OOP Healthcare Expenditures Research Articles

Determinants of out-of-Pocket Healthcare Expenditure by Households in Sierra Leone

The study sought to identify the determinants that influence Sierra Leonean households’ out-of-pocket healthcare expenditure. The research explicitly examined the demographic and socioeconomic determinants that impact out-of-pocket healthcare expenditure by households in Sierra Leone. The study was based on the positivism philosophy and used secondary data from the 2018 Siera Leone Household Integrated Survey to address the study objectives. Logistic regression analysis was conducted to see whether there were any relationships between the dependent and independent variables. The analysis revealed that Sierra Leone’s out-of-pocket healthcare expenditure is influenced by several demographic and socio-economic determinants which should be monitored by the policymakers. Sierra Leone households’ out-of-pocket healthcare expenditure is influenced by the household size (p < 0.001), place of residence (p=0.03), employment status of the head of household (p=0.008), health provider consultation (p <0.001) and wealth quintile (p<0.001). The government should continue to identify and address the main causes of high OOP healthcare expenditure. A concerted effort is necessary to reduce high out-of-pocket health expenditures by improving prepaid health payment arrangements. The study provides information that governments may use to establish policies that reduce the financial burden that families endure when seeking medical care. To address structural determinants of access to healthcare, such as availability, distribution, accessibility, and quality, regardless of an individual’s location or socioeconomic status, the government could implement policies and activities aimed at increasing the availability, accessibility, and quality of healthcare services without the households suffering financial burden. The study encountered limitations inherent in the use of secondary data; however, these constraints do not undermine the validity of the findings. Such estimations remain crucial in advancing research on healthcare financing, providing valuable insights despite the methodological challenges associated with secondary data sources.

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

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

What is the impact of multimorbidity on out-of-pocket healthcare expenditure among community-dwelling older adults in Ireland? A cross-sectional study

ObjectivesIndividuals with multimorbidity use more health services and take more medicines. This can lead to high out-of-pocket (OOP) healthcare expenditure. This study, therefore, aimed to assess the association between multimorbidity...

Magnitude and determinants of out of pocket health expenditure among patients visiting outpatients in public hospitals in East Shoa Zone, Ethiopia

BackgroundOut-of-pocket payment (OOP) for healthcare services remained the main means of the financing health system in developing countries for a decade. Therefore, we assessed the magnitude and determinants of OOP healthcare expenditure among patients visiting the outpatients in public Hospitals in East Shoa Zone, Ethiopia. MethodsWe conducted an institution-based cross-sectional study among participants in public hospitals in the East Shoa zone, Oromia Region. A multivariate logistic regression analysis was used to identify determinants of OOP healthcare expenditure and statistical significance was declared at a p-value of less than 0.05 and the association was described by using an Adjusted odds ratio (AOR) at a 95% Confidence Interval (CI). ResultOf the 378 respondents, 332(87.8%) were paid OOP healthcare expenditures at service delivery points. We found that, respondents aged 31-49 years old (AOR = 2.58, 95% CI (1.16–5.77), secondary education and above (AOR = 4.85, 95% CI (1.59–14.83), monthly income ≥4000 ETB (AOR = 5.67, 95% CI (1.97–16.31), urban residents (AOR = 3.61, 95% CI (1.29–10.16) and family size (AOR = 2.67, 95% CI (1.11–6.44) were significant determinants of OOP healthcare expenditure. ConclusionWe found that a significant number of outpatients' department users were paid out-of-pocket expenditures for medical services. Educational status, family size, residence, and respondents’ monthly income were significantly associated with out-of-pocket healthcare expenditure. So, the government and stakeholders should strengthen efforts to design the Urban CBHI scheme and Social health insurance, which guarantees urban communities access to health services without facing financial hardship for all communities.

Out-of-pocket payment for healthcare among urban citizens in Dhaka, Bangladesh

ObjectivesOut-of-pocket (OOP) payment is the major payment strategy for healthcare in Bangladesh, and the share of OOP expenditure has increased alarmingly. Dhaka is recognised as one of the fastest-growing megacities in the world. The objective of this study is to capture the self-reported illnesses among urban citizens and to identify whether and to what extent socioeconomic, demographic and behavioural factors of the population influence OOP healthcare expenditures.Subject and methodsThis study utilises cross-sectional survey data collected from May to August 2019 in urban Dhaka, Bangladesh. A total of 3,100 households were randomly selected. Simple descriptive statistics including frequencies, percentage, mean (95% CI), median and inter-quartile range were presented. Bivariate analysis and multivariate regression models were employed.ResultsWe observed that acute illnesses (e.g., fever, flu/cough) were dominant among participants. Among the chronic illnesses, approximately 9.6% of people had diabetes, while 5.3% had high/low blood pressure. The richest quintile only spent 5.2% of their household income on healthcare, while the poorest households spent approximately six times more than the richest households. We noted that various factors such as marital status, religion, source of care, access to safe water, income quintile and even the location of households had a significant relationship with OOP expenditure.ConclusionsOur findings can serve as important source of data in terms of disease- specific symptoms and out-of-pocket cost among urban citizens in Dhaka. The people belonging to wealthier households tended to choose better healthcare facilities and spend more. A pro-poor policy initiative and even an urban health protection scheme may be necessary to ensure that healthcare services are accessible and affordable, in line with the Bangladesh National Urban Health Strategy.

Out-of-Pocket Health Care Expenditure and Poverty Impact in a Fragile Indian State of Assam

Out-of-Pocket (OOP) expenditure on health care is one of the debilitating factors in pushing households into poverty. Households, especially the lower income groups and which do not have security measures like medical insurance, are the worst sufferers when faced with health shocks. Conventional methods of poverty estimation do not take into account health care consumption expenditure, which might understate the poverty headcount. In this study, poverty headcount and impoverishing effects of OOP health care expenditure have been analysed. The data have been collected from Chirang district of Indian state of Assam. The state is a fragile state due to ethnic violence, militancy and natural calamities like flood that the region has been experiencing for decades. The recall period for the inpatient care is 365 days, and six months for outpatient care. The poverty headcount is the difference between post Hp and pre Hp. The pre-payment (i.e. pre-OOP) ‘poverty headcount’ is calculated by comparing household’s consumption expenditure gross of payments for health care with the poverty line defined by the planning commission of India (2001). The post-OOP payment ‘poverty headcount’ is computed by netting out health care payments from a household’s consumption expenditure and then comparing with the poverty line. The intensity of poverty has been estimated with the help of the methods introduced by Wagstaff and Doorslaer (2003). The higher income households make higher OOP expenditure than the lower income households. The burden of OOP is higher on the lower income households because the proportion of OOP expenditure to total income of households is higher amongst the poor households compared to higher income households. OOP expenditure pushed households into poverty. This is more serious with the inpatient care compared to the OOP expenditure on outpatient care. The poverty gap or the intensity of poverty of the overall OOP expenditure is Rs. 279.28, which varies between outpatient and inpatient OOP expenditure.

Catastrophic Health Expenditure Associated With Frailty in Community-Dwelling Chinese Older Adults: A Prospective Cohort Analysis.

Background: Catastrophic health expenditure (CHE) represents a key indicator for excessive financial burden due to out-of-pocket (OOP) healthcare costs, which could push the household into poverty and is highly pronounced in households with members at an advanced age. Previous studies have been devoted to understanding the determinants for CHE, yet little evidence exists on its association with frailty, an important geriatric syndrome attracting growing recognition. We thus aim to examine the relationship between frailty and CHE and to explore whether this effect is moderated by socioeconomic-related factors.Methods: A total of 3,277 older adults were drawn from two waves (2011 and 2013) of the China Health and Retirement Longitudinal Study (CHARLS). CHE was defined when OOP healthcare expenditure exceeded a specific proportion of the capacity of the household to pay. Frailty was measured following the Fried Phenotype (FP) scale. Mixed-effects logistic regression models were employed to assess the longitudinal relationship between frailty and CHE, and stratification analyses were conducted to explore the moderation effect.Results: The incidence of CHE among Chinese community-dwelling older adults was 21.76% in 2011 and increased to 26.46% in 2013. Compared with non-frail individuals, prefrail or frail adults were associated with higher odds for CHE after controlling for age, gender, residence, education, marriage, income, health insurance, smoking, drinking, and comorbidity (prefrail: odds ratio (OR) = 1.32, 95%CI = 1.14–1.52; frail: OR = 1.67, 95%CI = 1.13–2.47). Three frailty components including weakness, exhaustion, and shrinking contributed to a significantly increased likelihood of CHE (all p < 0.05), while the other two components including slowness and inactivity showed a non-significant effect (all p > 0.05). Similar effects from frailty on CHE were observed across socioeconomic-related subgroups differentiated by gender, residence, education, household income, and social health insurance.Conclusions: Frailty is a significant predictor for CHE in China. Developing and implementing cost-effective strategies for the prevention and management of frailty is imperative to protect households from financial catastrophe.

Out-of-Pocket Expenditure of the Hospitalized Patients for Treatment of Liver Cirrhosis in a Tertiary Hopspital

Background: Out-of-pocket expenditure is the major financer for health care expenses in Bangladesh, causing financial burden on affected households. Chronic disease like liver cirrhosis requires long term treatment, exposing households to further economic stress, pushing them into a state where they fail to meet the necessary health expenses from their own household consumption and sacrifices basic necessities of living to pay for healthcare services. This study aims to estimate the OOP expenditure and resulting catastrophic health expenditure among hospitalized patients of liver cirrhosis.&#x0D; Methods: This was a cross-sectional study conducted among 42 diagnosed liver cirrhosis patients admitted at Bangabandhu Sheikh Mujib Medical University (BSMMU) under the department of hepatology and department of gastroenterology, aged 18 years and above. Convenient sampling technique was used and data were collected from the respondents using a semi-structured questionnaire through face-to-face interview during discharge from hospital.&#x0D; Results: Out of pocket expenditure for liver cirrhosis at BSMMU was BDT 24,898. Direct medical cost was BDT 21,202, direct non-medical cost was BDT 1,895 and indirect cost was BDT 1,801. Among the determinants of OOP healthcare expenditure, medicine and investigation costs were the major cost drivers, 36.91% and 44.13% of the total expenditure, respectively. OOP expenditure was found to be slightly higher among respondents from department of hepatology, than department of gastroenterology, BDT 21,834 and BDT 18,043 respectively, but this difference was not statistically significant. At 10% threshold level, 40.5% of the respondents were affected by Catastrophic Healthcare Expenditure (CHE). Nearly one-third (30.9%) of the respondents were facing distress financing due to OOP Expenditure.&#x0D; Conclusions: The high amount of OOP expenditure can be contributed mostly to the high cost of medicine and investigation. Making medicine readily available at an affordable price along with rational use of medication and investigation for diagnostic purpose can help reduce this financial burden on affected households.&#x0D; JOPSOM 2020; 39(2): 74-82

Assessing the responsiveness of out-of-pocket healthcare expenditure to macro-fiscal factors and different health financing systems: evidence from the European and OECD area

PurposeIn this paper, the authors assess the responsiveness of OOP healthcare expenditure to macro-fiscal factors, as well as to tax-based, SHI, mixed systems and voluntary PHI financing. Although the relationship between OOP expenditure, macroeconomy, aggregate public and PHI financing is well documented in the existing empirical literature, little is known for the impact of several macro-fiscal drivers and the existing health financing arrangements associated with voluntary PHI on OOP expenditure.Design/methodology/approachThe authors gather panel data by applying three official organizations’ databases. They elaborate static and dynamic panel data methodology to a dataset of 49 European and OECD countries from 2000 to 2015.FindingsThe authors’ findings do not indicate a considerable impact of GDP growth and general government debt as a share of GDP on OOP payments. Unemployment rate presents as a positive driver of OOP payments in all three compulsory national health systems post to the 2008 economic crisis. OOP payments are significantly influenced by countries’ fiscal capacity to increase general government expenditure to GDP in SHI and mixed health systems. Additionally, study findings present that government health financing, irrespective of the different health systems structure characteristics, and OOP healthcare payments follow different directions. Voluntary PHI financing considerably counteracts OOP payments only in tax-based health systems.Practical implicationsIn the backdrop of a new economic crisis associated to the COVID-19 epidemic, health policy planners have to deal with the emerging unprecedented challenges in financing of health systems, especially for these economies that have to face the fiscal capacity constraints owing to the 2008 financial crisis and its severe recession.Originality/valueTo the best of authors’ knowledge, there is no empirical consensus on the effects of macro-fiscal parameters, different compulsory health systems financing associated with the parallel voluntary PHI institution funding on OOP expenditure, for the majority of European and OECD settings.

Contemporary relationship between medical expenditures and quality of life among adults with epilepsy in the United States

AimsEpilepsy exacts substantial adverse economic and quality of life (QoL) costs. Clarifying the quantitative and qualitative relationships between total and out-of-pocket (OOP) healthcare expenditures and QoL could shed insights into how they influence each other, and have done so over recent times. MethodsWe used the Medical Expenditure Household Components 2003–2014 to identify a total of 2450 adults with epilepsy, representing a weighted population of 1,942,413. Quality of life was assessed using the Physical Component Summary (PCS) and the Mental Component Summary (MCS) derived from the Short-form 12 Version 2 (SF-12 V2), converted into quartiles of equal distribution, with higher quartiles indicating a better QoL. We computed unadjusted mean and adjusted (through a generalized linear model (GLM)) total and OOP healthcare expenditures by QoL categories among adults with epilepsy (reported as dollars in 2016). ResultsThe pooled estimates of total healthcare expenditures decreased as PCS and MCS quartiles of QoL increased [PCS: costs for quartile 1 = $21,792 (95% confidence interval (CI): $18,416–$25,168 vs. costs for quartile 4 = $6057 (95% CI: $4648–$7466) and MCS: costs for quartile 1 = $19,040 (95% CI: $15,544–$22,535) vs. quartile 4 = $12,939 (95% CI: $8450–$17,429)]. Similarly, the pooled estimates of OOP healthcare expenditures and QoL were inversely related [PCS: costs for quartile 1 = $1849 (95% CI: $1583–$2114) vs. costs for quartile 4 = $948 ($709–$1187) and MCS: costs for quartile 1 = 1812 (95% CI: $1483–2141) vs. quartile 4 = $1317 (95% CI: $982–$1652)]. The association between QoL and total and OOP healthcare expenditures was unchanged after adjusting for socioeconomic and healthcare system related confounders in the GLM. Overall, healthcare expenditures were stable across years independently of the QoL; only OOP expenditures decreased between 2003–2006 and 2011–2014 for quartile 1 of PCS and MCS. ConclusionQuality of life and OOP health expenditures are independently and inversely related to each other among adults with epilepsy. Over the decade studied in the United States, there was a decrease in OOP health expenditures among those patients with epilepsy with the lowest QoL, possibly reflecting a rise in insurance coverage after the Affordable Care Act.

Out-of-Pocket Healthcare Expenditures in Dependent Older Adults: Results From an Economic Evaluation Study in Mexico.

Background: Dependence is a significant health-related condition for older adults (OA) and implies that self-care is transferred to other people, the community or institutions. Recent studies have analyzed the relationship between out-of-pocket (OOP) healthcare expenditures and dependence. Nonetheless, these studies were not specifically designed to estimate the economic impact of dependence. Our aim was to estimate the total adjusted annual OOP healthcare expenditures in dependent older adults compared to independent ones. Additionally, we explore the potential combined effect of basic activities of daily living (ADL) and instrumental activities of daily living (IADL) dependence on OOP healthcare expenditures.Methods: Data comes from the cross-sectional study “Economic impact of physical dependence in older adults and the burden of informal care” conducted in 2018 with a sample of 735 community-dwelling older Mexican adults ages 60 and older. We used direct (medical and non-medical) and indirect costs to estimate the OOP healthcare expenditures associated with dependence. We applied the Katz scale to assess dependence in ADL and the Lawton scale to assess dependence in IADL. Two-Part regression models were used to analyze the relationship between dependence and OOP health expenditures.Results: Presence of ADL dependence represented a higher level of expenditure, 107% compared to non-dependent OA (β = 1.07, CI95%: 0.43–1.71), and 97% for IADL dependence (β = 0.97, CI95%: 0.49–1.45). The combined effect of ADL and IADL dependence (132%) was greater (β = 1.32, CI95%: 0.74–1.90) than the effect of ADL or IADL dependence alone. In monetary terms, OA with ADL dependence had a total annualized mean OOP healthcare expenditure of $31,865 (Mexican pesos), OA with IADL $26,912, and combined ADL and IADL $39,520.Conclusions: ADL and IADL dependence are associated with the total annualized OOP healthcare expenditures. This association is even higher when both conditions are present together. These findings highlight the economic implications of the dependence for individuals, their families, and the health system. Given that current evidence on effective interventions to prevent dependence in OA is insufficient, future studies should be conducted to estimate their costs and determine what interventions work, as well as their effectiveness and cost-effectiveness in different sub-groups of the population, and how these might be appropriately implemented.

Association Between Supplemental Private Health Insurance and Burden of Out-of-Pocket Healthcare Expenditure in China: A Novel Approach to Estimate Two-Part Model with Random Effects Using Panel Data.

IntroductionPrivate health insurance (PHI) is an important supplement to the basic health insurance schemes in the Chinese healthcare system. However, there is an absence of evidence on whether the strategy of engaging PHI to reduce burden is effective in China. As such, we aimed to investigate the association between supplemental PHI and the out-of-pocket (OOP) burden of household healthcare expenditure in China.MethodsWe conducted a panel data analysis using data from three waves of China Health and Retirement Longitudinal Study (CHARLS). Specifically, a two-part model (TPM) with a first-stage probit and second-stage generalized linear model (GLM) framework was used to analyze the data. To account for individual-level random effects in both stages and their correlation in the TPM analysis, we proposed a generalized structural equation modeling (GSEM) approach to implement the estimation. The proposed approach allowed us to simultaneously analyze the association of PHI with the probability of having any healthcare and the OOP burden conditional on having any healthcare expenditure.ResultsUsing the GSEM estimates, we found that supplemental PHI was significantly associated with a higher probability (4.29 percentage points) of having any OOP healthcare expenditure but a lower OOP burden conditional on having any expenditure (−2.37 percentage points). Overall, supplemental PHI was insignificantly associated with a lower OOP burden (−1.05 percentage points).DiscussionOur findings suggested that supplemental PHI in China may be able to effectively improve access to healthcare while keeping the OOP healthcare expenditure burden flat. Also, GSEM is a feasible method to estimate random-effect TPMs.

Healthcare utilization and out-of-pocket expenditures associated with depression in adults: a cross-sectional analysis in Nepal

BackgroundDespite attempts to improve universal health coverage (UHC) in low income countries like Nepal, most healthcare utilization is still financed by out-of-pocket (OOP) payments, with detrimental effects on the poorest and most in need. Evidence from high income countries shows that depression is associated with increased healthcare utilization, which may lead to increased OOP expenditures, placing greater stress on families. To inform policies for integrating mental healthcare into UHC in LMIC, we must understand healthcare utilization and OOP expenditure patterns in people with depression. We examined associations between symptoms of depression and frequency and type of healthcare utilization and OOP expenditure among adults in Chitwan District, Nepal.MethodsWe analysed data from a population-based survey of 2040 adults in 2013, who completed the PHQ-9 screening tool for depression and answered questions about healthcare utilization. We examined associations between increasing PHQ-9 score and healthcare utilization frequency and OOP expenditure using negative binomial regression. We also compared utilization of specific outpatient service providers and their related costs among adults with and without probable depression, determined by a PHQ-9 score of 10 or more.ResultsWe classified 80 (3.6%) participants with probable depression, 70.9% of whom used some form of healthcare in the past year compared to 43.9% of people without probable depression. Mean annual OOP healthcare expenditures were $118 USD in people with probable depression, compared to $110 USD in people without. With each unit increase in PHQ-9 score, there was a 14% increase in total healthcare visits (95% CI 7–22%, p < 0.0001) and $9 USD increase in OOP expenditures (95% CI $2–$17; p < 0.0001). People with depression sought most healthcare from pharmacists (30.1%) but reported the greatest expenditure on specialist doctors ($36 USD).ConclusionsIn this population-based sample from Central Nepal, we identified dose-dependent increases in healthcare utilization and OOP expenditure with increasing PHQ-9 scores. Future studies should evaluate whether provision of mental health services as an integrated component of UHC can improve overall health and reduce healthcare utilisation and expenditure, thereby alleviating financial pressures on families.

Hefty fee for a healthy life: finding predictors by econometric comparison

Bangladesh has made notable progress on many health indicators. However, out-of-pocket (OOP) healthcare costs continue to burden patients and their families as the need for public spending in the health sector grows. This article examines the effects of selected variables on OOP healthcare expenditure which have not previously been well researched. Data from the Bangladesh Household Income and Expenditure Survey (HIES) 2010/2011 (n = 4025) was analyzed. This study applied the double-hurdle model, the Tobit Model, and the truncated regression model to analyze the effects of selected independent variables on OOP healthcare expenditure. The presence of chronic illness, or any symptoms of illness, make people spend more on healthcare. People tend to expend more on those healthcare service providers who provide sufficient consultation time. If the healthcare service provider is chosen because of better treatment quality, people will pay more for the service. The study also showed that the time needed to reach the service provider and the waiting time to be treated by the service provider have a significant positive relationship with OOP healthcare expenditure. The desire for a healthy life motivates people to spend money on healthcare within or beyond their ability. People, in general, want to live healthy throughout their lifetime. Thus, the demand for seeking better healthcare service is inelastic in terms of income and price. These seemingly inevitable and high OOP payments are posing an economic burden for the patients and their families. An optimized payment policy can enhance the welfare of both the patients and the service providers.

PHP55 - The Impacts of The Aging on Out-Of-Pocket(Oop) Health Care Expenditures: An Analysis on The Chinese Statistic of 31 Provinces From 2011-2016

With the increasingly aging process, the control of the health care expenditures and alleviating patient economic burden has been a worldwide problem. This study aims to evaluate the effects of the aging on OOP health care expenditures of China. The data of this study were extracted from the China Statistical Yearbook from 2011-2016 and every province was used as an analysis unit. The OOP health care expenditures per capita was selected as the outcome variable and the proportion of elder people (>65 years) was employed to represent the aging. Other covariates included per capita disposable income, juvenile dependency ratio, old-age dependency ratio, the proportion of the urban population, government medical expenditure per capita, education, the coverage of health insurance, sulfur dioxide emissions and the time variable. Panel data mixed linear model and STATA 12.0 were used to estimate the impacts. We also analyzed the impacts in urban and rural areas respectively. One year lag on the proportion of elder people was adopted to deal with endogenous problems. The OOP health care expenditures per capita was significant positive correlation with the proportion of elder people (0.357, P<0.01). The result in urban areas appeared the same relation between them (0.240, P<0.01), while in rural areas the result was the opposite (-0.213, P>0.05). The OOP health care expenditures per capita were rising by the process of the aging, while the increasing of the coverage of health insurance and the government medical expenditure per capita reduced the OOP, thus relieving the degree. Moreover, the medical demands of the rural residents has not been met fully, which need more attention and might bring more pressure on the expenditures with the process of the aging.

Catastrophic healthcare expenditure and impoverishment in tropical deltas: evidence from the Mekong Delta region

BackgroundUniversal health coverage implies that people obtain the health services they need without experiencing financial hardship. While the factors contributing to catastrophic health expenditure (CHE) among households are well understood, few studies have examined this relationship in the context of environmentally vulnerable regions, such as tropical deltas. This study aims to examine the disparities in the prevalence of CHE and impoverishment due to out-of-pocket (OOP) healthcare payments in the Mekong Delta in comparison with rest of Vietnam. It also intends to investigate the associations between economic and environmental shocks, CHE and the impoverishment from healthcare payments.MethodsUsing data from the Vietnam Household Living Standards Survey 2012, the prevalence of CHE was estimated from the fraction of healthcare costs in relation to household consumption expenditure. The poverty headcount was estimated using the total household consumption expenditure considering both with and without OOP expenditure for healthcare in comparison with the national poverty-line. Simple and multiple logistic regression models were used to examine the associations between geography, health systems, environmental and demographic variables and OOP healthcare expenditure related CHE, and impoverishment respectively.ResultsBoth the level of OOP household healthcare expenditure and the proportion of households suffering from impoverishment as the result of such payments were higher in the Mekong Delta region compared to rest of Vietnam. Although the results from the multiple regression analysis showed that households in the Mekong Delta region were significantly less likely to suffer from CHE, they were significantly more likely to be impoverished due to OOP healthcare expenditure. While health insurance membership did not have a significant effect on either outcomes, households that faced an economic or an environmental shock in past 5 years were considerably more likely to suffer from CHE and impoverishment from OOP healthcare payments.ConclusionsThe findings suggest that the financial protection capacity of health insurance schemes in Vietnam should be improved and expanded to reduce impoverishment as the result of OOP healthcare payments, particularly in the Mekong Delta region. Additional investments in disaster preparedness strategies can further help to reduce the financial burden of households in this environmentally vulnerable region.

Distribution and Determinants of Out-of-pocket Healthcare Expenditures in Bangladesh.

ObjectivesAs in many low-income and middle-income countries, out-of-pocket (OOP) payments by patients or their families are a key healthcare financing mechanism in Bangladesh that leads to economic burdens for households. The objective of this study was to identify whether and to what extent socioeconomic, demographic, and behavioral factors of the population had an impact on OOP expenditures in Bangladesh.MethodsA total of 12 400 patients who had paid to receive any type of healthcare services within the previous 30 days were analyzed from the Bangladesh Household Income and Expenditure Survey data, 2010. We employed regression analysis for identify factors influencing OOP health expenditures using the ordinary least square method.ResultsThe mean total OOP healthcare expenditures was US dollar (USD) 27.66; while, the cost of medicines (USD 16.98) was the highest cost driver (61% of total OOP healthcare expenditure). In addition, this study identified age, sex, marital status, place of residence, and family wealth as significant factors associated with higher OOP healthcare expenditures. In contrary, unemployment and not receiving financial social benefits were inversely associated with OOP expenditures.ConclusionsThe findings of this study can help decision-makers by clarifying the determinants of OOP, discussing the mechanisms driving these determinants, and there by underscoring the need to develop policy options for building stronger financial protection mechanisms. The government should consider devoting more resources to providing free or subsidized care. In parallel with government action, the development of other prudential and sustainable risk-pooling mechanisms may help attract enthusiastic subscribers to community-based health insurance schemes.

Predictors of high out-of-pocket healthcare expenditure: an analysis using Bangladesh household income and expenditure survey, 2010

BackgroundPredictors of high out-of-pocket household healthcare expenditure are essential for creating effective health system finance policy. In Bangladesh, 63.3% of health expenditure is out-of-pocket and born by households. It is imperative to know what determines household health expenditure. This study aims to investigate the predicting factors of high out-of-pocket household healthcare expenditure targeting to put forward policy recommendations on equity in financial burden.MethodsBangladesh household income and expenditure survey 2010 provides data for this study. Predictors of high out-of-pocket household healthcare expenditure were analyzed using multiple linear regressions. We have modeled non-linear relationship using logarithmic form of linear regression. Heteroscedasticity and multicollinearity were checked using Breusch-Pagan/Cook-Weishberg and VIF tests. Normality of the residuals was checked using Kernel density curve. We applied required adjustment for survey data, so that standard errors and parameters estimation are valid.ResultsPresence of chronic disease and household income were found to be the most influential and statistically significant (p < 0.001) predictors of high household healthcare expenditure. Households in rural areas spend 7% less than urban dwellers. The results show that a 100% increase in female members in a family leads to a 2% decrease in household health expenditure. Household income, health shocks in families, and family size are other statistically significant predictors of household healthcare expenditure. Proportion of elderly and under-five members in the family show some positive influence on health expenditure, though statistically nonsignificant.ConclusionsThe findings call for emphasizing prevention of chronic diseases, as it is a strong predictor of household health expenditure. Innovative insurance scheme needs to be devised to prevent household from being impoverished due to health shocks in the family. Policy makers are urged to design an alternative source of healthcare financing in Bangladesh to minimize the burden of high OOP healthcare expenditure.

The economic burden of self-reported and undiagnosed cardiovascular diseases and diabetes on Indonesian households.

ObjectivesThe goal of this study is: (1) to estimate the current direct out-of-pocket (OOP) and indirect non-communicable diseases (NCD) burden on Indonesian households and (2) to project NCD prevalence and burden in 2020 focusing specifically on hypertension, diabetes, heart problems and stroke.MethodsThis study relies on econometric analyses based on four waves of the Indonesian Family Life Survey (IFLS).ResultsIn aggregate, of the NCDs studied, heart problems exert the greatest economic burden on households, costing Int$1.56 billion in OOP and indirect burden in 2010. This was followed by hypertension (Int$1.36 billion), diabetes (Int$0.81 billion) and stroke (Int$0.29 billion). The OOP and indirect burden of these conditions is estimated to be Int$4.02 billion. Diabetes and stroke are expected to have the largest proportional increases in burden by 2020; 56.0% for diabetes and 56.9% for stroke to total Int$1.27 billion and Int$0.45 billion respectively. The burden of heart problems in 2020 is expected to increase by 34.4% to total Int$2.09 billion and hypertension burden will increase by 46.1% to Int$1.99 billion. In 2020, these conditions are expected to impose an economic burden of Int$5.80 billion.ConclusionIn conclusion, this study demonstrates the significant burden of 4 primary NCDs on Indonesian households. In addition to the indirect burden, hypertension, diabetes, heart problems and stroke account for 8% of the nation's OOP healthcare expenditure, and due to rising disease prevalence and an aging population, this figure is expected to increase to 12% by 2020 without a significant health intervention.

Universal Health Insurance in India: Ensuring equity, efficiency, and quality

Indian health system is characterized by a vast public health infrastructure which lies underutilized, and a largely unregulated private market which caters to greater need for curative treatment. High out-of-pocket (OOP) health expenditures poses barrier to access for healthcare. Among those who get hospitalized, nearly 25% are pushed below poverty line by catastrophic impact of OOP healthcare expenditure. Moreover, healthcare costs are spiraling due to epidemiologic, demographic, and social transition. Hence, the need for risk pooling is imperative. The present article applies economic theories to various possibilities for providing risk pooling mechanism with the objective of ensuring equity, efficiency, and quality care. Asymmetry of information leads to failure of actuarially administered private health insurance (PHI). Large proportion of informal sector labor in India's workforce prevents major upscaling of social health insurance (SHI). Community health insurance schemes are difficult to replicate on a large scale. We strongly recommend institutionalization of tax-funded Universal Health Insurance Scheme (UHIS), with complementary role of PHI. The contextual factors for development of UHIS are favorable. SHI schemes should be merged with UHIS. Benefit package of this scheme should include preventive and in-patient curative care to begin with, and gradually include out-patient care. State-specific priorities should be incorporated in benefit package. Application of such an insurance system besides being essential to the goals of an effective health system provides opportunity to regulate private market, negotiate costs, and plan health services efficiently. Purchaser-provider split provides an opportunity to strengthen public sector by allowing providers to compete.