Out Of Pocket Health Expenditure Research Articles

Trends in out-of-pocket health expenditure inequality in Turkey under comprehensive health reforms

The success of Turkey's inclusive health policies has served as a strategic tool for building progressivity and improving social welfare. The objective of this study is to examine the inequality trend in out of pocket (OOP) health expenditures in Turkey. Data from the Turkish Statistical Institute's Household Budget Survey conducted in 2015 and 2019 were used to measure inequalities in OOP total health, pharmaceutical and hospital expenditure variables across socioeconomic status. Decomposition analysis was conducted to identify the factors contributing to inequalities. The study findings demonstrate that OOP health expenditure is higher among the poor in Turkey. Evidence suggests that in Turkey inequalities in OOP health expenditures continue to persist. The results show that OOP health, pharmaceutical, and hospital expenditures increased from 2015 to 2019. The inequality index and curve approaches reveal that the pro-rich distribution of OOP health expenditures is remarkable from 2015 to 2019. The burden of OOP pharmaceutical and hospital services expenditures stands on the shoulders of poor households. Progressive universalism is essential to achieve poverty alleviation strategies and reduce inequality for egalitarian development.

Is health insurance really benefitting Indian population? Evidence from a nationally representative sample survey.

Universal health coverage (UHC) is the centrepiece of the sustainable development goals and aims to ensure access to essential and quality healthcare services to all without facing financial hardships. Several health insurance programmes have been launched in India to progress towards UHC. This study aims to assess the impact of health insurance (overall health insurance, government sponsored health insurance (GSHI), and private voluntary health insurance) on accessibility and utilization of inpatient care, out-of-pocket health expenditure (OOPE), catastrophic health expenditure (CHE), and impoverishment in India. The 75th round of National Sample Survey Office was used in the study, which covered 555,115 individuals, 113,823 households, and 91,445 hospitalization incidence all over India. Descriptive statistics, multivariable logistic regression, and propensity score matching (PSM) methods were employed. Enrolment under health insurance has impacted the accessibility and utilization pattern of hospitalization to some extent for the insured. PSM showed that enrolment under GSHI schemes reduced OOPE by INR 3314 (USD 49) and CHE incidence by 1%-4% at various thresholds. Among poor persons, there was a marginal but statistically significant reduction of OOPE among those enrolled under GSHI schemes (p<0.05). However, GSHI schemes did not statistically significantly reduce the CHE burden for poor persons enrolled (p>0.05). Furthermore, enrolment under private voluntary health insurance reduced OOPE by INR 13,511 (USD 198) and CHE by 13.47% at 10% threshold, 4.61% at 25% threshold, and 2.65% at 40% threshold. However, its uptake was primarily confined to richer economic quintiles and urban areas that exacerbates equity concerns. All the results were confirmed through robustness measures employed. There is a necessity to increase awareness and uptake of health insurance, along with introducing comprehensive insurance packages covering both inpatient and outpatient care. Also, increasing public health spending, strengthening public healthcare facilities, and improving regulatory implementation of private healthcare providers are imperative to augment financial protection.

Financial burden of seeking diabetes mellitus care in India: Evidence from a Nationally Representative Sample Survey

AbstractBackgroundDiabetes mellitus (DM) is a major public health concern in India, and entails a severe burden in terms of disability, death, and economic cost. This study examined the out‐of‐pocket health expenditure (OOPE) and financial burden associated with DM care in India.MethodsThe study used data from the latest round of the National Sample Survey on health, which covered 555,115 individuals from 113,823 households in India. In the present study, data of 1216 individuals who sought inpatient treatment and 6527 individuals who sought outpatient care for DM were analysed.ResultsIn India, 10.04 per 1000 persons reported having DM during the last 15 days before the survey date, varying from 6.94/1000 in rural areas to 17.45/1000 in urban areas. Nearly 38% of Indian households with diabetic members experienced catastrophic health expenditure (at the 10% threshold) and approximately 10% of DM‐affected households were pushed below the poverty line because of OOPE, irrespective of the type of care sought. 48.5% of households used distressed sources to finance the inpatient costs of DM. Medicines constituted one of the largest proportion of total health expenditure, regardless of the type of care sought or type of healthcare facility visited. The average monthly OOPE was over 4.5‐fold and 2.5‐fold higher for households who sought inpatient and outpatient care, respectively, from private health facilities, compared with those treated at public facilities. Notably, the financial burden was more severe for households residing in rural areas, those in lower economic quintiles, those belonging to marginalised social groups, and those using private health facilities.ConclusionThe burden of DM and its associated financial ramifications necessitate policy measures, such as prioritising health promotion and disease prevention strategies, strengthening public healthcare facilities, improved regulation of private healthcare providers, and bringing outpatient services under the purview of health insurance, to manage the diabetes epidemic and mitigate its financial impact.

EFFECT OF HEALTH EXPENDITURE ON THE STANDARD OF LIVING IN NIGERIA

Health care expenditure is an essential component for a higher standard of living since a healthy population translates to an excellent labor force, which makes an economy function effectively. However, this is extremely difficult to achieve, especially in developing countries. Therefore, this paper examined the effect of health expenditure on the standard of living in Nigeria. Specifically, it investigated the relationship between health capital expenditure, health recurrent expenditure and out-of-pocket health expenditure, on standard of living using time series data from 1990 to 2021 and the Dynamic Ordinary Least Squares (DOLS) method was adopted in carrying out the empirical analysis. The paper found that health capital expenditure and out of pocket health expenditure had a positive but insignificant relationship with standard of living while health recurrent expenditure had a positive significant relationship with standard of living. The paper recommends that the Nigerian government should address the insignificant relationship between health capital expenditure, and standard of living by building new hospitals and clinics, buying medical equipment, and training healthcare workers. Also, government needs to prioritize allocation of adequate funds to sustain and improve healthcare services and implement policies such as tax incentives and subsidies to encourage citizens to invest more in their healthcare which will reduce out-of-pocket expenses for essential healthcare service.

Out of pocket and catastrophic health spending in Mexico in the face of the COVID-19 pandemic

INTRODUCTION: The measurement of the financial coverage of a health system uses key indicators such as household out-of-pocket spending as well as catastrophic health spending. Said indicators depend on the financing structure of the health system as well as quality criteria and efficiency of the system in patient care. In the case of Mexico, in recent years there have been important changes in the structure of the health system in addition to suffering from the COVID-19 pandemic events that have significantly impacted the access to health of patients. Therefore, it is relevant to quantify the impact of these events on out-of-pocket spending and catastrophic spending on health in Mexico and have a robust diagnosis of the financial coverage of the system public health in Mexico.OBJECTIVES: The main objective of this study is to quantify out-of-pocket spending and catastrophic spending on health in Mexican households for the year 2020. Comparing these estimates with previous years given the recent changes in the Mexican health system as well as the effect of the COVID-19 pandemic in these indicators.METHODS: Based on the information available in the 2020 National Household Income and Expenditure Survey (ENIGH), out-of-pocket and catastrophic spending on health were estimated following the methodology proposed by the World Health Organization. A quantile regression was estimated to assess the effect of income distribution on out-of-pocket spending.RESULTS: In Mexico in 2020, 67.7% (24.2 million) of households had an out-of-pocket health expenditure (OOHE) and 6% of these households had a catastrophic health expenditure (CHE), with respect to all households this percentage represents 4.04%. According to the classification stipulated by the World Health Organization, healthcare has six expenditure components: orthopedics, medicines, maternity, hospital, alternative medicines, and ambulatory expenses. The three main expenditure was attributable to drugs (39.9%), ambulatory (25.3%), and hospital costs (20.3%).CONCLUSION: The effect of recent modifications to the public health system in Mexico in addition to the COVID-19 pandemic has been reflected in an increase in the percentage of households with out-of-pocket spending in Mexico, as well as the percentage of households with catastrophic spending in health. The main expense item is made in medicines, ambulatory care follow-up and hospitalization. It is a priority to establish efficient financial protection schemes that allow reversing this situation in terms of efficient access to health in Mexico.

The total factor productivity growth of health systems in African least developed countries

Background: Given the several health policy reforms in various countries in the Sustainable Development Goals (SDGs) era, the need for efficient and productive health systems has become of great concern. This is even more urgent in African Least Developed Countries (African LDCs) that need to improve the health of their populations. Thus, the objective of this study is to assess the total factor productivity growth of health systems of 29 African Least Developed Countries for the 2008-2018 period. Methods: The study uses data from the World Bank and the World Health Organization. Using the Data Envelopment Analysis (DEA) Malmquist index, the inputs that were used in the study included domestic general government health expenditure, domestic private health expenditure, external health expenditure and out of pocket health expenditure while the outputs were life expectancy at birth, maternal mortality rate, under five mortality rate, and infant mortality rate. Results: Sixteen African LDCs registered progress in the total factor productivity growth of their health systems while thirteen registered a decline the total factor productivity growth of their health systems. Overall, there was 0.3% average increase in total factor productivity growth of health systems in African LDCs. This was attributed to a 1.2% increase in technical efficiency change and a 0.9% average decrease in the technical change of health systems in African LDCs. Conclusions: African LDCs with less productive health systems are advised to bench mark the policies of African LDCs with productive health systems.

Socioeconomic and geographic variation in coverage of health insurance across India.

In India, regular monitoring of health insurance at district levels (the most essential administrative unit) is important for its effective uptake to contain the high out of pocket health expenditures. Given that the last individual data on health insurance coverage at district levels in India was in 2016, we update the evidence using the latest round of the National Family Health Survey conducted in 2019-2021. We use the unit records of households from the latest round (2021) of the nationally representative National Family Health Survey to calculate the weighted percentage (and 95% CI) of households with at least one member covered by any form of health insurance and its types across socio-economic characteristics and geographies of India. Further, we used a random intercept logistic regression to measure the variation in coverage across communities, district and state. Such household level study of coverage is helpful as it represents awareness and outreach for at least one member, which can percolate easily to the entire household with further interventions. We found that only 2/5th of households in India had insurance coverage for at least one of its members, with vast geographic variation emphasizing need for aggressive expansion. About 15.5% were covered by national schemes, 47.1% by state health scheme, 13.2% by employer provided health insurance, 3.3% had purchased health insurance privately and 25.6% were covered by other health insurance schemes (not covered above). About 30.5% of the total variation in coverage was attributable to state, 2.7% to districts and 9.5% to clusters. Household size, gender, marital status and education of household head show weak gradient for coverage under "any" insurance. Despite substantial increase in population eligible for state sponsored health insurance and rise in private health insurance companies, nearly 60% of families do not have a single person covered under any health insurance scheme. Further, the existing coverage is fragmented, with significant rural/urban and geographic variation within districts. It is essential to consider these disparities and adopt rigorous place-based interventions for improving health insurance coverage.

A comprehensive examination ofthe economic impact ofout-of-pocket health expenditures inIndia.

More than 50% of health expenditure is financed through out-of-pocket payments in India, imposing a colossal financial burden on households. Amidst the rising incidence of non-communicable diseases, injuries, and an unfinished agenda of infectious diseases, this study examines comprehensively the economic impact of out-of-pocket health expenditure (OOPE) across 17 disease categories in India. Data from the latest round of the National Sample Survey (2017-18), titled 'Household Social Consumption: Health', were employed. Outcomes, namely, catastrophic health expenditure (CHE), poverty headcount ratio, distressed financing, foregone care, and loss of household earnings, were estimated. Results showed that 49% of households that sought hospitalization and/or outpatient care experienced CHE and 15% of households fell below the poverty line due to OOPE. Notably, outpatient care was more burdensome (CHE: 47.8% and impoverishment: 15.0%) than hospitalization (CHE: 43.1% and impoverishment: 10.7%). Nearly 16% of households used distressed sources to finance hospitalization-related OOPE. Cancer, genitourinary disorders, psychiatric and neurological disorders, obstetric conditions, and injuries imposed a substantial economic burden on households. OOPE and associated financial burden were higher among households where members sought care in private healthcare facilities compared with those treated in public facilities across most disease categories. The high burden of OOPE necessitates the need to increase health insurance uptake and consider outpatient services under the purview of health insurance. Concerted efforts to strengthen the public health sector, improved regulation of private healthcare providers, and prioritizing health promotion and disease prevention strategies are crucial to augment financial risk protection.

HPR27 Socioeconomic Inequalities in out of Pocket and Catastrophic Health Expenditures Among the Households in Pakistan

The analysis of health inequality is essential for providing the evidence on who is being left behind and informs equity-oriented policies, programs, and practices. Therefore, socioeconomic inequalities in Out-of-Pocket Health Expenditures (OOPHEs), Catastrophic Health Expenditures (CHEs) and contribution of different factors in inequalities are assessed in this study.

Out-of-pocket health expenditure and associated factors among patients with hypertension in Debre-Tabor Comphrensive Specialized Hospital, South Gondar zone, Northwest Ethiopia, 2020.

Hypertension is a non-communicable chronic disease that has a wide financial effect at the individual and household levels especially in developing countries due to its complexity and chronicity. Nevertheless, there are limited studies in Ethiopia. Therefore the aim of this study was to assess out-of pocket health expenditure and associated factors among adult patients with hypertension in Debre-Tabor Comphrensive Specialized Hospital. A facility-based cross-sectional study was conducted in total of 357 adult hypertensive patients from March to April 2020 using a systematic random sampling technique. Descriptive stastics were used to estimate the magnitude of out-of-pocket health expenditure, while after checking the assumptions linear regression model was fitted for identifying the factors associated with the outcome variable at a significance level of value of p < 0.05 and 95% confidence interval. A total of 346 study participants interviewed with a response rate of 96.92%. Annual mean out of pocket health expenditure of the participant was $113.40 ± $10.18 with 95% CI = (102.63, 124.16) per patient. The direct medical mean out of pocket health expenditure of the participant was $68.86 per patient per year and the median of non-medical components of the out of pocket health expenditure of the participant was $3.53. Sex, wealth status, distance from hospital, comorbidity, health insurance and number of visit are factors significantly associated to out-of-pocket expenditure. This study revealed that out of pocket health expenditure among adult patients with hypertension was found high compared to the national per capita health expenditure. Sex, wealth index, distance away from hospital, frequency of visit, comorbidities, and health insurance coverage were factors significantly associated with high out-of-pocket health expenditure. Ministry of health together with regional health bureaus and other concerned stakeholders work on strengthening early detection and prevention strategies of chronic comorbidities of hypertensive patients,promote health insurance coverage and better to subsidize medication costs for the poors.

The impact of health reform on poverty estimates in Iran: Implications for monitoring the first goal of Sustainable Development Goals.

Iran launched a series of health reforms called Health Transformation Plan (HTP) in order to improve financial protection and access to health care in 2014. This study aimed to investigate the extent of impoverishment due to out of pocket (OOP) payments during 2011-2016 and to assess the implications of health expenditures to overall national poverty rate before and after the HTP implementation, with a focus on monitoring the first Sustainable Development Goals (SDGs). The study relied on data from a nationally representative household income and expenditure survey. Two measures of poverty were estimated in this study: the prevalence (poverty headcount) and the intensity of poverty before and after OOP health payments (poverty gap). Proportion of the population fell into poverty due to OOP spending for health care from total poor population calculated for 2years before and after the HTP implementation using three poverty lines suggested by the World Bank for global poverty comparison ($1.90, $3.2 and $5.5 per day in 2011 purchasing power parity (PPP) $). Our results indicate that the incidence of impoverishing health expenditures has remainedrelatively low during 2011-2016. At the 2011 PPP $5.5 daily poverty line, the average incidence rate at the national level was 1.36% during the period. The percentage of population impoverished due to OOP health expenditures increased after HTP implementation, irrespective of the poverty line used. However, the proportion of individuals that pushed further into poverty decreased after HTP implementation. It was estimated that around 12.5% of total poor population fell below poverty line due to paying OOP payments in 2016. Although health care costs are not major causes of impoverishment in Iran, the relative impact of OOP spending for health is not negligible. To attain SDG 1, pro-poor interventions that aim to reduce the burden of OOP payments should be advocated and implemented with an inter-sectoral approach.

Assessing Lesotho's Financial Burden of Household Payments and Access to Healthcare, 2022

Background: Health care financing is primarily about paying for health care. It motivates health care providers to increase the supply of health care goods and services to ensure that all individuals have access to effective public health and personal health care services and goods. The ultimate intent is to improve the health of individuals and the general population in line with the principles of Universal Health Coverage. When patients’ OOP reaches a certain level, some people forgo health care due to the price, and others who access services face financial difficulties. Objective: The specific objective of the present study is to determine access to essential health services by households and the financial burden posed as a result of their intent to utilize theses services. Methods: The paper uses data from the national household income and expenditure survey (2018/19). It provides an insight into the health care expenditure and evidence on whose health service needs the health system meets and the household financial burden by health payments. Results: Out-of-pocket health expenditure (OOP) as a share of total health expenditure on average stands at 11.1% in 2018/19. About 3.3 % of households or 4,295 households that corresponds to about 17,180 individuals spend 52.1 % of their net of food income (non-subsistence income) on healthcare – a catastrophic level of household spending. Conclusion: Despite the low rate of out-of-pocket investing by families, and moderately expanding domestic investing in health care, Lesotho health care system requires a combination of policies to ensure fair financing of health care.

Climate change and the burden of healthcare financing in African households.

Climate change is a mounting pressure on private health financing in Africa - directly because of increased disease prevalence and indirectly because of its negative impact on household income. The sources and consequences of the pressure constitute an important area of policy discourse, especially as it relates to issues of poverty and inequality. Relying on a panel dataset involving 49 African countries and the period 2000-2019, as well as a random effect regression analysis, this report shows that climate change has a positive and significant impact on the level of out-of-pocket health expenditure (OPHE) in Africa, and an increase in the level of greenhouse (CO2) emissions by 1% could bring about a 0.423% increase in the level of OPHE. Indirectly, the results show that, compared with the regional average, countries that have higher government health expenditure levels, above 1.7% regional average, and face higher climate change risk may likely record an increase in OPHE. Alternatively, countries with higher per capita income (above the regional annual average of $2300.00) are likely to record a drop in OPHE. Countries with lower climate change risk and a lower than the regional average age dependency (above the regional average of 80.4%) are also likely to record a drop in OPHE. It follows that there is a need for policy alignment, especially with regard to how climate change influences primary health care funding models in Africa.Contribution: The results of this research offer policymakers in-depth knowledge of how climate change erodes healthcare financing capacity of government and shifts the burden to households. This raises concerns on the quality of accessible healthcare and the link with poverty and inequality.

Decomposition of socioeconomic inequalities in catastrophic out-of-pocket expenditure for healthcare in Canada

Despite a publicly financed health system for physician and hospital services, out-of-pocket health expenditure (OHE) accounts for a significant proportion of healthcare financing in Canada. We pooled annual Surveys of Household Spending conducted from 2010 to 2017 (n=34,105) to estimate the catastrophic out-of-pocket expenditure (COHE) burden using two definitions: the budget share (OHE exceeding 10% of a household's total consumption) and capacity-to-pay (OHE exceeding 40% of a household's total consumption minus basic subsistence needs). The Wagstaff index (WI) and the Erreygers Index (EI) were used to quantify and decompose socioeconomic inequalities in COHE. Results demonstrate that approximately 6% and 10% of the households faced COHE in Canada, depending on whether we used the budget share or capacity-to-pay approach to measure COHE. The COHE was found to be concentrated among low socioeconomic status (SES) households. Decomposition results indicate that besides SES, household characteristics (e.g., households headed by females and the presence of senior(s) in the households) were the most important factors contributing to the concentration of COHE among the poorer households. The lower utilization of healthcare services among the poor resulted in reduced COHE among these households. A higher burden of COHE is a major concern in Canada. Policies to enhance risk protection among specific populations such as the seniors are required to improve equity in healthcare financing in Canada.

Effect of Out-of-Pocket Health Expenditure on Household Welfare: Evidence from Uganda National Household Survey: 2016–2017

Out-of-Pocket health expenditures (OOP) in Uganda are increasingly rising due to the limited share of the national budget allocation to the health sector. Using Uganda National Household Survey data (UNHS) 2016/17, this study investigates the effect of OOP health expenditures on household welfare in Uganda. Due to the presence of endogeneity, the study employs a robust sampling instrumental variable technique to control for simultaneous causality between household welfare and the OOP health expenditure variable in the model. The findings show that a unit increase in OOP health expenditure reduces household food consumption expenditure by 9% and the household asset base by 2%, respectively. This study thus recommends the effective implementation of the Uganda National Health Insurance Scheme (NHIS), increased investment in preventive care services, and promotion of activities aimed at empowering health beneficiaries in Uganda to improve their household welfare.

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.

Financial and Geographic Barriers to Health Care Access in Kenya: The Quest towards Universal Health Coverage

Abstract Background: Access to health care services without being plunged into financial hardship is a life blood of the Universal Health Coverage. Kenya's health sector is heavily dependent on out of pocket health expenditure. This model of health financing is inequitable and leads to underutilization of the much needed health care services. Majority of Kenyans travel for longer distances to access health care services. The geographic access barrier is linked to delayed care, missed appointments, delayed medication and undue loss of life. This study examines the correlates of financial and geographic health care access barriers in the UHC implementing Counties in Kenya. Methodology: The study used a cross-sectional data collected from 249 respondents using exit interviews at the health facilities drawn from the Kenya Master Health Facility List (KMHL). A multivariate log it regression model was used to analyze the predictors of probability of failure to access health care services owing to prohibitive health care and transport costs. Results: High out-of-pocket monthly expenditure on medicine; wider proximity, higher transportation cost and a longer traveling time to a health facility increases the probability of not seeking medical treatment owing to prohibitive health care and transportation costs. These factors thus, acts as key barriers to health care access. Conclusion: Financial and geographic access barriers negatively impact on health care access. To hasten the realization of the Universal Health Coverage, prepayment models such as use of taxes and insurance should be pursued.

DETERMINANTS OF SATISFACTORY PUBLIC HEALTH CARE SERVICES IN RURAL BANGLADESH

Quality of public health care services is a necessary step in the process of improving health care services. It plays an important role for preventing the overuse, underuse and misuse of health care services and ensuring patient safety. Thus, the study aims to investigate the determinants of satisfactory public health care services in rural Bangladesh. Data are collected from 150 respondents of six upazilas in Khulna and Bagerhat districts who spend at least one day in the upazila health complex for receiving treatment. Quantitative analysis is performed through factor analysis and ordered logistic regression. This study demonstrates that almost three-fourth of the respondents visit hospitals at least 3-4 times in a year, also exerts that almost 70% of the respondents earn/month on an average between BDT 5,001-10,000, whereas nearly 40% of the respondents are compelled to spend almost about BDT 2,001-4,000 for availing medical facilities. Ordered logistic regression demonstrates that, educational status of the respondents, financial &amp; physical access to care and health personnel conduct have positively associated with the respondent level of satisfaction on health care services rendered by public health complexes. Therefore, it is vital to improve the related facilities to increase the satisfaction level. Thus, authors suggest improving the overall structure of rural health complex, ensure availability of essential drugs, increase the financial support to government or initiate community-based health insurance to reduce the out of pocket health expenditure to increase the patient satisfaction level.

The impacts of long-term care insurance on health care utilization and expenditure: evidence from China.

Long-term care insurance (LTCI) is one of the important institutional responses to the growing care needs of the ageing population. Although previous studies have evaluated the impacts of LTCI on health care utilization and expenditure in developed countries, whether such impacts exist in developing countries is unknown. The Chinese government has initiated policy experimentation on LTCI to cope with the growing and unmet need for aged care. Employing a quasi-experiment design, this study aims to examine the policy treatment effect of LTCI on health care utilization and out-of-pocket health expenditure (OOP) in China. The Propensity Score Matching with difference-in-difference approach was used to analyse the data obtained from four waves of China Health and Retirement Longitudinal Study. Our findings indicate that, in the aspect of health care utilization, the introduction of LTCI significantly reduced the number of outpatient visits by 0.322 times (P < 0.05), the number of hospitalizations by 0.158 times (P < 0.01) and the length of inpatient stay during last year by 1.441 days (P < 0.01). In the aspect of OOP, we found that LTCI significantly reduced the inpatient OOP during last year by 533.47 yuan (P < 0.01), but it did not exhibit an impact on the outpatient OOP during last year. LTCI also had a significantly negative impact on the total OOP by 512.56 yuan. These results are stable in the robustness tests. Considering the evident policy treatment effect of LTCI on health care utilization and OOP, the expansion of LTCI could help reduce the needs for health care services and contain the increases in OOP in China.

Impoverishing effects of out-of-pocket healthcare expenditures in India.

Out of the 1.324 billion people in India (2016), around 12.4% of the population is below the poverty line. In India, out-of-pocket health expenditure (OOP) expenses account for about 62.6% of total health expenditure - one of the highest in the world. High OOP health expenditures push many households into poverty. This study aims to identify the impoverishing effects of OOP health expenditures in India. Data from the recent national survey by the National Sample Survey Organization - Social Consumption in Health 2014 are used to investigate the effect of OOP health expenditure on household poverty. Poverty headcounts and poverty gaps were estimated at the household level before and after making OOP healthcare payments. A logistic regression model is for predicting the effect of various factors on the incidence of impoverishment due to OOP health expenditures. There were 65,932 households in the sample. The total poverty headcount in the population before making OOP payments was 16.44% and it increased to 19.05% after making OOP payments. This 2.61% increase in the poverty headcount corresponds to 6.47 million households. Logistic regression results showed that medium and large households, household members with increased duration of stay in the hospital, utilization of private health facility and the presence of chronic illness increased odds of impoverishment due to OOP health expenditures. Health insurance programmes must be expanded to cover outpatient and preventive health services, include people above the poverty line, cover the whole household irrespective of the number of members living in the household and the coverage threshold limits must be increased. Urban poor must be enrolled in health insurance programmes without any delay.