Financial hardship associated with catastrophic out-of-pocket spending tied to primary care services in low- and lower-middle-income countries: findings from a modeling study.

BACKGROUND: Financial risk protection (FRP) is a key component of universal health coverage (UHC): all individuals must be able to obtain the health services they need without experiencing financial hardship. In many low-income and lower-middle-income countries, however, the health system fails to provide sufficient protection against high out-of-pocket (OOP) spending on health services. In 2018, OOP health spending comprised approximately 40% of current health expenditures in low-income and lower-middle-income countries. METHODS: We model the household risk of catastrophic health expenditures (CHE), conditional on having a given disease or condition-defined as OOP health spending that exceeds a threshold percentage (10, 25, or 40%) of annual income-for 29 health services across 13 disease categories (e.g., diarrheal diseases, cardiovascular diseases) in 34 low-income and lower-middle-income countries. Health services were included in the analysis if delivered at the primary care level and part of the Disease Control Priorities, 3rd edition "highest priority package." Data were compiled from several publicly available sources, including national health accounts, household surveys, and the published literature. A risk of CHE, conditional on having disease, was modeled as depending on usage, captured through utilization indicators; affordability, captured via the level of public financing and OOP health service unit costs; and income. RESULTS: Across all countries, diseases, and health services, the risk of CHE (conditional on having a disease) would be concentrated among poorer quintiles (6.8% risk in quintile 1 vs. 1.3% in quintile 5 using a 10% CHE threshold). The risk of CHE would be higher for a few disease areas, including cardiovascular disease and mental/behavioral disorders (7.8% and 9.8% using a 10% CHE threshold), while lower risks of CHE were observed for lower cost services. CONCLUSIONS: Insufficient FRP stands as a major barrier to achieving UHC, and risk of CHE is a major problem for health systems in low-income and lower-middle-income countries. Beyond its threat to the financial stability of households, CHE may also lead to worse health outcomes, especially among the poorest for whom both ill health and financial risk are most severe. Modeling the risk of CHE associated with specific disease areas and services can help policymakers set progressive health sector priorities. Decision-makers could explicitly include FRP as a criterion for consideration when assessing the health interventions for inclusion in national essential benefit packages.

The role of physical activity on healthcare utilization in China.

BACKGROUND: Evidence on the role of physical activity (PA) on healthcare utilization and expenditure is limited in China. We aimed to examine the association between the total physical activity (TPA) per week, healthcare service use and expenditure. METHODS: We extracted the data from China Health and Retirement Longitudinal Study (CHARLS) 2011, 2013, and 2015. Participants more than 50 years old who completed the follow-up for the three waves were enrolled. We converted the volume of vigorous physical activity (VPA) into an equivalent volume of moderate physical activity (MPA) and calculated the TPA per week for each participant. 12,927 of the 17,708 participants in CHARLS were included in our analysis. More than one-third of participants over 50 years old never participate in any moderate or intensity activity, and the median of self-reported moderate or intensity PA was about 525 (IQR 0-1680) MET-minutes per week in 2015. RESULTS: Compared to inactive subjects, the highest level of TPA was significantly related to the decreased risk number of inpatient visits (IRR: 0.58; 95% CI:0.50-0.67, p < 0.001), inpatient hospital days (IRR: 0.60; 95% CI: 0.42-0.84, p < 0.01), healthcare expenditure (IRR: 0.71; 95% CI: 0.65-0.79, p < 0.001) and catastrophic health expenditures (OR: 0.57; 95% CI: 0.45-0.72, p < 0.001) after adjusting for covariates. CONCLUSIONS: Engaging in moderate-to-vigorous PA may drive a potential decrease in healthcare utilization, healthcare expenditure and household financial risk with a dose-response relationship in China, and some possible policy implications in public health may be considered to promote exercise in the middle-aged and elderly to reduce the medical burden on individuals and healthcare systems.

Economic burden of non-communicable diseases on households in Nigeria: evidence from the Nigeria living standard survey 2018-19.

BACKGROUND: The importance of non-communicable diseases (NCDs) in Nigeria is reflected in their growing burden that is fast overtaking that of infectious diseases. As most NCD care is paid for through out-of-pocket (OOP) expenses, and NCDs tend to cause substantial income losses through chronic disabilities, the rising NCD-related health burden may also be economically detrimental. Given the lack of updated national-level evidence on the economic burden of NCDs in Nigeria, this study aims to produce new evidence on the extent of financial hardship experienced by households with NCDs in Nigeria due to OOP expenditure and productivity loss. METHODS: This study analysed cross-sectional data from the most recent round (2018-19) of the Nigeria Living Standard Survey (NLSS). Household-level health and consumption data were used to estimate catastrophic health expenditure (CHE) and impoverishing effects due to OOP health spending, using a more equitable method recently developed by the World Health Organization European region in 2018. The productivity loss by individuals with NCDs was also estimated from income and work-time loss data, applying the input-based human capital approach. RESULTS: On average, a household with NCDs spent ₦ 122,313.60 or $ 398.52 per year on NCD care, representing 24% of household food expenditure. The study found that OOP on cancer treatment, mental problems, and renal diseases significantly contribute to the cost of NCD care. The OOP expenditure led to catastrophic and impoverishing outcomes for households. The estimations showed that about 30% of households with NCDs experienced CHE in 2018, using the WHO Europe method at the 40% threshold. The study also found that the cost of NCD medications was a significant driver of CHE among NCD-affected households. The results showed heterogeneity in CHE and impoverishment across states and geographical regions in Nigeria, with a higher concentration in rural and North East geopolitical locations. The study also found that 20% of NCD-affected households were impoverished or further impoverished by OOP payment, and another 10% were on the verge of impoverishment. The results showed a negligible rate of unmet needs among households with NCDs. CONCLUSIONS: The study highlights the significant effect of NCDs on Nigerian households and the need for effective policy interventions to address this challenge, particularly among the poor and vulnerable.

Policy analysis of the protection of Iranian households against catastrophic health expenditures: a qualitative analysis.

BACKGROUND: Despite the adoption of various policies and strategies in recent decades, the Iranian health system has not succeeded in protecting households against catastrophic health expenditures (CHE) and impoverishment. Accordingly, this qualitative study aimed to critically analyze current policies for reducing CHE. METHODS: This qualitative study was conducted as a retrospective policy analysis based on a document review and semi-structured interviews with key informants between July to October 2022. Two theoretical frameworks were used, including the Analysis of Determinants of Policy Impact (ADEPT) model and Walt and Gilson's "Policy Triangle framework." The country's related documents were searched through databases. In total, 35 participants were interviewed. Interviews and documents were analyzed using directed content analysis in MAXQDA v12 software. Interobserver reliability, peer check, and member check were done to confirm the trustworthiness of the data. RESULTS: Twelve main themes and 42 sub-themes emerged from the data. The findings revealed that policy accessibility, policy background, and a clear statement of goals influenced the policy process. However, resources, monitoring and evaluation, opportunities, and obligations negatively affected the implementation process. In addition, a policy analysis based on the policy triangle framework demonstrated that the main factors affecting the policy on reducing CHE in Iran were "conflicts of interest," "contextual factors," "monitoring and evaluation," and "intersectoral relationship" factors. CONCLUSION: The present study reflected the multifaceted nature of the barriers to reducing CHE in Iran. The implementation of the policy on reducing CHE requires the political will to improve intersectoral collaboration, strengthen the stewardship role of the Ministry of Health, design monitoring and evaluation mechanisms, and prevent personal and organizational conflicts of interest.

Catastrophic Health Expenditures Associated With Open Reduction Internal Fixation of Distal Radius Fractures.

PURPOSE: Distal radius fracture is one of the most common upper-extremity traumatic injuries. These injuries result in time off work and potential financial consequences for patients. Therefore, we aimed to understand the risk of catastrophic health expenditures (CHEs) after open reduction and internal fixation of distal radius fractures and examine the association between patient characteristics and the risk of CHE. METHODS: We used data from patients undergoing open reduction and internal fixation of a distal radius fracture from a large, urban, level I trauma center (2018-2020). The risk of CHE was defined as out-of-pocket expenses of ≥40% of postsubsistence income. We used multivariable logistic regression to assess the impact of age, sex, race, and insurance status on the risk of CHE. RESULTS: In our cohort of 394 patients, 121 patients (30.7%) were at risk of CHE after their distal radius fracture. After controlling for patient characteristics and insurance status, patients aged 26-34 years were 5.7 times more likely to be at risk of CHE (odds ratio, 5.73; 95% CI, 1.81-18.13) than patients aged ≥65 years. Patients who were uninsured were six times more likely to be at risk of CHE than patients with employer-sponsored health insurance (odds ratio, 6.02; 95% CI, 1.94-18.66). Lastly, non-White patients were at a higher risk of CHE (odds ratio, 3.63; 95% CI, 1.70-7.79) than White patients. CONCLUSIONS: Distal radius fractures are unexpected and place patients at risk of financial harm, with one in three patients at risk of CHEs. Policies aimed at minimizing cost-sharing after traumatic injury may help alleviate the financial consequences of health care delivery and reduce disparities. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decision Analysis II.

Informal employment and catastrophic health expenditures: Evidence from Pakistan.

Workers in informal employment suffered significant out-of-pocket healthcare expenditures (OOPHEs) due to their low earnings and a lack of a social safety net or health insurance. There is little or no evidence of impoverishment caused by OOPHEs in the context of labor market categorization. Therefore, this study examines the economic burden of OOPHEs and its associated consequences on households, whose members are in informal employment. This study estimates the incidence of catastrophic health expenditures (CHEs) and impoverishment across the households in formal and informal employment and their key determinants in Pakistan by employing the data from the two rounds of the Household Integrated Economic Survey (2015-16, 2018-19). For measuring CHEs and impoverishment, the budget share and capacity-to-pay approaches are applied. Various thresholds are used to demonstrate the sensitivity of catastrophic measures. We found a higher incidence of catastrophic healthcare payments among the informal workers, that is, 4.03% and 7.11% for 2015-16 and 2018-19, respectively, at a 10% threshold, while at a 40% threshold, the incidence of CHEs is found to be 0.40% and 2.34% for 2015-16 and 2018-19, respectively. These OOPHEs caused 1.53% and 3.66% of households who are in informal employment to become impoverished, compared with their formal counterparts. The study demonstrates that the probability of incurring CHEs and becoming impoverished is high among informal workers, compared with their formal counterparts. This result has clear policy implications, in which to protect the informal workers, it is necessary to expand the insurance coverage, particularly during the COVID-19 response and recovery efforts.

Estimation of economic burden throughout course of cervical squamous intraepithelial lesion and cervical cancer in China: A nationwide multicenter cross-sectional study.

Objective: Cervical squamous intraepithelial lesion (SIL) and cervical cancer are major threats to females' health and life in China, and we aimed to estimate the economic burden associated with their diagnosis and treatment. Methods: A nationwide multicenter, cross-sectional, hospital-based survey was conducted in 26 qualified hospitals across seven administrative regions of China. We investigated females who had been pathologically diagnosed with SIL and cervical cancer, and included five disease courses ("diagnosis", "initial treatment", "chemoradiotherapy", "follow-up" and "recurrence/progression/metastasis") to estimate the total costs. The median and interquartile range (IQR) of total costs (including direct medical, direct non-medical, and indirect costs), reimbursement rate by medical insurance, and catastrophic health expenditures in every clinical stage were calculated. Results: A total of 3,471 patients in different clinical stages were analyzed, including low-grade SIL (LSIL) (n=549), high-grade SIL (HSIL) (n=803), cervical cancer stage IA (n=226), IB (n=610), IIA (n=487), IIB (n=282), III (n=452) and IV (n=62). In urban areas, the estimated total costs of LSIL and HSIL were [Formula: see text]1,637.7 (IQR: [Formula: see text]956.4-[Formula: see text]2,669.2) and [Formula: see text]2,467.1 (IQR: [Formula: see text]1,579.1-[Formula: see text]3,762.3), while in rural areas the costs were [Formula: see text]459.0 (IQR: [Formula: see text]167.7-[Formula: see text]1,330.3) and [Formula: see text]1,230.5 (IQR: [Formula: see text]560.6-[Formula: see text]2,104.5), respectively. For patients with cervical cancer stage IA, IB, IIA, IIB, and III-IV, the total costs were [Formula: see text]15,034.9 (IQR: [Formula: see text]11,083.4-[Formula: see text]21,632.4), [Formula: see text]19,438.6 (IQR: [Formula: see text]14,060.0-[Formula: see text]26,505.9), [Formula: see text]22,968.8 (IQR: [Formula: see text]16,068.8-[Formula: see text]34,615.9), [Formula: see text]26,936.0 (IQR: [Formula: see text]18,176.6-[Formula: see text]41,386.0) and [Formula: see text]27,332.6 (IQR: [Formula: see text]17,538.7-[Formula: see text]44,897.0), respectively. Medical insurance covered 43%-55% of direct medical costs for cervical cancer patients, while the coverage for SIL patients was 19%-43%. For most cervical cancer patients, the expense was catastrophic, and the extent of catastrophic health expenditure was about twice large for rural patients than that for urban patients in each stage. Conclusions: The economic burden of SIL and cervical cancer in China is substantial, with a significant proportion of the costs being avoidable for patients with LSIL. Even for those with medical insurance, catastrophic health expenditures are also a major concern for patients with cervical cancer, particularly for those living in rural areas.

Improvements and Gaps in Financial Risk Protection Among Veterans Following the Affordable Care Act.

BACKGROUND: Despite public perception, most of the nearly 20 million US veterans have health coverage outside the Veterans Health Administration (VHA), and VHA eligibility and utilization vary across veterans. Out-of-pocket healthcare spending thus remains a potential source of financial hardship for veterans. The Affordable Care Act (ACA) aimed to expand health insurance access, but its effect on veterans' financial risk protection has not been explored. OBJECTIVE: To evaluate whether ACA implementation was associated with changes in veterans' risk of catastrophic health expenditures, and to characterize drivers of catastrophic health spending among veterans post-ACA. DESIGN: Using multivariable linear probability regression, we examined changes in likelihood of catastrophic health spending after ACA implementation, stratifying by age (18-64 vs 65+), household income tercile, and payer (VHA vs non-VHA). Among veterans with catastrophic spending post-ACA, we evaluated sources of out-of-pocket spending. PARTICIPANTS: Nationally representative sample of 13,030 veterans aged 18+ from the 2010 to 2017 Medical Expenditure Panel Survey. INTERVENTION: ACA implementation, January 1, 2014. MAIN MEASURES: Likelihood of catastrophic health expenditures, defined as household out-of-pocket spending exceeding 10% of household income. KEY RESULTS: Among veterans aged 18-64, ACA implementation was associated with a 26% decrease in likelihood of catastrophic health expenditures (absolute change, -1.4 percentage points [pp]; 95% CI, -2.6 to -0.2; p=0.03), which fell from 5.4% pre-ACA to 3.9% post-ACA. This was driven by a 38% decrease in catastrophic spending among veterans with non-VHA coverage (absolute change, -1.8pp; 95% CI, -3.0 to -0.6; p=0.003). In contrast, catastrophic expenditure rates among veterans aged 65+ remained high, at 13.0% pre- and 12.5% post-ACA. Major drivers of veterans' spending post-ACA include dental care, prescription drugs, and home care. CONCLUSIONS: ACA implementation was associated with reduced household catastrophic health expenditures for younger but not older veterans. These findings highlight gaps in veterans' financial protection and areas amenable to policy intervention.

Catastrophic health expenditures, insurance churn, and nonemployment among gynecologic cancer patients in the United States.

BACKGROUND: In recent years, there has been growing recognition of the financial burden of severe illness, including associations with higher rates of nonemployment, uninsurance, and catastrophic out-of-pocket health spending. Patients with gynecologic cancer often require expensive and prolonged treatments, potentially disrupting employment and insurance coverage access, and putting patients and their families at risk for catastrophic health expenditures. OBJECTIVE: This study aimed to describe the prevalence of insurance churn, nonemployment, and catastrophic health expenditures among nonelderly patients with gynecologic cancer in the United States, to compare within subgroups and to other populations and assess for changes associated with the Affordable Care Act. STUDY DESIGN: We identified respondents aged 18 to 64 years from the Medical Expenditure Panel Survey, 2006 to 2017, who reported care related to gynecologic cancer in a given year, and a propensity-matched cohort of patients without cancer and patients with cancers of other sites, as comparison groups. We applied survey weights to extrapolate to the US population, and we described patterns of insurance churn (any uninsurance or insurance loss or change), catastrophic health expenditures (>10% annual family income), and nonemployment. Characteristics and outcomes between groups were compared with the adjusted Wald test. RESULTS: We identified 683 respondents reporting care related to a gynecologic cancer diagnosis from 2006 to 2017, representing an estimated annual population of 532,400 patients (95% confidence interval, 462,000-502,700). More than 64% of patients reported at least 1 of 3 primary negative outcomes of any uninsurance, part-year nonemployment, and catastrophic health expenditures, with 22.4% reporting at least 2 of 3 outcomes. Catastrophic health spending was uncommon without nonemployment or uninsurance reported during that year (1.2% of the population). Compared with patients with other cancers, patients with gynecologic cancer were younger and more likely with low education and low family income (≤250% federal poverty level). They reported higher annual risks of insurance loss (8.8% vs 4.8%; P=.03), any uninsurance (22.6% vs 14.0%; P=.002), and part-year nonemployment (55.3% vs 44.6%; P=.005) but similar risks of catastrophic spending (12.6% vs 12.2%; P=.84). Patients with gynecologic cancer from low-income families faced a higher risk of catastrophic expenditures than those of higher icomes (24.4% vs 2.9%; P<.001). Among the patients from low-income families, Medicaid coverage was associated with a lower risk of catastrophic spending than private insurance. After the Affordable Care Act implementation, we observed reductions in the risk of uninsurance, but there was no significant change in the risk of catastrophic spending among patients with gynecologic cancer. CONCLUSION: Patients with gynecologic cancer faced high risks of uninsurance, nonemployment, and catastrophic health expenditures, particularly among patients from low-income families. Catastrophic spending was uncommon in the absence of either nonemployment or uninsurance in a given year.

Short and longer-term impacts of health insurance on catastrophic health expenditures in Kwara State, Nigeria.

BACKGROUND: Out- of-pocket health expenditures (OOPs) constitute a significant proportion of total health expenditures in many low- and middle-income countries (LMICs), leading to an increased likelihood of exposure to financial catastrophe in the event of illness. Health insurance has the potential to reduce catastrophic health expenditures (CHE), but rigorous evidence of its sustained impact is limited, especially in LMICs. This study examined the short- and longer-term effects of a health insurance program in Kwara State, Nigeria on CHE. METHODS: The analysis is based on a panel dataset consisting of 3 waves of household surveys in program and comparison areas. The balanced data consists of 1,039 households and 3,450 individuals. We employed a difference-in-differences (DiD) regression approach to estimate intention-to-treat effects, and then computed average treatment effects on the treated by combining DiD with propensity score weighting and an instrumental variables analysis. CHE was measured as OOPs exceeding 10% of household consumption and 40% of capacity-to-pay (CTP). RESULTS: Using 10% of consumption as a CHE measure, we found that living in the program area was associated with a 4.3 percentage point (pp) decrease in CHE occurrence (p < 0.05), while the effect on insured households was 5.7 pp (p < 0.05). The longer-term impact four years after program introduction was not significant. Heterogeneity analyses show a reduction in CHE of 7.2 pp (p < 0.01) in the short-term for the poorest tercile. No significant effects were found for the middle and richest terciles, nor in the longer-term. Households with a chronically ill member experienced a reduction in CHE of 9.4 pp (p < 0.01) in the short-term, but not in the longer-term. Most estimates based on the 40% of CTP measure were not statistically significant. CONCLUSION: These findings highlight the critical role of health insurance in reducing the likelihood of catastrophic health expenditures, especially for vulnerable populations such as the poor and the chronically ill, and by extension in achieving universal health coverage. They also show that the beneficial impacts of health insurance may attenuate over time, as households potentially adjust their health-seeking behavior to the new scheme.

Catastrophic health expenditure and its determinants in households with lung cancer patients in China: a retrospective cohort study.

BACKGROUND: Numerous studies have examined catastrophic health expenditures (CHE) worldwide, mostly focusing on general or common chronic populations, rather than particularly vulnerable groups. This study assessed the medical expenditure and compensation of lung cancer, and explored the extent and influencing factors of CHE among households with lung cancer patients in China. METHODS: During 2018-2019, a hospital-based multicenter retrospective survey was conducted in seven provinces/municipalities across China as a part of the Cancer Screening Program of Urban China. CHE was measured according to the proportion of out-of-pocket (OOP) health payments of households on non-food expenditures. Chi-square tests and logistic regression analysis was adjusted to determine the factors that significantly influenced the likelihood of a household with lung cancer patient to incur in CHE. RESULTS: In total, 470 households with lung cancer patients were included in the analysis. Health insurance was shown to protect some households from the impact of CHE. Nonetheless, CHE incidence (78.1%) and intensity (14.02% for average distance and 22.56% for relative distance) were still relatively high among households with lung cancer patients. The incidence was lower in households covered by the Urban Employee Basic Medical Insurance (UEMBI) insurance, with higher income level and shorter disease course. CONCLUSION: More attention is needed for CHE incidence among vulnerable populations in China. Households with lung cancer patients were shown to be more likely to develop CHE. Therefore, policy makers should focus on improving the financial protection and reducing the economic burden of this disease.

Household catastrophic health expenditure and its effective factors: a case of Iran.

BACKGROUND: The World Health Organization (WHO) has placed special emphasis on protecting households from health care expenditures. Many households face catastrophic health expenditures (CHEs) from a combination of economic poverty and financing the treatment of medical conditions. The present study aimed to measure the percentage of households facing catastrophic CHEs and the factors associated with the occurrence of CHEs in Shiraz, Iran in 2018. METHODS: The present cross-sectional study was performed on 740 randomly selected households from different districts of Shiraz, Iran in 2018 using a multi-stage sampling method. Data were collected using the Persian version of the "WHO Global Health Survey" questionnaire. CHEs were defined as health expenditures exceeding 40% of households' capacity to pay. Households living below the poverty line before paying for health services were excluded from the study. The associations between the households' characteristics and facing CHEs were determined using the Chi-Square test as well as multiple logistic regression modeling in SPSS 23.0 at the significance level of 5%. RESULTS: The results showed that 16.48% of studied households had faced CHEs. The higher odds of facing CHEs were observed in the households living in rented houses (OR = 3.14, P-value < 0.001), households with disabled members (OR = 27.98, P-value < 0.001), households with children under 5 years old (OR = 2.718, P-value = 0.02), and those without supplementary health insurance coverage (OR = 1.87, P-value = 0.01). CONCLUSION: CHEs may be reduced by increasing the use of supplementary health insurance coverage by individuals and households, increasing the support of the Social Security and the State Welfare Organizations for households with disabled members, developing programs such as the Integrated Child Care Programs, and setting home rental policies and housing policies for tenants.

Incidence of household catastrophic and impoverishing health expenditures among patients with Breast Cancer in Iran.

BACKGROUND: Breast cancer disease is the most common cancer among Iranian women and imposing a significant financial burden on the households. This study calculated out-of-pocket (OOP), catastrophic health expenditure (CHE), and impoverishing health spending attributed to breast cancer in Iran. METHODS: In this cross-sectional household study, clinical and financial information on breast cancer and also household information (expenditures and income) were obtained through face-to-face interviews and completing a questionnaire by 138 women with this disease in 2019. We applied three non-food expenditure thresholds of 40, 20, and 10% to defining the CHE. Disease costs included periodical visits, diagnostic services, hospitalization care, treatment and rehabilitation services, home, and informal care. Households were disaggregated into socioeconomic status quintiles based on their Adult Equivalent values standardized monthly consumption expenditures. To identify the factors affecting these indicators, we performed the two different multivariate logistic regression models. RESULTS: This study finds that each patient had a monthly average OOP payment of $US 97.87 for the requested services, leading to impoverished of 5.07% and exposed 13.77% of their households to CHE. These indicators have been mainly concentrated among the poor, as they have spent a large part of their meager income on buying the needed services, and for this purpose, most of them forced to sell their assets, borrow, or take a bank loan. CONCLUSIONS: The patients in lower SES quintiles can be protected from impoverishing and catastrophic health spending by expanding insurance coverage, providing financial risk protection programs, and increasing access to quality and effective public sector services. Alongside, expanding inpatient coverage and adding drug benefits for the poor can significantly decrease their OOP payments.

Trends and determinants of catastrophic health expenditure in China 2010-2018: a national panel data analysis.

BACKGROUND: Catastrophic health expenditures (CHE) are out-of-pocket payments (OOP) that exceed a predefined percentage or threshold of a household's resources, usually 40 %, that can push households into poverty in China. We analyzed the trends in the incidence and intensity, and explored the determinants, of CHE, and proposed policy recommendation to address CHE. METHODS: A unique 5-year national urban-rural panel database was constructed from the China Family Panel Studies (CFPS) surveys. CHE incidence was measured by calculating headcount (percentage of households incurring CHE to the total household sample) and intensity was measured by overshoot (degree by which an average out of pocket health expenditure exceeds the threshold of the total sample). A linear probability model was employed to assess the trend in the net effect of the determinants of CHE incidence and a random effect logit model was used to analyse the role of the characteristics of the household head, the household and household health utilization on CHE incidence. RESULTS: CHE determinants vary across time and geographical location. From 2010 to 2018, the total, urban and rural CHE incidence all showed a decreasing tend, falling from 14.7 to 8.7 % for total households, 12.5-6.6 % in urban and 16.8-10.9 % in rural areas. CHE intensity decreased in rural (24.50-20.51 %) and urban (22.31-19.57 %) areas and for all households (23.61-20.15 %). Inpatient services were the most important determinant of the incidence of CHE. For urban households, the random effect logit model identified household head (age, education, self-rated health); household characteristics (members 65 + years, chronic diseases, family size and income status); and healthcare utilization (inpatient and outpatient usage) as determinants of CHE. For rural areas, the same variables were significant with the addition of household head's sex and health insurance. CONCLUSIONS: The incidence and intensity of CHE in China displayed a downward trend, but was higher in rural than urban areas. Costs of inpatient service usage should be a key intervention strategy to address CHE. The policy implications include improving the economic level of poor households, reforming health insurance and reinforcing pre-payment hospital insurance methods.

Incidence and determinants of catastrophic health expenditures and impoverishment in Pakistan.

OBJECTIVES: Out-of-pocket (OOP) payment is a major health financing mechanisms across developing nations such as Pakistan. Private health expenditures are estimated to be 64.4%, of which 89% are OOP made by the households (National Health Accounts, 2015-16). These high health care expenditures cause households to face financial burden resulting in poverty. This study aims to estimate the incidence and determinants of catastrophic health expenditures and impoverishment for Pakistan. STUDY DESIGN: Household-based cross-section study. METHODS: We used the data from the Household Integrated Economic Survey (2015-16 and 2018-19), carried out by the Pakistan Bureau of Statistics. The well known methodology developed by Wagstaff and Doorslaer was used in this study for estimating the incidence and impoverishment effect of catastrophic health spending. RESULTS: It is found that at 10% threshold (out of total consumption expenditures), catastrophic health payments are incurred by 4.51% and 13.15% of households for 2015-16 and 2018-19, respectively. Moreover, following the 40% threshold (out of non-food expenditures), this incidence is 0.45% and 4.57%. Poverty headcount was 23.28% and 18.43% gross of health payments in both the considered years, respectively, whereas it turns out to be 24.68% and 22.02% net of healthcare payments for the respective years, representing an increase in poverty headcounts of 1.4% and 3.59%. CONCLUSION: OOP health payments exert pressure on household's capacity to pay and push them into poverty. This article recommends that the burden of OOP expenditures borne by households should be reduced to prevent them from falling into poverty by initiating some strategies (health financing policy reforms in terms of financial protection) with political support.

Catastrophic health expenditures for children with disabilities in Iran: A national survey.

OBJECTIVE: The aim of this study was to investigate the percentage of households with disabled children aged 0-8 years who had faced catastrophic health expenditures (CHEs) due to the health costs of these children in Iran. METHODS: This cross-sectional study was carried out on 2000 households with disabled children aged 0-8 years in five provinces of Iran in 2020. Data were collected using the World Health Survey questionnaire and face-to-face interview. Determinants of CHE were identified using logistic regression. RESULTS: 32.7% of households with disabled children had faced CHE. Head of household being female (Adjusted OR = 18.89, 95%CI: 10.88-29.42), poor economic status of the household (Q1: Adjusted OR = 20.26, 95% CI, 11.42-35.94; Q2: Adjusted OR = 8.27, 95%CI, 4.45-15.36; Q3: Adjusted OR = 13.88, 95%CI, 7.89-24.41), lack of supplementary insurance by a child with disabilities (Adjusted OR = 6.13, 95%CI, 3.39-11.26), having a child with mental disability (Adjusted OR = 2.71, 95%CI, 1.60-4.69), and type of basic health insurance (having Iranian Health Insurance: Adjusted OR = 2.20, 95%CI, 1.38-3.49; having Social security insurance: Adjusted OR = 1.66, 95%CI, 1.06-2.61) significantly increased the chances of facing CHE. CONCLUSION: A significant percentage of households with disabled children had faced CHE because of their disabled child's health costs. The key determinants of CHE should be considered by health policy-makers in order to more financial protection of these households.

Can the reform of integrating health insurance reduce inequity in catastrophic health expenditure? Evidence from China.

BACKGROUND: China's fragmentation of social health insurance schemes has become a key obstacle that hampers equal access to health care and financial protection. This study aims to explores if the policy intervention Urban and Rural Residents Basic Medical Insurance (URRBMI) scheme, which integrates Urban Resident Basic Medical Insurance (URBMI) and New Rural Cooperative Medical Scheme (NCMS), can curb the persistent inequity of catastrophic health expenditure (CHE) and further analyses the determinants causing inequity. METHODS: Data were derived from the Fifth National Health Service Survey (NHSS). A total of 11,104 households covered by URRBMI and 20,590 households covered by URBMI or NCMS were selected to analyze CHE and the impoverishment rate from medical expenses. Moreover, the decomposition method based on a probit model was employed to analyse factors contributing CHE inequity. RESULTS: The overall incidence of CHE under integrated insurance scheme was 15.53%, about 1.10% higher than the non-integrated scheme; however, the intensity of CHE and impoverishment among the poorest was improved. Although CHE was still concentrated among the poor under URRBMI (CI = -0.53), it showed 28.38% lower in the degree of inequity. For URRBMI households, due to the promotion of integration reform to the utilization of rural residents' better health services, the factor of residence (24.41%) turns out to be a major factor in increasing inequity, the factor of households with hospitalized members (- 84.53%) played a positive role in reducing inequity and factors related to social economic status also contributed significantly in increasing inequity. CONCLUSION: The progress made in the integrated URRBMI on CHE equity deserves recognition, even though it did not reduce the overall CHE or the impoverishment rate effectively. Therefore, for enhanced equity, more targeted solutions should be considered, such as promoting more precise insurance intervention for the most vulnerable population and including costly diseases suitable for outpatient treatment into benefit packages. Additionally, comprehensive strategies such as favourable targeted benefit packages or job creation are required for the disadvantaged.

Determinants of catastrophic health expenditures in Iran: a systematic review and meta-analysis.

BACKGROUND: Catastrophic health expenditures (CHE) are of concern to policy makers and can prevent individuals accessing effective health care services. The exposure of households to CHE is one of the indices used to evaluate and address the level of financial risk protection in health systems, which is a key priority in the global health policy agenda and an indicator of progress toward the UN Sustainable Development Goal for Universal Health Coverage. This study aims to assess the CHE at population and disease levels and its influencing factors in Iran. METHODS: This study is a systematic review and meta-analysis. The following keywords and their Persian equivalents were used for the review: Catastrophic Health Expenditures; Health Equity; Health System Equity; Financial Contribution; Health Expenditures; Financial Protection; Financial Catastrophe; and Health Financing Equity. These keywords were searched with no time limit until October 2019 in PubMed, Web of Science, Scopus, ProQuest, ScienceDirect, Embase, and the national databases of Iran. Studies that met a set of inclusion criteria formed part of the meta-analysis and results were analyzed using a random-effects model. RESULTS: The review identified 53 relevant studies, of which 40 are conducted at the population level and 13 are disease specific. At the population level, the rate of CHE is 4.7% (95% CI 4.1% to 5.3%, n = 52). Across diseases, the percentage of CHE is 25.3% (95% CI 11.7% to 46.5%, n = 13), among cancer patients, while people undergoing dialysis face the highest percentage of CHE (54.5%). The most important factors influencing the rate of CHE in these studies are health insurance status, having a household member aged 60-65 years or older, gender of the head of household, and the use of inpatient and outpatient services. CONCLUSION: The results suggest that catastrophic health spending in Iran has increased from 2001 to 2015 and has reached its highest levels in the last 5 years. It is therefore imperative to review and develop fair health financing policies to protect people against financial hardship. This review and meta-analysis provides evidence to help inform effective health financing strategies and policies to prioritise high-burden disease groups and address the determinants of CHE.

Does insurance protect individuals from catastrophic payments for surgical care? An analysis of Ghana's National Health Insurance Scheme at Korle-Bu teaching Hospital.

BACKGROUND: According to the World Health Organization, essential surgery should be recognized as an essential component of universal health coverage. In Ghana, insurance is associated with a reduction in maternal mortality and improved access to essential medications, but whether it eliminates financial barriers to surgery is unknown. This study tested the hypothesis that insurance protects surgical patients against financial catastrophe. METHODS: We interviewed patients admitted to the general surgery wards of Korle-Bu Teaching Hospital (KBTH) between February 1, 2017 - October 1, 2017 to obtain demographic data, income, occupation, household expenditures, and insurance status. Surgical diagnoses and procedures, procedural fees, and anesthesia fees incurred were collected through chart review. The data were collected on a Qualtrics platform and analyzed in STATA version 14.1. Fisher exact and Student T-tests were used to compare the insured and uninsured groups. Threshold for financial catastrophe was defined as health costs that exceeded 10% of household expenditures, 40% of non-food expenditures, or 20% of the individual's income. RESULTS: Among 196 enrolled patients, insured patients were slightly older [mean 49 years vs 40 years P < 0.05] and more of them were female [65% vs 41% p < 0.05]. Laparotomy (22.2%) was the most common surgical procedure for both groups. Depending on the definition, 58-87% of insured patients would face financial catastrophe, versus 83-98% of uninsured patients (all comparisons by definition were significant, p < .05). CONCLUSION: This study-the first to evaluate the impact of insurance on financial risk protection for surgical patients in Ghana-found that although insured patients were less likely than uninsured to face financial catastrophe as a result of their surgery, more than half of insured surgical patients treated at KBTH were not protected from financial catastrophe under the Ghana's national health insurance scheme due to out-of-pocket payments. Government-specific strategies to increase the proportion of cost covered and to enroll the uninsured is crucial to achieving universal health coverage inclusive of surgical care. TRIAL REGISTRATION: Registered at www.clinical trials.gov identifier NCT03604458.

Equitable realization of the right to health in Haiti: how household data inform health seeking behavior and financial risk protection.

BACKGROUND: Though the right to health is included in Haiti's constitution, little progress has been made to expand universal health coverage nationwide, a strategy to ensure access to health services for all, while preventing financial hardship among the poor. Realizing universal health coverage will require a better understanding of inequities in health care utilization and out-of-pocket payments for health. This study measures inequality in health services utilization and the determinants of health seeking behavior in Haiti. It also examines the determinants of catastrophic health expenditures, defined by the Sustainable Development Goal Framework (Indicator 3.8.2) as expenditures that exceed 10% of overall household expenditures. METHODOLOGY: Three types of analysis were conducted using the 2012 and 2013 Household Surveys (Enquête sur les Conditions de Vie des Ménages Après Séisme (ECVMAS I (2012) and ECVMAS II (2013)) to measure: 1) outpatient services as a measure of inequalities using the 2013 Concentration Index; 2) drivers of health seeking behavior using a logistic regression model for 2013; and 3) determinants of catastrophic health expenditures using Seemingly Unrelated Regressions for both 2012 and 2013. RESULTS: The rate of catastrophic health expenditures increased nationwide from 9.43% in 2012 to 11.54% in 2013. This increase was most notable among the poorest wealth quintile (from 11.62% in 2012 to 18.20% in 2013), yet declined among the richest wealth quintile (from 9.49% to 4.46% during the same period). The increase in the rate of catastrophic health expenditures among the poorest coincides with a sharp decrease in external donor funding for the health sector. Regression analysis indicated that the rich wealth quintiles were less likely than poor wealth quintiles to incur catastrophic health expenditures. Interestingly, households were less likely to incur catastrophic health expenditures when they accessed care from Community Health Workers than when they received care from other types of providers, including public and private health care facilities. This study also shows that Community Health Worker-provided services have a negative concentration index (- 0.22) and are therefore most utilized by poor quintiles. In contrast, both public and private outpatient services had positive concentration indexes (0.05 and 0.12 respectively) and are most utilized by the rich wealth quintiles. Seeking care from traditional healers was found to be pro-poor in Haiti (concentration index of - 0.18) yet was also associated with higher catastrophic health expenditures albeit the coefficient was not significant. CONCLUSION: The expansion of universal health coverage in Haiti is evolving in a 'pro-rich' manner. Realizing Haiti's right to health will require a course-correction supported by national policies that protect the poor wealth quintiles from catastrophic health expenditures. Such policies may include Community Health Worker service delivery expansion in underserved areas. Evidence-based interventions may also be required to lower outpatient user fees, subsidize drug costs and promote efficiencies in pro-poor disaster relief programming.