-of-pocket health expenditures as a ratio of non-food consumption expenditures exceeds 40% threshold level. We estimated the magnitude of socio-economic inequality using the Erreygers corrected concentration index and used decomposition analysis to assess the contribution of inequality in each determinant of catastrophic health expenditure to the overall socio-economic inequality. The magnitude of the Erreygers corrected concentration index of catastrophic health expenditure (CI = 0.004) is small and positive which indicates that inequality is concentrated among the better-off. Inequality in catastrophic health expenditure is largely due to inequalities in rural residency (127%), socio-economic status (-40%), household size (14%), presence of a child under five years old (10%) and region of the household (10%). The findings indicate that socio-economic inequality in catastrophic health expenditures is concentrated among the better-off in Malawi. The results imply that policies that aim to reduce inequalities in catastrophic health expenditures should simultaneously address urban-rural and income inequalities.

Addressing data and methodological limitations in estimating catastrophic health spending and impoverishment in India, 2004\u201318

BackgroundEstimates of catastrophic health expenditure (CHE) are counterintuitive to researchers, policy makers, and developmental partners due to data and methodological limitation. While inferences drawn from use of capacity-to-pay (CTP) and budget share (BS) approaches are inconsistent, the non-availability of data on food expenditure in the health survey in India is an added limitation.MethodsUsing data from the health and consumption surveys of National Sample Surveys over 14 years, we have overcome these limitations and estimated the incidence and intensity of CHE and impoverishment using the CTP approach.ResultsThe incidence of CHE for health services in India was 12.5% in 2004, 13.4% in 2014 and 9.1% by 2018. Among those households incurring CHE, they spent 1.25 times of their capacity to pay in 2004 (intensity of CHE), 1.71 times in 2014 and 1.31 times by 2018. The impoverishment due to health spending was 4.8% in 2004, 5.1% in 2014 and 3.3% in 2018. The state variations in incidence and intensity of CHE and incidence of impoverishment is large. The concentration index (CI) of CHE was − 0.16 in 2004, − 0.18 in 2014 and − 0.22 in 2018 suggesting increasing inequality over time. The concentration curves based on CTP approach suggests that the CHE was concentrated among poor. The odds of incurring CHE were lowest among the richest households [OR 0.22; 95% CI: 0.21, 0.24], households with elderly members [OR 1.20; 95% CI:1.12, 1.18] and households using both inpatient and outpatient services [OR 2.80, 95% CI 2.66, 2.95]. Access to health insurance reduced the chance of CHE and impoverishment among the richest households. The pattern of impoverishment was similar to that of CHE.ConclusionIn the last 14 years, the CHE and impoverishment in India has declined while inequality in CHE has increased.

Decomposition of changes in socioeconomic inequalities in catastrophic health expenditure in Kenya.

BackgroundCatastrophic health expenditure (CHE) is frequently used as an indicator of financial protection. CHE exists when health expenditure exceeds a certain threshold of household consumption. Although CHE is reported to have declined in Kenya, it is still unacceptably high and disproportionately affects the poor. This study examines the socioeconomic factors that contribute to inequalities in CHE as well as the change in these inequalities over time in Kenya.MethodsWe used data from the Kenya household health expenditure and utilisation (KHHEUS) surveys in 2007 and 2013. The concertation index was used to measure the socioeconomic inequalities in CHE. Using the Wagstaff (2003) approach, we decomposed the concentration index of CHE to assess the relative contribution of its determinants. We applied Oaxaca-type decomposition to assess the change in CHE inequalities over time and the factors that explain it.ResultsThe findings show that while there was a decline in the incidence of CHE, inequalities in CHE increased from -0.271 to -0.376 and was disproportionately concentrated amongst the less well-off. Higher wealth quintiles and employed household heads positively contributed to the inequalities in CHE, suggesting that they disadvantaged the poor. The rise in CHE inequalities overtime was explained mainly by the changes in the elasticities of the household wealth status.ConclusionInequalities in CHE are persistent in Kenya and are largely driven by the socioeconomic status of the households. This implies that the existing financial risk protection mechanisms have not been sufficient in cushioning the most vulnerable from the financial burden of healthcare payments. Understanding the factors that sustain inequalities in CHE is, therefore, paramount in shaping pro-poor interventions that not only protect the poor from financial hardship but also reduce overall socioeconomic inequalities. This underscores the fundamental need for a multi-sectoral approach to broadly address existing socioeconomic inequalities.

Explaining Socioeconomic Inequality Differences in Catastrophic Health Expenditure Between Urban and Rural Areas of Iran After Health Transformation Plan Implementation.

ObjectiveEnsuring fair financial contribution is one of the main goals of the Health Transformation Plan (HTP) of Iran. This study aims to estimate socioeconomic inequality differences in catastrophic health expenditure (CHE) between urban and rural areas of Iran after the implementation of the HTP during 2017.Materials and MethodsData from a representative survey of households’ income and xpenditure from the Iran Statistical Center (ISC) were used for the analysis. We applied the World Health Organization (WHO) cut-off of 40% payment for CHE, and Wagstaff’s normalized concentration index (C) to measure and decompose the inequality. Also, Blinder–Oaxaca decomposition analysis was used to decompose contributors of inequality differences between rural and urban areas.ResultsThe overall incidence of CHE among Iranian households during the year 2017 was 3.32% with a standard deviation (SD) of 17.91%, and the mean (SD) levels of CHE in rural and urban areas of Iran were 4.37% (20.45%) and 2.97% (16.99%), respectively. The aggregate socioeconomic status (SES)-related inequality in CHE was significantly (p<0.001) different from zero (C=−0.238) and there was a significant (p<0.05) difference between rural (C=-0.150) and urban (C=0.218) areas. SES was the highest contributor to inequality in both rural (130.09) and urban (144.17) areas. The Blinder–Oaxaca decomposition revealed that SES (175.01%) followed by outpatient services (120.29%) were the main contributors to differences in inequality in rural and urban areas. Sex (−101.42%) and health insurance coverage were among negative contributors to this inequality difference.ConclusionOur findings revealed a significant pro-rich inequality in CHE. Also, some variables, such as sex and region, made different contributions in rural and urban areas. However, SES, itself, made the highest contribution in both areas and explained the greatest share of difference in inequality between the two areas. This issue calls for revision of the HTP to further address the risk of CHE and socioeconomic disparity among Iranian households, especially those with lowSES.

Socio-economic inequality in catastrophic health expenditure among households in India: A decomposition analysis

The paper investigates the socioeconomic-related inequality in the incidence of catastrophic health expenditure (CHE) over the decade (2004–2014). We tested four hypotheses: (1) whether the incidence of CHE has changed over the decade? (2) Whether the inequality in the incidence of CHE is significantly pro-rich or pro-poor? (3) What are the major determinants contributing to inequality in CHE? and (4) Whether the change in various socio-economic determinants and health policies affects inequality over the decade? We have used two rounds of surveys: NSSO (2004 and 2014) and IHDS (2004–2005 and 2011–2012), and we adopted the generalized linear model with probit link function, concentration index (CI), and Oaxaca decomposition method for the study. The post-estimation decomposition method determines the major contributing factors to inequality and as well as its relative importance to the total inequality. We find that the mean out-of-pocket health expenditure has increased over the decade. Richer household is found to be spending more on inpatient care while the poor spend more on outpatient care. There has been a slight decrease in the incidences of CHE for outpatient care, but has significantly increase in inpatient care, particularly more towards the poor household. However, the inequality in incidences of CHE for inpatient care has decreased while in the case of outpatient care it has increased over the decade. The absence of any effective health insurance coverage, household size, income, and regional differences are found to be major contributing factors towards inequality in the incidence of CHE.

Measuring Out-of-pocket Payment, Catastrophic Health Expenditure and the Related Socioeconomic Inequality in Peru: A Comparison Between 2008 and 2017.

Objectives:Describe out-of-pocket payment (OOP) and the proportion of Peruvian households with catastrophic health expenditure (CHE) and evaluate changes in socioeconomic inequalities in CHE between 2008 and 2017.Methods:We used data from the 2008 and 2017 National Household Surveys on Living and Poverty Conditions (ENAHO in Spanish), which are based on probabilistic stratified, multistage and independent sampling of areas. OOP was converted into constant dollars of 2017. A household with CHE was assumed when the proportion between OOP and payment capacity was ≥0.40. OOP was described by median and interquartile range while CHE was described by weighted proportions and 95% confidence intervals (CIs). To estimate the socioeconomic inequality in CHE we computed the Erreygers concentration index.Results:The median OOP reduced from 205.8 US dollars to 158.7 US dollars between 2008 and 2017. The proportion of CHE decreased from 4.9% (95% CI, 4.5 to 5.2) in 2008 to 3.7% (95% CI, 3.4 to 4.0) in 2017. Comparison of socioeconomic inequality of CHE showed no differences between 2008 and 2017, except for rural households in which CHE was less concentrated in richer households (p<0.05) and in households located on the rest of the coast, showing an increase in the concentration of CHE in richer households (p<0.05).Conclusions:Although OOP and CHE reduced between 2008 and 2017, there is still socioeconomic inequality in the burden of CHE across different subpopulations. To reverse this situation, access to health resources and health services should be promoted and guaranteed to all populations.

Catastrophic health expenditure incidence and its equity in China: a study on the initial implementation of the medical insurance integration system

BackgroundBy 2013, several regions in China had introduced health insurance integration policies. However, few studies addressed the impact of medical insurance integration in China. This study investigates the catastrophic health expenditure and equity in the incidence of catastrophic health expenditure by addressing its potential determinants in both integrated and non-integrated areas in China in 2013.MethodsThe primary data are drawn from the fifth China National Health Services Survey in 2013. The final sample comprises 19,788 households (38.4%) from integrated areas and 31,797 households (61.6%) from non-integrated areas. A probit model is employed to decompose inequality in the incidence of catastrophic health expenditure in line with the methodology used for decomposing the concentration index.ResultsThe incidence of catastrophic health expenditure in integrated areas is higher than in non-integrated areas (13.87% vs. 13.68%, respectively). The concentration index in integrated areas and non-integrated areas is − 0.071 and − 0.073, respectively. Average household out-of-pocket health expenditure and average capacity to pay in integrated areas are higher than those in non-integrated areas. However, households in integrated areas have lower share of out-of-pocket expenditures in the capacity to pay than households in non-integrated areas. The majority of the observed inequalities in catastrophic health expenditure can be explained by differences in the health insurance and householders’ educational attainment both in integrated areas and non-integrated areas.ConclusionsThe medical insurance integration system in China is still at the exploratory stage; hence, its effects are of limited significance, even though the positive impact of this system on low-income residents is confirmed. Moreover, catastrophic health expenditure is associated with pro-poor inequality. Medical insurance, urban-rural disparities, the elderly population, and use of health services significantly affect the equity of catastrophic health expenditure incidence and are key issues in the implementation of future insurance integration policies.

Decomposition of Socioeconomic Inequality in Catastrophic Health Expenditure: An Evidence from Iran

BackgroundEvidences showed that the incidence of catastrophic health expenditure is unequally distributed among disadvantaged populations. The present study has tried to explain the contributors of this unfair inequality in Hamadan, Iran. MethodsThe target population was households that utilized inpatient services in hospitals of Hamadan. A proportional stratified random sampling method was used to determine study sample (N = 770). The associated factors of catastrophic health expenditure were estimated using logistic regression analysis. The inequality of catastrophic health expenditure was measured by concentration index and explained by decomposition analysis. The data were analyzed by using STATA version 12. ResultsThe key determinants of catastrophic health expenditure were poor economic status, lower household size, lack of supplementary insurance and the number of hospitalizations. The overall concentration index of catastrophic health expenditure in Hamadan was −0.163 (95% CI: −0.242 to −0.083). Household economic status (63.60%) and household size (39.90%) were considered as the first and the second largest contributors of catastrophic health expenditure inequality, respectively. ConclusionIt is demonstrated that catastrophic health expenditure inequality in Iran could be explained by the factors beyond the health sector scope. Hence, future policy efforts need to consider both health system factors and the factors beyond the health system to eliminate catastrophic health spending burden and its inequality.

Decomposing inequality in catastrophic health expenditure for self-reported hypertension household in Urban Shaanxi, China from 2008 to 2013: two waves’ cross-sectional study

ObjectiveDespite the latest wave of China’s healthcare reform initiated in 2009 has achieved unprecedented progress in rural areas, little is known for specific vulnerable groups’ catastrophic health expenditure (CHE) in...

Effect of the New Health Care Reform on catastrophic health expenditure in households of patients with chronic diseases in Shaanxi Province: a before-and-after analysis

BackgroundIn 2009, China officially launched the New Health Care Reform. This study aimed to measure the occurrence of catastrophic health expenditure of households with at least one member diagnosed with chronic diseases (hereafter referred to as chronic households) in Shaanxi Province before and after the reform, and explore the influence of the New Health Care Reform on catastrophic health expenditure. MethodsThe data were from the fourth and fifth National Household Health Service Surveys of Shaanxi Province. In total, 1942 chronic households in 2008 (954 in urban areas and 988 in rural areas) and 7704 households in 2013 (2870 in urban areas and 4834 in rural areas) were selected for analysis. WHO's method was used to estimate catastrophic health expenditure, which was defined as an out-of-pocket payment for health care equal to or higher than 40% of a household's capacity to pay. A multilevel logistic regression model was used to explore the influence of the New Health Care Reform on the presence of catastrophic health expenditure. We used the concentration index to measure the income-related inequality in catastrophic health expenditure. FindingsIn rural areas, the proportion of households incurring catastrophic health expenditure dropped (288 [29%] households in 2008 vs 1142 (24%) in 2013; χ2 13·517, p=0·00024). However, in urban areas, the proportion of households suffering from catastrophic health expenditure increased (183 [19%] households in 2008 vs 716 [25%] in 2013; χ2 13.235, p=0·00027). After controlling for confounding variables (eg, commercial insurance, household size, having elderly members, having children, household economic status, and age, gender, education, marital status, and employment status of household head), the random-intercept logistic regression model showed a significant interaction term between year and geographic location, implying that the influence of the New Health Care Reform on catastrophic health expenditure differed between urban and rural areas. From 2008 to 2013, the concentration index of catastrophic health expenditure in rural areas increased from −0·4572 to −0·5499 (difference −0·0927, Z −2·22, p=0·026). InterpretationOur study suggested that the implementation of the New Health Care Reform might not have been effective in reducing catastrophic health expenditure for households of patients with chronic diseases, especially in urban areas. Additionally, the income inequality of catastrophic health expenditure was greater in 2013 than in 2008 in rural areas. Although the reform resulted in higher insurance coverage and higher government expenditure in health care, the financial burden of health care on households did not necessarily improve. Further efforts to develop the current health insurance system and optimise the hierarchical health-care system are required to improve protection against catastrophic health expenditure. FundingXi'an Jiaotong University (grant number GG1K004).

Inequalities in Household Catastrophic Health Expenditure and Impoverishment Associated With Noncommunicable Diseases in Chi Linh, Hai Duong, Vietnam.

A costly modern-day double burden, the expenses of noncommunicable diseases (NCDs) are becoming a devastating epidemic. The World Health Organization estimates $7 trillion in economic losses from NCDs in 2011-2025. Although regarded as affluent diseases, the burden of NCDs is shifting into poorer groups. In this study, we assessed the socioeconomic inequalities in catastrophic health expenditure and impoverishment associated with NCDs in Northern Vietnam. We also identified associated factors for catastrophic health expenditure and impoverishment. Households self-reporting NCD diagnoses had the highest association with both catastrophic health expenditure and impoverishment, followed by those in urban areas. Such households were likely poorer according to our calculations estimating socioeconomic inequalities. Households with at least 1 member older than 60 years were also more likely to suffer catastrophic health expenditures. These findings suggest that targeted policy to prevent or subsidize care for NCDs could prevent catastrophic health expenditure and impoverishment among those already most disadvantaged.

Does the new cooperative medical scheme reduce inequality in catastrophic health expenditure in rural China?

BackgroundIn 2003, the New Cooperative Medical Scheme (NCMS) was introduced in China to re-establish health insurance for the country’s vast rural population. In addition, the coverage of NCMS has been expanding after the new health care reform launched in 2009. This study aims to examine whether the NCMS and its recent expansion have reached the goal of reducing the risk and inequality of catastrophic health spending for rural residents in China.MethodsWe conducted a face-to-face household survey in three counties of the Shandong province in 2009 and 2012. Using this unique panel data, we examined the changes in the incidence and intensity of catastrophic health expenditures (CHEs) before and after NCMS reimbursement. We used concentration index (CI) and decomposition method to study the changes in inequality in CHEs.ResultsWe found that NCMS reimbursement played a role of reducing both the incidence and intensity of CHEs, and that this impact was stronger after the new health care reform was launched. After reimbursement, the concentration indices for CHEs were 0.073 and 0.021 in 2009 and 2012, indicating that the rich had a greater tendency to incur CHEs and there existed less inequality in the incidence of CHEs after reimbursement in 2012 compared with 2009. The decomposition analysis results suggested that changes in CHE inequality between 2009 and 2012 were attributed to changes in economic status and household size rather than reimbursement levels.ConclusionsOur results indicated that inequality was shrinking from 2009 to 2012, which could be a result of fewer rich people having CHEs in 2012 compared with 2009. The impact of NCMS in alleviating the financial burden of rural residents was still limited, especially among the poor. Health care reform policies in China that aim to reduce CHEs must continue to place an emphasis on improving reimbursement, cost containment, and reducing income inequalities.

Socioeconomic inequalities in catastrophic health expenditure and impoverishment associated with non-communicable diseases in urban Hanoi, Vietnam

BackgroundThe catastrophic health expenditure and impoverishment indices offer guidance for developing appropriate health policies and intervention programs to decrease financial inequity. This study assesses socioeconomic inequalities in catastrophic health expenditure and impoverishment in relation to self-reported non-communicable diseases (NCD) in urban Hanoi, Vietnam.MethodsA cross-sectional survey was conducted from February to March 2013 in Hanoi, the capital city of Vietnam. We estimated catastrophic health expenditure and impoverishment using information from 492 slum household and 528 non-slum households. We calculated concentration indexes to assess socioeconomic inequalities in catastrophic health expenditure and impoverishment. Factors associated with catastrophic health expenditure and impoverishment were modelled using logistic regression analysis.ResultsThe poor households in both slum and non-slum areas were at higher risk of experiencing catastrophic health expenditure, while only the poor households in slum areas were at higher risk of impoverishment because of healthcare spending. Households with at least one member reporting an NCD were significantly more likely to face catastrophic health expenditure (odds ratio [OR] = 2.4; 95 % confidence interval [CI], 1.8–4.0) and impoverishment (OR = 2.3; 95 % CI, 1.1–6.3) compared to households without NCDs. In addition, households in slum areas, with people age 60 years and above, and belonging to the poorest socioeconomic group were significantly associated with increased catastrophic health expenditure, while only households that lived in slum areas, and belonging to the poor or poorest socioeconomic groups were significantly associated with increased impoverishment because of healthcare spending.ConclusionFinancial interventions to prevent catastrophic health expenditure and impoverishment should target poor households, especially those with family members suffering from NCDs, with older members and those located in slum areas in Hanoi Vietnam. Potential interventions derived from this study include targeting and monitoring of health insurance enrolment, and developing a specialized NCD service package for Vietnam’s social health insurance program.

Socioeconomic inequality in catastrophic health expenditure in Brazil.

OBJECTIVE To analyze the evolution of catastrophic health expenditure and the inequalities in such expenses, according to the socioeconomic characteristics of Brazilian families.METHODS Data from the National Household Budget 2002-2003 (48,470 households) and 2008-2009 (55,970 households) were analyzed. Catastrophic health expenditure was defined as excess expenditure, considering different methods of calculation: 10.0% and 20.0% of total consumption and 40.0% of the family’s capacity to pay. The National Economic Indicator and schooling were considered as socioeconomic characteristics. Inequality measures utilized were the relative difference between rates, the rates ratio, and concentration index.RESULTS The catastrophic health expenditure varied between 0.7% and 21.0%, depending on the calculation method. The lowest prevalences were noted in relation to the capacity to pay, while the highest, in relation to total consumption. The prevalence of catastrophic health expenditure increased by 25.0% from 2002-2003 to 2008-2009 when the cutoff point of 20.0% relating to the total consumption was considered and by 100% when 40.0% or more of the capacity to pay was applied as the cut-off point. Socioeconomic inequalities in the catastrophic health expenditure in Brazil between 2002-2003 and 2008-2009 increased significantly, becoming 5.20 times higher among the poorest and 4.17 times higher among the least educated.CONCLUSIONS There was an increase in catastrophic health expenditure among Brazilian families, principally among the poorest and those headed by the least-educated individuals, contributing to an increase in social inequality.

A look at catastrophic medical expenses and the poor.

A look at catastrophic medical expenses and the poor.