Intensity Of Catastrophic Health Expenditure Research Articles

Incidence and intensity of catastrophic health expenditure and impoverishment among the elderly: an empirical evidence from India

World health statistics (2022) report that about 1.4 billion people have incurred catastrophic health expenditure (CHE), and half of its population have pushed into extreme poverty due to healthcare payments. The elderly population faces a higher risk of ill health, and seeking treatment reflects in high out-of-pocket health spending (OOPHS) that results in CHE and further impoverishment. This study aims to investigate the incidence and intensity of OOPHS, CHE, and impoverishment among the older adults in India. Data utilizes from the 75th round of the national sample survey (NSS) based on household social consumption: health (schedule 25.0), 2018. The incidence and intensity of CHE and impoverishment among older adults in India estimated by using standard measures. The older adults spend about 17.4% of household consumption expenditure on healthcare services. The poorest older adults are spending the highest share of consumption expenditure (24.8%) on healthcare among economic quantiles. Similarly, the elderly from rural (20.3%), male (18.4%), scheduled castes (21.5%), and Hinduism (17.9%) show a larger share of consumption expenditure on healthcare services. The incidence and intensity of CHE among older adults are 46.5% and 16.1% at 10% threshold level of household consumption expenditure, respectively. However, as the threshold level rises the incidence and intensity of CHE decline. The estimates of normalized poverty gap using the poverty line of Tendulkar committee as well as Rangarajan committee show that the intensity of impoverishment among older adults are 56.4% and 57.9% respectively, which is quite high. Financial protection along with vision might mitigate the risk of CHE and impoverishment among older adults in India.

Incidence and intensity of catastrophic health expenditure and impoverishment among the elderly: an empirical evidence from India

World health statistics (2022) report that about 1.4 billion people have incurred catastrophic health expenditure (CHE), and half of its population have pushed into extreme poverty due to healthcare payments. The elderly population faces a higher risk of ill health, and seeking treatment reflects in high out-of-pocket health spending (OOPHS) that results in CHE and further impoverishment. This study aims to investigate the incidence and intensity of OOPHS, CHE, and impoverishment among the older adults in India. Data utilizes from the 75th round of the national sample survey (NSS) based on household social consumption: health (schedule 25.0), 2018. The incidence and intensity of CHE and impoverishment among older adults in India estimated by using standard measures. The older adults spend about 17.4% of household consumption expenditure on healthcare services. The poorest older adults are spending the highest share of consumption expenditure (24.8%) on healthcare among economic quantiles. Similarly, the elderly from rural (20.3%), male (18.4%), scheduled castes (21.5%), and Hinduism (17.9%) show a larger share of consumption expenditure on healthcare services. The incidence and intensity of CHE among older adults are 46.5% and 16.1% at 10% threshold level of household consumption expenditure, respectively. However, as the threshold level rises the incidence and intensity of CHE decline. The estimates of normalized poverty gap using the poverty line of Tendulkar committee as well as Rangarajan committee show that the intensity of impoverishment among older adults are 56.4% and 57.9% respectively, which is quite high. Financial protection along with vision might mitigate the risk of CHE and impoverishment among older adults in India.

Catastrophic Health Expenditure and Associated Factors Among Hospitalized Cancer Patients in Addis Ababa, Ethiopia.

Out-of-pocket (OOP) health expenditures for cancer care expose households to unanticipated economic consequences. When the available health services are mainly dependent on OOP expenditure, the household faces catastrophic health expenditure (CHE). This study aimed to estimate the incidence and intensity of CHE in hospitalized cancer patients and identify coping strategies and associated factors. Hospital-based cross-sectional study design was conducted on 305 cancer inpatients in Addis Ababa between November 2021 and February 2022. All patients with cancer who were hospitalized during the data collection period were included in the study. The incidence of CHE was estimated at the 40% threshold of households' non-food expenditure and the intensity of CHE was captured based on the amount by which household expenditure exceeded the threshold and mean positive overshoot, the mean level by which CHE exceeds the threshold used. Multivariate logistic regression was used to assess the relationship between CHE levels and the independent variables. The incidence of CHE at the 40% threshold of households' non-food expenditure was 77.7%, while the O and MPO were 36.2% and 46.6%, respectively. CHE for cancer care was significantly associated with patient residence, increased number of chemotherapy cycles, increased duration of hospital admission, lack of insurance enrolment, and lower-income quintiles. Saving and selling assets were identified as the primary coping mechanisms. The incidence and intensity of CHE among inpatients with cancer were high and which could lead to impoverishment of households. Improved quality and coverage of health insurance and decentralizing cancer care to regions standards similar to Addis Ababa will save households from incurring CHE.

Assessing the impact of measurement error in household consumption on estimates of catastrophic health expenditure in India

The National Sample Survey (NSS) collects reliable data on morbidity, health care, and health spending through its annual multi-subject and multi-round health surveys. Evidences from these surveys have been extensively used for research and policy. While these surveys collect comprehensive information on morbidity, hospitalisation, health expenditure, information on household consumption expenditure (which is used to explain the economic gradient in health outcomes) is collected through a single question. Literature suggests that having a single question on consumption expenditure results in measurement errors. In this paper, we examine the effect of measurement errors of household consumption expenditure on estimates of catastrophic health expenditure (CHE) in India using data from the 68th round of the consumption survey (2011–12) and the 71st round of the health survey (2014), carried out by the National Sample Survey (NSS). The consumption survey canvassed a detailed schedule on consumption and interviewed 101,651 households, whereas the health survey interviewed 65,932 households from across the country. Descriptive statistics, estimates of CHE, and logistic regression models were used in the analysis. We used both the budget share approach and the capacity-to-pay approach for estimating CHE. The NSS health survey was found to have underestimated monthly per capita consumption expenditure (MPCE) in India by 32%, with the level of underestimation being significant across the states. Using the budget share approach, the CHE of India in 2014–15 was estimated at 23.4% without adjusting for the underestimation of consumption and 21.1% after adjusting for it. Similarly, using the capacity-to-pay approach, CHE was estimated to be 13.4% without adjustment and 10.4% with adjustment. The estimates differed considerably across the states. In general, it was observed that the use of a single question on consumption overestimated CHE in India. The pattern was similar regarding the intensity of CHE. The predictors of CHE were similar using both the methods, but the unadjusted estimates of CHE showed significantly higher predicted probabilities of incurring CHE across household characteristics. It is recommended to include disaggregated questions on household consumption in the future rounds of the NSS-based health surveys. Researchers using NSS data need to be aware of the effect of measurement errors of consumption expenditure on estimates of catastrophic expenditure. Adjusting for the underestimation of MPCE may improve the estimation of CHE in India.

Effects of multimorbidity patterns and socioeconomic status on catastrophic health expenditure of widowed older adults in China.

The high multimorbidity and lower socioeconomic status (SES) of older adults, can lead to catastrophic health expenditures (CHEs) for older adults' households. However, whether widowed older adults will bear such a financial burden has yet to be explored. The aim of this study was to investigate the influence of multimorbidity patterns and SES on CHE in Chinese widowed older adults. Data was obtained from the 2018 China Health and Retirement Longitudinal Study (CHARLS). This is a cross-sectional study. A total of 1,721 widowed participants aged 60 years and older were enrolled in the study. Latent class analysis was performed based on 14 self-reported chronic diseases to identify multimorbidity patterns. The logistic model and Tobit model were used to analyze the influence of multimorbidity patterns and SES on the incidence and intensity of CHE, respectively. About 36.72% of widowed older adults generated CHE. The incidence and intensity of CHE were significantly higher in the cardiovascular class and multisystem class than in the minimal disease class in multimorbidity patterns (cardiovascular class, multisystem class, and minimal disease class). Among SES-related indicators (education, occupation and household per capita income), respondents with a middle school and above education level were more likely to generate CHE compared to those who were illiterate. Respondents who were in the unemployed group were more likely to generate CHE compared to agricultural workers. In addition, respondents aged 70-79 years old, geographically located in the east, having other medical insurance, or having fewer family members are more likely to generate CHE and have higher CHE intensity. Widowed older adults are at high risk for CHE, especially those in the cardiovascular and multisystem disease classes, and those with low SES. Several mainstream health insurances do not provide significant relief. In addition, attention should be paid to the high-risk characteristics associated with CHE. It is necessary to carry out the popularization of chronic disease knowledge, improve the medical insurance system and medical service level, and provide more policy preferences and social support to widowed older adults.

Catastrophic health expenditure and household impoverishment in Togo.

The main way of financing healthcare in low-income countries continues to be out-of-pocket payments. Despite the efforts of national authorities and international partners to protect households from impoverishment arising from seeking healthcare, the risk of incurring catastrophic healthcare expenses remains very high for households in developing countries. This study aims to analyse catastrophic health expenditures and their effects on household impoverishment in Togo. Data were obtained from the CWIQ survey, a nationally representative survey conducted in 2015 among 2400 households.We calculated the incidence and the intensity of catastrophic health expenditures in Togo through various thresholds and then estimated the effects of these expenditures on the level of households' impoverishment by determining poverty levels using consumption expenditure before and after making payments for healthcare. The results indicate that the incidence of catastrophic expenditure varies between 6% and 57% depending on the thresholds used. Households at risk of catastrophic expenditure spend between 19% and 64% of their spending on healthcare. Based on total expenditure and above 20%, the richest households are more prone to catastrophic health expenditures. The findings also show that the incidence of impoverishment caused by health expenditure payments is 8.2% in relative terms and 4.52% in absolute terms. In Togo, 4.52% of households are impoverished by catastrophic health expenditures. This impoverishment effect is greater for male-headed households. Health system reforms aiming at accessibility to quality care and the development of pre-payment mechanisms will promote the earlier use of healthcare services and thus reduce the higher healthcare costs generated by later attendance at them.

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.

Effect of community-based health insurance on catastrophic health expenditure among chronic disease patients in Asella referral hospital, Southeast Ethiopia: a comparative cross-sectional study

BackgroundChronic disease-related catastrophic health spending is frequent in Ethiopia affecting several households, particularly the poorest ones. A community-based health insurance (CBHI) scheme has been in place in Ethiopia since 2011. The scheme aims to provide financial protection against health expenditure but there is little evidence of how well it protects chronic patients financially.ObjectiveThe objective of the study was to evaluate the effect of community-based health insurance in reducing the incidence of catastrophic health expenditure among patients attending chronic disease follow-up departments in Asella referral hospital, Southeast Ethiopia.MethodA health facility-based comparative cross-sectional study was conducted in Asella referral hospital from March 2022 to May 2022. Systematic random sampling was used to select 325 chronic patients. Data were collected using an open data kit (ODK) collect app and then imported to STATA version 16 for analysis. Propensity score matching was used to evaluate the effect of community-based health insurance on catastrophic health expenditure.ResultThe study enrolled a total of 325 chronic patients (157 insurance members and 168 nonmembers). More than 30% of the study participants incurred health spending that could be catastrophic based on the 15% nonfood threshold. Catastrophic health expenditure was found in 31% of insured and 47% of uninsured participants. Overshoot and mean positive overshoot were 10% and 33% for insured members, respectively and the corresponding figures were 18% and 39% for nonmembers. Community-based health insurance contributes to a 19% ((ATT = -0.19, t = -2.97)) reduction in the incidence of catastrophic health expenditure among chronic patients. This result is found to be consistent for alternative measurements of the outcome variable and the use of alternative matching algorithms.ConclusionChronic patients, particularly those in uninsured households, had a high incidence and intensity of catastrophic health expenditure. Hence, it is relevant to expand community-based health insurance to provide financial protection for people suffering from chronic conditions.

Association between multimorbidity patterns and catastrophic health expenditure among Chinese older adults living alone

BackgroundMultimorbidity is prevalent among older adults and may result in catastrophic health expenditures (CHEs) on older adults’ households. However, whether older adults living alone suffer such a financial burden is unknown. We aimed to investigate the association between multimorbidity patterns and CHE in Chinese older adults living alone. MethodsWe included 884 participants aged 60 years and over and living alone from the 2018 wave of the China Health and Retirement Longitudinal Study (CHARLS). Latent class analysis was performed to identify multimorbidity patterns based on 14 self-reported chronic diseases. The logit model and Tobit model were adopted to analyze the association of multimorbidity patterns with the incidence and intensity of CHE, respectively. ResultsApproximately 20.2% of the older adults living alone experienced CHE. Among the four multimorbidity groups (minimal disease, cardiovascular, lung and asthma, and multisystem), the multisystem group and cardiovascular group had significantly higher incidence and intensity of CHE than the minimal disease group. ConclusionsOlder adults living alone had high risks of CHE, especially those belonging to the multisystem pattern and cardiovascular pattern. Integrated care should be adopted in the treatment of multimorbidity to reduce health costs. More elder services and social assistance should be provided to solitary older adults with certain patterns of multimorbidity.

Provincial variations in catastrophic health expenditure and medical impoverishment in China: a nationwide population-based study

Financial protection, as a key dimension of Universal Health Coverage (UHC), has been under increasing attention in recent years. A series of studies have examined the nationwide extent of catastrophic health expenditure (CHE) and medical impoverishment (MI) in China. However, disparities in financial protection at the province level have rarely been studied. The aim of this study was to investigate provincial variations in financial protection as well as its inequality across provinces. Using data from the 2017 China Household Finance Survey (CHFS), this study estimated the incidence and intensity of CHE and MI for 28 Chinese provinces. Ordinary least square (OLS) estimation, using robust standard errors, was used to explore the factors associated with financial protection at the province level. Moreover, this study examined the urban-rural differences in financial protection within each province, and calculated the concentration index of CHE and MI indicators for each province using household income per capita. The study revealed large provincial variations in financial protection within the nation. The nationwide CHE incidence was 11.0% (95% CI: 10.7%, 11.3%), ranging from 6.3% (95% CI: 5.0%, 7.6%) in Beijing to 16.0% (95% CI: 14.0%, 18.0%) in Heilongjiang; the national MI incidence was 2.0% (95% CI: 1.8%, 2.1%), ranging from 0.03% (95% CI: 0.00%, 0.06%) in Shanghai to 4.6% (95% CI: 3.3%, 5.9%) in Anhui province. We also found similar patterns for provincial variations in intensity of CHE and MI. Moreover, substantial provincial variations in income-related inequality and urban-rural gap existed across provinces. Eastern developed provinces in general had much lower inequality within them, compared with central and western provinces. Despite the great advances towards UHC in China, substantial provincial variations exist in financial protection across provinces. Policymakers should pay special attention to low-income households in central and western provinces. Provision of better financial protection for these vulnerable groups will be key to achieving UHC in China. This research was supported by the National Natural Science Foundation of China (Grant Number: 72074049)and the Shanghai Pujiang Program (2020PJC013).

Which indicator should be used? A comparison between the incidence and intensity of catastrophic health expenditure: using difference-in-difference analysis

BackgroundCatastrophic health expenditure (CHE) represents out-of-pocket payment as a share of household income. Most previous studies have focused on incidence aspects when assessing health policy effects. However, because CHE incidence is a binary variable, the effect of the health policy could not accurately be evaluated. On the contrary, the intensity of CHE is a continuous variable that can yield completely different results from previous studies. This study reassesses the coverage expansion plan for four serious diseases using the intensity of CHE in Korea.MethodsWe used the Korea Health Panel Study from 2013 to 2015 to conduct the analysis. The study population is households with chronic diseases patients. We divided the population into two groups: the policy beneficiary group, i.e., households with a patient of any of the four serious diseases, and the non-beneficiary group. A difference-in-difference model was employed to compare the variation in the intensity and incidence of CHE between the two groups. We defined the incidence of CHE as when the ratio of out-of-pocket medical expenses to household income is more than a threshold of 10%, and the intensity of CHE is the height of the ratio subtracting the threshold 10%.ResultsThe increased rate of CHE intensity in households with four serious diseases was lower than that in households with other chronic diseases. The interaction term, which represents the effect of the policy, has a significant impact on the intensity but not on the incidence of CHE.ConclusionsCHE indicators should be applied differently according to the purpose of policy evaluation. The incidence of CHE should be used as the final achievement indicator, and the intensity of CHE should be used as the process indicator. Furthermore, because CHE has an inherent characteristic that is measured by the ratio of household income to medical expenses, to lower this, a differential out-of-pocket maximum policy for each income class is more appropriate than a policy for strengthening the coverage for specific diseases.

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.

The microeconomic impact of out-of-pocket medical expenditure on the households of cardiovascular disease patients in general and specialized heart hospitals in Ibadan, Nigeria.

Cardiovascular diseases (CVDs) present a huge threat to population health and in addition impose severe economic burden on individuals and their households. Despite this, there is no research evidence on the microeconomic impact of CVDs in Nigeria. Therefore, this study estimated the incidence and intensity of catastrophic health expenditures (CHE), poverty headcount due to out-of-pocket (OOP) medical spending and the associated factors among the households of a cohort of CVDs patients who accessed healthcare services in public and specialized heart hospitals in Ibadan, Nigeria. This study adopts a descriptive cross-sectional study design. A standardized data collection questionnaire developed by the Initiative for Cardiovascular Health Research in Developing Countries was adapted to electronically collect data from all the 744 CVDs patients who accessed healthcare services in public and specialized heart hospitals in Ibadan between 4th November 2019 to the 31st January 2020. A sensitivity analysis, using rank-dependent thresholds of CHE which ranged from 5%-40% of household total expenditures was carried out. The international poverty line of $1.90/day recommended by the World Bank was utilized to ascertain poverty headcounts pre-and post OOP payments for healthcare services. Categorical variables like household socio-demographic and clinical characteristics, CHE and poverty headcounts, were presented using percentages and proportions. Unadjusted and adjusted logistic regression models were used to assess the factors associated with CHE and poverty. Data were analyzed using STATA version 15 and estimates were validated at 5% level of significance. Catastrophic OOP payment ranged between 3.9%-54.6% and catastrophic overshoot ranged from 1.8% to 12.6%. Health expenditures doubled poverty headcount among households, from 8.13% to 16.4%. Having tertiary education (AOR: 0.49, CI: 0.26-0.93, p = 0.03) and household size (AOR: 0.40, CI: 0.24-0.67, p = 0.001) were significantly associated with CHE. Being female (AOR: 0.41, CI: 0.18-0.92, p = 0.03), household economic status (AOR: 0.003, CI: 0.0003-0.25, p = <0.001) and having 3-4 household members (AOR: 0.30, CI: 0.15-0.61, p = 0.001) were significantly associated with household poverty status post payment for medical services. OOP medical spending due to CVDs imposed enormous strain on household resources and increased the poverty rates among households. Policies and interventions that supports universal health coverage are highly recommended.

A STUDY OF CATASTROPHIC HEALTH EXPENDITURES IN INDIA - EVIDENCE FROM NATIONALLY REPRESENTATIVE SURVEY DATA: 2014-2018

Background: India is taking steps to provide Universal Health Coverage (UHC). Out-of-pocket (OOP) health care payment is the most important mechanism for health care payment in India. This study aims to investigate the effect of OOP health care payments on catastrophic health expenditures (CHE). Methods: Data from the National Sample Survey Organization, Social Consumption in Health 2014 and 2018 are used to investigate the effect of OOP health expenditure on household welfare in India. Three aspects of catastrophic expenditure were analyzed in this paper: (i) incidence and intensity of ‘catastrophic’ health expenditure, (ii) socioeconomic inequality in catastrophic health expenditures, and (iii) factors affecting catastrophic health expenditures. Results: The odds of incidence and intensity of CHE were higher for the poorer households. Using the logistic regression model, it was observed that the odds of incidence of CHE was higher among the households with at least one child aged less than 5 years, one elderly person, one secondary educated female member, and if at least one member in the household used a private healthcare facility for treatment. The multiple regression model showed that the intensity of CHE was higher among households with members having chronic illness, and if members had higher duration of stay in the hospital. Subsidizing healthcare to the households having elderly members and children is necessary to reduce CHE. Conclusion: Expanding health insurance coverage, increasing coverage limits, and inclusion of coverage for outpatient and preventive services are vital to protect households. Strengthening public primary health infrastructure and setting up a regulatory organization to establish policies and conduct regular audits to ensure that private hospitals do not increase hospitalizations and the duration of stay is necessary.

A STUDY OF CATASTROPHIC HEALTH EXPENDITURES IN INDIA - EVIDENCE FROM NATIONALLY REPRESENTATIVE SURVEY DATA: 2014-2018.

Background: India is taking steps to provide Universal Health Coverage (UHC). Out-of-pocket (OOP) health care payment is the most important mechanism for health care payment in India. This study aims to investigate the effect of OOP health care payments on catastrophic health expenditures (CHE). Methods: Data from the National Sample Survey Organization, Social Consumption in Health 2014 and 2018 are used to investigate the effect of OOP health expenditure on household welfare in India. Three aspects of catastrophic expenditure were analyzed in this paper: (i) incidence and intensity of 'catastrophic' health expenditure, (ii) socioeconomic inequality in catastrophic health expenditures, and (iii) factors affecting catastrophic health expenditures. Results: The odds of incidence and intensity of CHE were higher for the poorer households. Using the logistic regression model, it was observed that the odds of incidence of CHE was higher among the households with at least one child aged less than 5 years, one elderly person, one secondary educated female member, and if at least one member in the household used a private healthcare facility for treatment. The multiple regression model showed that the intensity of CHE was higher among households with members having chronic illness, and if members had higher duration of stay in the hospital. Subsidizing healthcare to the households having elderly members and children is necessary to reduce CHE. Conclusion: Expanding health insurance coverage, increasing coverage limits, and inclusion of coverage for outpatient and preventive services are vital to protect households. Strengthening public primary health infrastructure and setting up a regulatory organization to establish policies and conduct regular audits to ensure that private hospitals do not increase hospitalizations and the duration of stay is necessary.

Catastrophic health expenditure and impoverishment in Vietnam: Evidence from national Household Living Standards Surveys 2008–2018

One of the strategic objectives of the Vietnamese government in achieving universal health coverage (UHC) is to develop a sustainable, equitable, and effective health financing system. This study aimed to examine the incidence and intensity of catastrophic health expenditure (CHE) and impoverishment in Vietnam at different thresholds of expenditure. The data were obtained from six national representative Household Living Standards Surveys from 2008 to 2018. We found that the incidence and intensity of CHE declined significantly over study years. Additionally, we found a substantial reduction in the incidence and intensity of medical impoverishment in Vietnam. The increase in the poverty gap in 2012 and 2014 was because non-poor households became poor after out-of-pocket (OOP) health payments. However, the rise in poverty gaps in 2008, 2010, 2016 and 2018 was attributable to the worsening state of existing poor households after healthcare payments. In addition, we found that the CHE rate and impoverishment were more concentrated in the poor quintile groups. Furthermore, we found that the Red River Delta had the highest CHE rate, whereas the Northern Midland region experienced the strongest poverty impact of OOP payments. Generally, in Vietnam, the health financing system has had no considerable success in reducing inequality across quintiles and regions. Finally, our findings revealed that health insurance showed positive impacts on households’ financial protection against CHE and impoverishment, after enacting both the first Health Insurance Law in 2009 and the Revised Health Insurance Law in 2015. The results suggest that the health insurance scheme should be reviewed to continue reducing CHE and impoverishment, promoting equity and enhancing the performance of the health financing system in Vietnam.

Can health poverty alleviation project reduce the economic vulnerability of poor households? Evidence from Chifeng City, China

Poverty is a worldwide problem. The Chinese government proposed the Health Poverty Alleviation Project (HAPA) from the health care perspective in 2016. The project aims to prevent poverty caused by disease or a return to poverty due to disease. We employ the propensity score matching and difference-in-differences method and an economic vulnerability indicator to evaluate the project effects using 2017–2020 internal data from the government of Chifeng (a prefecture-level city in the Inner Mongolia Autonomous Region). We analyze the impact of the HPAP on the catastrophic health expenditures of families with different levels of poverty and health. We also discuss its effect on poverty alleviation and its connection with other poverty alleviation projects. We show that the HPAP reduces the occurrence and intensity of catastrophic health expenditures by 17.1% and 31.2%, respectively. For families with poor health and extremely poor families, the effect is stronger, and the project has effectively alleviated the economic vulnerability of poor families. In addition, we find a connection between education and health poverty alleviation and confirm the scientific rationality of China's targeted poverty alleviation system.

Measurement and determinants of financial protection in health in Afghanistan

BackgroundOut of pocket (OOP) payments for health are significant health financing challenges in Afghanistan as it is a source of incurrence of catastrophic health expenditure (CHE) and impoverishment. Measuring and understanding the drivers and impacts of this financial health hardship is an economic and public health priority, particularly in the time of COVID-19. This is the first study that measures the financial hardship and determines associated factors in Afghanistan.MethodsAfghanistan Living Conditions Survey data for 2016–2017 was used for this study. We calculated incidence and intensity of catastrophic health expenditure by using different thresholds ranging from 5 to 40% of total and nonfood consumption and subsequent impoverishment due to OOPs. Logistic regression was used to assess the degree to which Afghan households are protected from the catastrophic household expenditure.ResultsResults revealed that 32% of the population in Afghanistan incurred catastrophic health expenditure (as 10% of total consumption) and when healthcare payments are netted out of household consumption, the Afghan population live in extreme poverty ($1.9 in 2011 PPP), increased from 29 to 36%. Based on our findings from logistic regression in Afghanistan, having an educated head or being employed are protective factors from financial hardship while having a female head, an elderly member, a disabled, or a sick member are the risk factors of facing catastrophic health expenditure. Moreover, the people living in rural/nomadic areas or facing an economic shock are more likely to face catastrophic health expenditure and hence to be impoverished due to direct OOPs on health.ConclusionsThe high rate of poverty and catastrophic health expenditure in Afghanistan emphasizes the need to strengthen the health financing system. Although Afghanistan has made great efforts to support households against health expenditure burden during the pandemic, households are at higher risk of poverty and financial hardship due to OOPs. Therefore, there is need for more financial and supportive response policies by providing a better and easier access to primary health services, extending to all entitlement to health services particularly in the public sector, eliminating user fees for COVID-19 health services and suspending fees for other essential health services, expanding coverage of income support, and strengthening the overall health financing system.

Assessing the household economic burden of non-communicable diseases in India: evidence from repeated cross-sectional surveys

BackgroundFinancing for NCDs is encumbered by out-of-pocket expenditure (OOPE) assuming catastrophic proportions. Therefore, it is imperative to investigate the extent of catastrophic health expenditure (CHE) on NCDs, which are burgeoning in India. Thus, our paper aims to examine the extent of CHE and impoverishment in India, in conjunction with socio-economic determinants impacting the CHE.MethodsWe used cross-sectional data from nationwide healthcare surveys conducted in 2014 and 2017–18. OOPE on both outpatient and inpatient treatment was coalesced to estimate CHE on NCDs. Incidence of CHE was defined as proportion of households with OOPE exceeding 10% of household expenditure. Intensity of catastrophe was ascertained by the measure of Overshoot and Mean Positive Overshoot Indices. Further, impoverishing effects of OOPE were assessed by computing Poverty Headcount Ratio and Poverty Gap Index using India’s official poverty line. Concomitantly, we estimated the inequality in incidence and intensity of catastrophic payments using Concentration Indices. Additionally, we delineated the factors associated with catastrophic expenditure using Multinomial Logistic Regression.ResultsResults indicated enormous incidence of CHE with around two-third households with NCDs facing CHE. Incidence of CHE was concentrated amongst poor that further extended from 2014(CI = − 0.027) to 2017–18(CI = − 0.065). Intensity of CHE was colossal as households spent 42.8 and 34.9% beyond threshold in 2014 and 2017-18 respectively with poor enduring greater overshoot vis-à-vis rich (CI = − 0.18 in 2014 and CI = − 0.23 in 2017–18). Significant immiserating impact of NCDs was unraveled as one-twelfth in 2014 and one-eighth households in 2017–18 with NCD burden were pushed to poverty with poverty deepening effect to the magnitude of 27.7 and 30.1% among those already below poverty on account of NCDs in 2014 and 2017–18 respectively. Further, large inter-state heterogeneities in extent of CHE and impoverishment were found and multivariate analysis indicated absence of insurance cover, visiting private providers, residing in rural areas and belonging to poorest expenditure quintile were associated with increased likelihood of incurring CHE.ConclusionSubstantial proportion of households face CHE and subsequent impoverishment due to NCD related expenses. Concerted efforts are required to augment the financial risk protection to the households, especially in regions with higher burden of NCDs.

Urban-rural differences in catastrophic health expenditure among households with chronic non-communicable disease patients: evidence from China family panel studies

BackgroundThe prevalence of chronic non-communicable diseases (NCDs) challenges the Chinese health system reform. Little is known for the differences in catastrophic health expenditure (CHE) between urban and rural households with NCD patients. This study aims to measure the differences above and quantify the contribution of each variable in explaining the urban-rural differences.MethodsUnbalanced panel data were obtained from the China Family Panel Studies (CFPS) conducted between 2012 and 2018. The techniques of Fairlie nonlinear decomposition and Blinder-Oaxaca decomposition were employed to measure the contribution of each independent variable to the urban-rural differences.ResultsThe CHE incidence and intensity of households with NCD patients were significantly higher in rural areas than in urban areas.The urban-rural differences in CHE incidence increased from 8.07% in 2012 to 8.18% in 2018, while the urban-rural differences in CHE intensity decreased from 2.15% in 2012 to 2.05% in 2018. From 2012 to 2018, the disparity explained by household income and self-assessed health status of household head increased to some extent. During the same period, the contribution of education attainment to the urban-rural differences in CHE incidence decreased, while the contribution of education attainment to the urban-rural differences in CHE intensity increased slightly.ConclusionsCompared with urban households with NCD patients, rural households with NCD patients had higher risk of incurring CHE and heavier economic burden of diseases. There was no substantial change in urban-rural inequality in the incidence and intensity of CHE in 2018 compared to 2012. Policy interventions should give priority to improving the household income, education attainment and health awareness of rural patients with NCDs.