The out-of-pocket cost of living with obesity: Results from a survey in Spain, South Korea, Brazil, India, Italy, and Japan.

Objectives: In many countries, obesity treatments are not fully reimbursed by healthcare systems. People living with obesity (PwO) often pay out-of-pocket (OOP) for pharmacological and non-pharmacological interventions, placing them in a position of financial risk to manage their condition. This study sought to understand the OOP expenditures and non-financial costs incurred by PwO to manage weight. Methods: A 25-min cross-sectional online survey was conducted with PwO between ages 18-60 in Italy, Japan, India, Brazil, Spain and South Korea. Respondents were recruited using proprietary vendor panels and non-probability sampling. N = 600 participants completed the survey (n = 100 per country). Results: The mean annual OOP expenditure related to weight loss/management was $7,351, accounting for nearly 17% of annual household income. Costs generally increased by BMI. Half or more of the respondents agreed that obesity affected multiple aspects of their lives (outside activities, running a household, social life, work, family life, traveling). 46% agreed that obesity limited their job prospects. Conclusion: PwO spend a notable amount of their income paying OOP expenditures related to managing their weight. Quantifying the individual economic burden of living with obesity can inform the understanding of the resources required and policy changes needed to treat obesity as a disease.

Factors associated with financial risk due to health spending in Argentina.

This article aims to assess the association between household demographic and socioeconomic characteristics and catastrophic health expenditure (CHE) in Argentina during 2017-2018. CHE was estimated as the proportion of household consumption capacity (using both income and total consumption in separate estimations) allocated for Out-of-Pocket (OOP) health expenditure. For assessing the determinants, we estimated a generalized ordered logit model using different intensities of CHE (10%, 15%, 20% and 25%) as the ordinal dependent variable, and socioeconomic, demographic and geographical variables as explanatory factors. We found that having members older than 65 years and with long-term difficulties increased the likelihood of incurring CHE. Additionally, having an economically inactive household head was identified as a factor that increases this probability. However, the research did not yield consistent results regarding the relationship between public and private health insurance and consumption capacity. Our results, along with the robustness checks, suggest that the magnitude of the coefficients for the household head characteristics could be exaggerated in studies that overlook the attributes of other household members. In addition, these results emphasize the significance of accounting for long-term difficulties and indicate that omitting this factor could overestimate the impact of members aged over 65.

Persistent inequities in maternal mortality in Latin America and the Caribbean, 1990-2019.

BACKGROUND: Despite the resources and personnel mobilized in Latin America and the Caribbean to reduce the maternal mortality ratio (MMR, maternal deaths per 100 000 live births) in women aged 10-54 years by 75% between 2000 and 2015, the region failed to meet the Millenium Development Goals (MDGs) due to persistent barriers to access quality reproductive, maternal, and neonatal health services. METHODS: Using 1990-2019 data from the Global Burden of Disease project, we carried out a two-stepwise analysis to (a) identify the differences in the MMR temporal patterns and (b) assess its relationship with selected indicators: government health expenditure (GHE), the GHE as percentage of gross domestic product (GDP), the availability of human resources for health (HRH), the coverage of effective interventions to reduce maternal mortality, and the level of economic development of each country. FINDINGS: In the descriptive analysis, we observed a heterogeneous overall reduction of MMR in the region between 1990 and 2019 and heterogeneous overall increases in the GHE, GHE/GDP, and HRH availability. The correlation analysis showed a close, negative, and dependent association of the economic development level between the MMR and GHE per capita, the percentage of GHE to GDP, the availability of HRH, and the coverage of SBA. We observed the lowest MMRs when GHE as a percentage of GDP was close to 3% or about US$400 GHE per capita, HRH availability of 6 doctors, nurses, and midwives per 1,000 inhabitants, and skilled birth attendance levels above 90%. CONCLUSIONS: Within the framework of the Sustainable Development Goals (SDGs) agenda, health policies aimed at the effective reduction of maternal mortality should consider allocating more resources as a necessary but not sufficient condition to achieve the goals and should prioritize the implementation of new forms of care with a gender and rights approach, as well as strengthening actions focused on vulnerable groups.

Health, economic growth, and Gini index in North America using a panel model / Salud, crecimiento económico, e índice Gini en Norteamérica usando un modelo panel

Abstract Objective: The objective of this paper is assessed the nexus among health status, economic growth, and the Gini index in North America and its countries using a panel model. Materials and Method: The materials consist of annual data regarding life expectancy, government health expenditure as percentage of the gross domestic product, Gini index, and gross domestic product at constant 2015 US$ for the period 2000-2019. The method applies a panel model for North America and its three countries: Canada, Mexico and The United States. North America diversity treatment among countries is dealt with fixed and random effects. Results: North America inhabitants health status are negatively influenced by an increasing income inequality, and a reduction on economic growth. The country that expends more in health care is The United States, follow by Canada and Mexico. The biggest reduction on life expectancy from an increase in income inequality is in The United States, followed by Canada and Mexico. Life expectancy increases when Canada and The United States experience economic growth. The countries with inarticulate health policy responses to an increase in income inequality are first Mexico followed by The United States. Conclusions: In North America and its countries an increasing income inequality reduces life expectancy, and government health expenditure. Economic growth benefits life expectancy and government health expenditure. Health status seems to improve with a reduction in income inequality and a greater public health expenditure. Therefore, policies that increases income inequality and reduces public health expenditure seems to be advocates of a reduction: in health status, population welfare and economic growth.

Resumen: Objetivo: Un análisis cuantitativo de las relaciones entre salud, crecimiento económico e índice de Gini en América del Norte y sus países se realiza mediante un modelo de panel. El estado de salud está representado por la esperanza de vida y los sistemas de salud pública por el gasto público en salud. El crecimiento económico es el cambio porcentual del producto interno bruto. La desigualdad de ingresos se representa con el índice de Gini. Materiales y método: Los materiales consisten en datos anuales de esperanza de vida, gasto público en salud como porcentaje del producto interno bruto, índice de Gini y producto interno bruto en dólares estadounidenses constantes de 2015 para el período 2000-2019. El método consiste en aplicar un modelo de panel para América del Norte y sus tres países: Canadá, México y Estados Unidos. El tratamiento de la diversidad entre los países de América del Norte es abordada con efectos fijos y aleatorios. Resultados: El estado de salud de los habitantes de América del Norte se ve influenciado negativamente por la creciente desigualdad de ingresos y la reducción del crecimiento económico. El país que más gasta en salud es los Estados Unidos, seguido de Canadá y México. La mayor reducción en la esperanza de vida debido a un aumento en la desigualdad de ingresos se encuentra en los Estados Unidos, seguido de Canadá y México. La esperanza de vida aumenta cuando Canadá y Estados Unidos experimentan crecimiento económico. Los países con respuestas de política de salud desarticuladas ante un aumento en la desigualdad de ingresos son primero México seguido de Estados Unidos. Conclusiones: Las políticas que aumentan la desigualdad de ingresos y reducen el gasto público en salud parecen ser promotoras de una reducción: en el estado de salud, el bienestar de la población, y el crecimiento económico.

Future health expenditure in the BRICS countries: a forecasting analysis for 2035.

BACKGROUND: Accelerated globalization especially in the late 1980s has provided opportunities for economic progress in the world of emerging economies. The BRICS nations' economies are distinguishable from other emerging economies due to their rate of expansion and sheer size. As a result of their economic prosperity, health spending in the BRICS countries has been increasing. However, health security is still a distant dream in these countries due to low public health spending, lack of pre-paid health coverage, and heavy out-of-pocket spending. There is a need for changing the health expenditure composition to address the challenge of regressive health spending and ensure equitable access to comprehensive healthcare services. OBJECTIVE: Present study examined the health expenditure trend among the BRICS from 2000 to 2019 and made predictions with an emphasis on public, pre-paid, and out-of-pocket expenditures for 2035. METHODS: Health expenditure data for 2000-2019 were taken from the OECD iLibrary database. The exponential smoothing model in R software (ets ()) was used for forecasting. RESULTS: Except for India and Brazil, all of the BRICS countries show a long-term increase in per capita PPP health expenditure. Only India's health expenditure is expected to decrease as a share of GDP after the completion of the SDG years. China accounts for the steepest rise in per capita expenditure until 2035, while Russia is expected to achieve the highest absolute values. CONCLUSION: The BRICS countries have the potential to be important leaders in a variety of social policies such as health. Each BRICS country has set a national pledge to the right to health and is working on health system reforms to achieve universal health coverage (UHC). The estimations of future health expenditures by these emerging market powers should help policymakers decide how to allocate resources to achieve this goal.

Impacto del Aseguramiento en Salud en la Economía de los Hogares Peruanos, 2010-2019

Objetivo : Determinar el impacto del aseguramiento en salud en la economía de los hogares peruanos en el periodo 2010-2019. Materiales y Métodos : Estudio analítico transversal, que utilizó la base de datos de la Encuesta Nacional de Hogares de los años 2010, 2014 y 2019 para analizar el impacto del aseguramiento en salud en términos de gasto de bolsillo en salud, gasto catastrófico y empobrecimiento de los hogares peruanos, así como determinar qué otros factores se encuentran asociados. Resultados : Durante el periodo de estudio se observó que los hogares peruanos presentaron una disminución del gasto de bolsillo en salud promedio mensual (S/.119,9 en 2010 a S/.107,9 en 2019), así como del porcentaje de hogares con gasto catastrófico en salud (4,06 % en 2010 a 3,47 % en 2019) y del porcentaje de hogares que empobrecen por gastos de bolsillo en salud (1,78 % en 2010 a 1,51 % en 2019). Los factores asociados al gasto catastrófico en salud y al empobrecimiento fueron el menor nivel de escolaridad del jefe del hogar, la presencia de miembros con enfermedad crónica y el área de residencia rural. La ausencia de aseguramiento en salud se asoció significativamente a un mayor riesgo de gasto de bolsillo en salud catastrófico, mas no al empobrecimiento. Conclusiones : El aumento de la cobertura de aseguramiento en salud contribuye a la protección financiera de los hogares peruanos frente al gasto de bolsillo en salud; sin embargo, las barreras para el acceso efectivo a los servicios de salud y otros factores socioeconómicos pueden limitar significativamente su impacto.

Objective : To determine the impact of health insurance in the economy of Peruvian households during the 2010-2019 period. Material and Methods : This is a cross-sectional analytical study that used the database of the National Peruvian Household Surveys from years 2010, 2014, and 2019, aiming to analyze the impact of health insurance in terms of pocket money spending for health issues, catastrophic healthcare spending, and impoverishment in Peruvian households, and also to determine the presence of other associated factors. Results : During the study period, it was observed that Peruvian households reduced their monthly average pocket money spending for health issues (119.9 PEN in 2010 and 107.9 PEN in 2029), as well as the percentage of household with catastrophic healthcare expenses (4.06% in 2010 to 3.47% in 2019), and the percentage of households who became impoverished because of pocket money expenses for health issues (1.78% in 2020 to 1.51% in 2019). Factors associated to catastrophic healthcare expenses and to impoverishment were lower educational level for the household leader, the presence of family members with chronic diseases, and living in a rural area. The absence of health insurance was significantly associated to a greater risk for catastrophic healthcare expenses, but not to impoverishment. Conclusions : Increased healthcare insurance coverage contributes to financial protection of Peruvian households against pocket money spending for health issues; however, barriers for effective access to healthcare services, and other socioeconomical factors may significantly limit this impact.

Out-of-pocket expenditures associated with congenital zika syndrome in Brazil: an analysis of household health spending / Gastos out-of-pocket associados à síndrome congênita do vírus Zika no Brasil: uma análise dos gastos domiciliares em saúde

Objective: The study aims to estimate catastrophic health expenditures associated with the diagnosis and follow-up treatment of Congenital Zika Syndrome (CZS) in children affected during the 2015-2016 epidemic in Brazil. Catastrophic health expenditures are defined as health spending that exceeds a predefined proportion of the household's total expenditures, exposing family members to financial vulnerability. Methods: Ninety-six interviews were held in the cities of Fortaleza and Rio de Janeiro in a convenience sample, using a questionnaire on sociodemographic characteristics and private household expenditures associated with the syndrome, which also allowed estimating catastrophic expenditures resulting from care for CZS. Results: Most of the mothers interviewed in the study were brown, under 34 years of age, unemployed, and reported a monthly family income of two minimum wages or less. Spending on medicines accounted for 77.6% of the medical expenditures, while transportation and food were the main components of nonmedical expenditures, accounting for 79% of this total. The affected households were largely low-income and suffered catastrophic expenditures due to the disease. Considering the family income metric, in 41.7% of the households, expenses with the child's disease exceeded 10% of the household income. Conclusion: Public policies should consider the financial and healthcare needs of these families to ensure adequate support for individuals affected by CZS.

Objetivo: O estudo tem como objetivo estimar os gastos catastróficos em saúde associados ao diagnóstico e acompanhamento do tratamento da síndrome congênita do Zika (SCZ) em crianças afetadas durante a epidemia de 2015-2016 no Brasil. Gastos catastróficos em saúde são definidos como gastos com saúde que excedem uma proporção predefinida dos gastos totais do domicílio, expondo os membros da família à vulnerabilidade financeira. Métodos: Foram realizadas 96 entrevistas nas cidades de Fortaleza e Rio de Janeiro numa amostra de conveniência, por meio de questionário sobre características sociodemográficas e gastos privados domiciliares associados à síndrome, o que também permitiu estimar gastos catastróficos decorrentes do cuidado à SCZ. Resultados: A maioria das mães entrevistadas no estudo era parda, com menos de 34 anos, desempregada e com renda familiar mensal igual ou inferior a dois salários mínimos. Os gastos com medicamentos representaram 77,6% dos gastos médicos, enquanto transporte e alimentação foram os principais componentes dos gastos não médicos, respondendo por 79% desse total. Os domicílios afetados eram, em grande parte, de baixa renda e sofreram gastos catastróficos devido à doença. Considerando a métrica de renda familiar, em 41,7% dos domicílios, os gastos com a doença da criança ultrapassaram 10% da renda familiar. Conclusão: As políticas públicas devem considerar as necessidades financeiras e de saúde dessas famílias para garantir o suporte adequado aos indivíduos acometidos pela SCZ.

Lessons for Developing Countries From Outlier Country Health Systems.

Building good health systems is an important objective for policy makers in any country. Developing countries which are just starting out on their journeys need to do this by using their limited resources in the best way possible. The total health expenditure of a country exerts a significant influence on its health outcomes but, given the well-understood failures of price-based market-mechanisms, countries that spend the most money do not necessarily end-up building the best health systems. To help developing country policy makers gain a deeper insight into what factors matter, in this study the contribution of per-capita total, out-of-pocket, and pooled health expenditures, to the cross-country variation in Disability Adjusted Life Years lost per 100,000 population (DALY Rates), a summary measure of health outcomes, is estimated. The country-specific residuals from these analyses are then examined to understand the sources of the rest of the variation. The study finds that these measures are able to explain between 40 and 50% of the variation in the DALY Rates with percentage increases in per-capita out-of-pocket and pooled expenditures being associated with improvements in DALY Rates of about 0.06% and 0.095%, respectively. This suggests that while increases in per-capita total health expenditures do matter, moving them away from out-of-pocket to pooled has the potential to produce material improvements in DALY Rates, and that taken together these financial parameters are able to explain only about half the cross-country variation in DALY Rates. The analysis of the residuals from these regressions finds that while there may be a minimum level of per-capita total health expenditures (> $100) which needs to be crossed for a health system to perform (Bangladesh being a clear and sole exception), it is possible for countries to perform very well even at very low levels of these expenditures. Colombia, Thailand Honduras, Peru, Nicaragua, Jordan, Sri Lanka, and the Krygyz Republic, are examples of countries which have demonstrated this. It is also apparent from the analysis that while very high rates (> 75%) of pooling are essential to build truly high performing health systems (with DALYRates < 20, 000), a high level of pooling on its own is insufficient to deliver strong health outcomes, and also that even at lower levels of pooling it is possible for countries to out-perform their peers. This is apparent from the examples of Ecuador, Mexico, Honduras, Malaysia, Vietnam, Kyrgyz Republic, and Sri Lanka, which are all doing very well despite having OOP% in the region of 40-60%. The analysis of residuals also suggests that while pooling (in any form) is definitely beneficial, countries with single payer systems are perhaps more effective than those with multiple payers perhaps because, despite their best efforts, they have insufficient market power over customers and providers to adequately manage the pulls and pressures of market forces. It can also be seen that countries and regions such as Honduras, Peru, Nicaragua, Jordan, Sri Lanka, Bangladesh, Kerala, and the Kyrgyz Republic, despite their modest levels of per-capita total health expenditures have delivered attractive DALY Rates on account of their consistent prioritization of public-health interventions such as near 100% vaccine coverage levels and strong control of infectious diseases. Additionally, countries such as Turkey, Colombia, Costa Rica, Thailand, Peru, Nicaragua, and Jordan, have all delivered low DALY Rates despite modest levels of per-capita total health expenditures on account of their emphasis on primary care. While, as can be seen from the discussion, several valuable conclusions can be drawn from this kind of analysis, the evolution of health systems is a complex journey, driven by multiple local factors, and a multi-country cross-sectional study of the type attempted here runs the risk of glossing over them. The study attempts to address these limitations by being parsimonious and simple in its approach toward specifying its quantitative models, and validating its conclusions by looking deeper into country contexts.

Future health spending forecast in leading emerging BRICS markets in 2030: health policy implications.

BACKGROUND: The leading emerging markets of Brazil, Russia, India, China and South Africa (BRICS) are increasingly shaping the landscape of the global health sector demand and supply for medical goods and services. BRICS' share of global health spending and future projections will play a prominent role during the 2020s. The purpose of the current research was to examine the decades-long underlying historical trends in BRICS countries' health spending and explore these data as the grounds for reliable forecasting of their health expenditures up to 2030. METHODS: BRICS' health spending data spanning 1995-2017 were extracted from the Institute for Health Metrics and Evaluation (IHME) Financing Global Health 2019 database. Total health expenditure, government, prepaid private and out-of-pocket spending per capita and gross domestic product (GDP) share of total health spending were forecasted for 2018-2030. Autoregressive integrated moving average (ARIMA) models were used to obtain future projections based on time series analysis. RESULTS: Per capita health spending in 2030 is projected to be as follows: Brazil, $1767 (95% prediction interval [PI] 1615, 1977); Russia, $1933 (95% PI 1549, 2317); India, $468 (95% PI 400.4, 535); China, $1707 (95% PI 1079, 2334); South Africa, $1379 (95% PI 755, 2004). Health spending as a percentage of GDP in 2030 is projected as follows: Brazil, 8.4% (95% PI 7.5, 9.4); Russia, 5.2% (95% PI 4.5, 5.9); India, 3.5% (95% PI 2.9%, 4.1%); China, 5.9% (95% PI 4.9, 7.0); South Africa, 10.4% (95% PI 5.5, 15.3). CONCLUSIONS: All BRICS countries show a long-term trend towards increasing their per capita spending in terms of purchasing power parity (PPP). India and Russia are highly likely to maintain stable total health spending as a percentage of GDP until 2030. China, as a major driver of global economic growth, will be able to significantly expand its investment in the health sector across an array of indicators. Brazil is the only large nation whose health expenditure as a percentage of GDP is about to contract substantially during the third decade of the twenty-first century. The steepest curve of increased per capita spending until 2030 seems to be attributable to India, while Russia should achieve the highest values in absolute terms. Health policy implications of long-term trends in health spending indicate the need for health technology assessment dissemination among the BRICS ministries of health and national health insurance funds. Matters of cost-effective allocation of limited resources will remain a core challenge in 2030 as well.

Internações hospitalares para tratamento de aneurismas cerebrais rotos e não rotos no Sistema Único de Saúde do Brasil, 2009-2018: um estudo descritivo / Ingresos hospitalarios para el tratamiento de aneurismas cerebrales rotos y no rotos en el Sistema Único de Salud de Brasil, 2009-2018: un estudio descriptivo / Hospital admissions for treatment of ruptured and unruptured cerebral aneurysms within the Brazilian National Health System, 2009-2018: a descriptive study

Objetivo: Analisar internações para tratamento de aneurismas cerebrais rotos e não rotos com realização de embolização e de microcirurgia cerebral no Sistema Único de Saúde (SUS), Brasil, 2009-2018. Métodos: Estudo descritivo, utilizando dados do Sistema de Informações Hospitalares do SUS. Descreveu-se a frequência das internações, procedimentos, utilização de unidade de tratamento intensivo (UTI), letalidade e gastos. Resultados: Das 43.927 internações, 22.622 (51,5%) resultaram em microcirurgia. Embolização e microcirurgia foram mais frequentes no sexo feminino. A duração das internações com embolização foi de 7,7 dias (±9,0), e com microcirurgia, 16,2 (±14,2) dias, a frequência de admissão em UTI, 58,6% e 85,3%, e a letalidade, 5,9% e 10,9%, respectivamente. Do gasto total, US$ 240 milhões, 66,3% corresponderam às internações com embolização. Conclusão: As internações com embolização para tratamento de aneurismas cerebrais no SUS apresentaram menor duração, menor frequência de utilização de UTI e menor letalidade, porém maior gasto em relação à microcirurgia cerebral.

Objetivo: Analizar las internaciones para tratamiento de aneurismas cerebrales rotos y no rotos en cuanto a embolización y microcirugía cerebral en el Sistema Único de Salud (SUS), Brasil, de 2009 a 2018. Métodos: Estudio descriptivo utilizando datos del Sistema de Información Hospitalaria (SIH)/SUS relacionados con la frecuencia de hospitalizaciones, procedimientos, uso de la unidad de cuidados intensivos (UCI), letalidad y gastos. Resultados: De los 43.927 ingresos, 22.622 (51,5%) correspondieron a microcirugía. Hubo una mayor frecuencia de procedimientos de embolización y microcirugía entre las personas del sexo femenino. De las hospitalizaciones con embolización y microcirugía, respectivamente, la duración de la estadía fue de 7,7 (±9,0) y 16,2 (±14,2) días, la frecuencia de ingreso en la UCI fue del 58,6% y el 85,3% y la letalidad del 5,9% y el 10,9%. El gasto total fue de US$ 240 millones, de los cuales el 66,3% correspondió a hospitalizaciones con embolización. Conclusión: Las hospitalizaciones con embolización, para el tratamiento de aneurismas cerebrales en el SUS, tuvieron menor tiempo de estadía, menor frecuencia de uso de la UCI y menor letalidad, pero mayores gastos en relación a la microcirugía cerebral.

Objective: To analyze hospital admissions for treatment of ruptured and unruptured cerebral aneurysms with embolization and brain microsurgery performed within the Brazilian National Health System (SUS), 2009-2018. Methods: This was a descriptive study, using data from the SUS's Hospital Information System. Frequency of hospital admissions, procedures, use of intensive care unit (ICU), case fatality ratio and expenditures were described. Results: Of the 43,927 hospital admissions, 22,622 (51.5%) resulted in microsurgery. Embolization and cerebral microsurgery were more frequent among females. Length of hospital stay with embolization procedure was 7.7 days (±9.0), and with microsurgery, 16.2 (±14.2) days, frequency of ICU admission, 58.6% and 85.3%, and case fatality ratio, 5.9% and 10.9% respectively. Of the total expenditure, USD 240 million, 66.3% corresponded to hospitalizations with embolization procedure. Conclusion: Hospital admissions with embolization procedure for treatment of cerebral aneurysms within the SUS showed a shorter length of stay, less frequent use of ICU and lower case fatality ratio, but higher expenditure when compared to brain microsurgery.

Asociación entre gastos de bolsillo de salud y pobreza utilizando datos de la Encuesta Permanente de Hogares en Paraguay en el 2014 / Association between out-of-pocket health expenses and poverty using data from the Permanent Household Survey in Paraguay in 2014

La cobertura y acceso universal de salud requiere de protección financiera, lo que puede evaluarse a través del gasto de bolsillo ante una enfermedad. El objetivo del trabajo fue analizar la asociación entre el gasto de bolsillo de salud y la pobreza en Paraguay. Se utilizó la Encuesta Permanente de Hogares del 2014 para determinar la razón entre gasto de bolsillo ante una enfermedad con los ingresos del hogar, con las transferencias estatales para pobres, con la canasta básica de consumo y de alimentos. Fueron incluidos 5.165 hogares de los cuales 21,49% eran pobres. Hubo gasto de bolsillo en el 45,19% de los hogares asociándose significativamente con la pobreza (OR: 1,8; IC95%: 1,57 a 2,06). El 1,99% de los hogares tuvo gasto de bolsillo mayor a 25% de sus ingresos y el 5,98% mayor a 10% de sus ingresos, ambos indicadores se asociaron significativamente con la pobreza (OR: 3,70; IC95%: 2,50 a 5,50 y OR: 3,04; IC95%: 2,40 a 2,06, respectivamente). Hubo empobrecimiento en el 1,44% de los hogares, y la brecha de la pobreza pasó de 34,58% a 37,67%. Entre los hogares pobres el gasto de bolsillo fue equivalente a 4,9 días de consumo, a 11,5 días de alimentación y a 42% del valor de transferencias estatales. Estos hallazgos reflejan una insuficiente protección financiera del sistema de salud en Paraguay

Universal health coverage and access requires financial protection, which can be assessed through out-of-pocket costs for illness. The objective of the study was to analyze the association between out-of-pocket health spending and poverty in Paraguay. The 2014 Permanent Household Survey was used to determine the ratio between out-of-pocket expenses for illness and household income, state transfers for the poor, and the basic consumption and food basket. Five thousand one hundred sixty five households were included, of which 21.49% were poor. There was out-of-pocket spending in 45.19% of the households, significantly associated with poverty (OR: 1.8; 95%CI: 1.57 to 2.06), 1.99% of households had out-of-pocket expenses greater than 25% of their income and 5.98% greater than 10% of their income, both indicators were significantly associated with poverty (OR: 3.70; 95%CI: 2.50 to 5.50 and OR: 3.04; 95%CI: 2.40 to 2.06, respectively). There was impoverishment in 1.44% of households, and the poverty gap went from 34.58% to 37.67%. Among poor households, out-of-pocket spending was equivalent to 4.9 days of consumption, 11.5 days of food, and 42% of the value of state transfers. These findings reflect insufficient financial protection for the health system in Paraguay

Longevidade e custo da assistência: o desafio de um plano de saúde de autogestão / Longevity and cost of care: the challenge of a self-managed health plan

Resumo O objetivo deste artigo é analisar a relação entre o custo da assistência e o envelhecimento da população assistida por um plano de autogestão, refletindo sobre possibilidades de enfrentamento do desafio advindo dessa conjunção de fatores. Trata-se de um estudo descritivo do período 1997 a 2016, efetivado a partir de dados secundários provenientes da operadora do plano de saúde em estudo, e outro banco administrativo de operadora de autogestão de grande abrangência nacional. Os idosos (mais de 60 anos) aumentaram no período do estudo 55,5%. Já os chamados "muito idosos" (acima de 80 anos) cresceram em quantidade 332,8%. A população acima de 60 anos corresponde a 25,7% do total sendo responsável por 68,8% das despesas. A grande maioria da população atendida (84,6%) está localizada no Estado no Rio de Janeiro, o qual tem o mais alto custo per capita em saúde no País. Foi encontrada relação entre o envelhecimento da população beneficiária e o aumento das despesas. É imperioso investir em iniciativas de promoção da saúde e prevenção de doenças como forma de melhora da qualidade de vida e viabilidade financeira do plano, além de definir um sub-sistema que delimite e discipline o acesso à rede e seja aceito pelos beneficiários.

Abstract This paper aims to analyze the relationship between the cost of health care and the aging of the population assisted by a self-managed plan, reflecting on the ways to address the challenge arising from this conjunction of population demographic changes. This is a descriptive study of the 1997-2016 period based on secondary data from the management operator of the health plan under study and from another administrative database of a self-managing provider with broad nationwide coverage. Older adults (over 60 years) increased 55% during the study period. On the other hand, the so-called "very old" (over 80 years) grew 332.8%. The population above 60 years corresponds to 25.7% of the total, and accounts for 68.8% of expenses. Most of the population covered (84,6%) is located in the State of Rio de Janeiro, which has the highest per capita health care cost in Brazil. We found a relationship between aging of the beneficiary population and increased expenditure. It is imperative to invest in health promotion and disease prevention initiatives as a way of improving the quality of life and financial sustainability of the plan, and define a subsystem that delimits and regulates access to the network and is accepted by the beneficiaries.

Out-of-pocket expenditure for hypertension care: a population-based study in low-income urban Medellin, Colombia.

Background Hypertension requires life-long medical care, which may cause economic burden and even lead to catastrophic health expenditure. Objective To estimate the extent of out-of-pocket expenditure for hypertension care at a population level and its impact on households' budgets in a low-income urban setting in Colombia. Methods We conducted a cross-sectional survey in Santa Cruz, a commune in the city of Medellin. In 410 randomly selected households with a hypertensive adult, we estimated annual basic household expenditure and hypertension-attributable out-of-pocket expenditure. For socioeconomic stratification, we categorised households according to basic expenditure quintiles. Catastrophic hypertension-attributable expenditure was defined as out-of-pocket expenditure above 10% of total household expenditure. Results The average annual basic household expenditure was US dollars at purchasing power parity (USD-PPP) $12,255.59. The average annual hypertension-attributable out-of-pocket expenditure was USD-PPP $147.75 (95% CI 120.93-174.52). It was incurred by 73.9% (95% CI 69.4%-78.1%) of patients, and consisted mainly of direct non-medical expenses (76.7%), predominantly for dietary requirements prescribed as non-pharmacological treatment and for transport to attend health care consultations. Medical out-of-pocket expenditure (23.3%) was for the most part incurred for pharmacological treatment. Hypertension-attributable out-of-pocket expenditure represented on average 1.6% (95% CI 1.3%-1.9%) of the total annual basic household expenditure. Eight households (2.0%; 95% CI 1.0%-3.8%) had catastrophic health expenditure; six of them belonged to the two lowest expenditure quintiles. Payments related to dietary requirements and transport to consultations were critical determinants of their catastrophic expenditure. Conclusions Out-of-pocket expenditure for hypertension care is moderate on average, but frequent, and mainly made up of direct non-medical expenses. Catastrophic health expenditure is uncommon and affects primarily households in the bottom socioeconomic quintiles. Financial protection should be strengthened by covering the costs of chronic diseases-related dietary requirements and transport to health services in the most deprived households. Abbreviations NCDs: Non-communicable diseases; LMICs: Low and middle-income countries; WHO: World Health Organization; HTN: hypertension; CVDs: Cardiovascular diseases; OOPE: out-of-pocket expenditure; USD-PPP: US dollars at purchasing power parity; CI: Confidence interval.

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

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

Government Expenditure on Maternal Health and Family Planning Services for Adolescents in Mexico, 2003-2015.

The purpose of this study was to assess whether government policies to expand the coverage of maternal health and family planning (MHFP) services were benefiting the adolescents in need. To this end, we estimated government MHFP expenditure for 10- to 19-year-old adolescents without social security (SS) coverage between 2003 and 2015. We evaluated its evolution and distribution nationally and sub-nationally by level of marginalization, as well as its relationship with demand indicators. Using Jointpoint regressions, we estimated the average annual percent change (AAPC) nationally and among states. Expenditure for adolescents without SS coverage registered 15% for AAPC for the period 2003-2011 and was stable for the remaining years, with 88% of spending allocated to maternal health. Growth in MHFP expenditure reduced the ratio of spending by 13% among groups of states with greater/lesser marginalization; nonetheless, the poorest states continued to show the lowest levels of expenditure. Although adolescents without SS coverage benefited from greater MHFP expenditure as a consequence of health policies directed at achieving universal health coverage, gaps persisted in its distribution among states, since those with similar demand indicators exhibited different levels of expenditure. Further actions are required to improve resource allocation to disadvantaged states and to reinforce the use of FP services by adolescents.

Análise dos gastos públicos em saúde e da cobertura da atenção primária dos municípios pernambucanos: tendência 2008 a 2018 / Analysis of public spending on health and primary care coverage of Pernambuco's municipalities: trend 2008 to 2018

A criação do Sistema Único de Saúde (SUS), tem sido analisada como a mais bemsucedida reforma da área social sob o novo regime democrático brasileiro. Tem na Atenção Primária a Saúde (APS), uma estratégia de organização voltada para responder de forma regionalizada, contínua e sistematizada à maior parte das necessidades de saúde de uma população. Integra ações preventivas e curativas, representando o primeiro nível de contato dos indivíduos, da família e da comunidade com o sistema nacional de saúde. As transferências dos recursos federais para o financiamento da APS sofreram mudanças que colaboraram com a expansão desta, com ênfase na municipalização e descentralização. Com demandas cada vez maiores e escassez nos recursos, o desafio dos gestores públicos tem sido planejar seus gastos de modo que o aspecto econômico não comprometa a prestação de serviços adequados a população. Para um melhor controle e transparência no uso desses recursos, o ministério da saúde criou o Sistema de Informações sobre Orçamentos Públicos de Saúde (SIOPS). Este trabalho se motiva a demonstrar a evolução dos gastos públicos em saúde dos municípios pernambucanos, bem como, quer-se identificar os fatores que tiveram maior participação nos gastos em saúde destes municípios no período de 2008 a 2018. Se baseia em um estudo quantitativo, descritivo, retrospectivo e longitudinal, que analisou dados do SIOPS, do IBGE e do e-Gestor Atenção Básica. A análise demonstrou uma tendência crescente, com um incremento de 11,63% na média populacional da região, um aumento real de 179,8% na média dos gastos totais em saúde dos municípios, um aumento real de 122,76% na média de gastos per capita oriundo de arrecadação própria, um crescimento de 3,9 pontos percentuais na média de investimentos em saúde, um crescimento de 6,26 pontos percentuais na média de participação de serviços terceirizados por pessoas jurídicas, uma redução de 2,29 pontos percentuais na média de gastos com medicamentos e uma redução de 3,4 pontos percentuais na média de gastos com pessoal na saúde. A média cobertura da estratégia de saúde da família e da atenção básica também seguiu uma tendência crescente, saindo de 87,78% e 88,35%, respectivamente em 2008, e atingindo uma média 92,11% e 92,99% de cobertura, respectivamente em 2018. Os resultados evidenciam um aumento substancial dos gastos em saúde, a participação, cada vez maior, dos recursos dos tesouros municipais, para manutenção e ampliação da atenção primária à saúde e melhor infraestrutura para a saúde da família.

The creation of the Unified Health System (SUS), has been analyzed as the most successful reform of the social area under the new Brazilian democratic regime. Primary Health Care (PHC) has an organizational strategy aimed at responding in a regionalized, continuous and systematic way to most of the health needs of a population. It integrates preventive and curative actions, representing the first level of contact of individuals, family and community with the national health system. The transfers of federal resources for PHC financing underwent changes that contributed to its expansion, with an emphasis on municipalization and decentralization. With increasing demands and scarcity of resources, the challenge for public managers has been to plan their spending so that the economic aspect does not compromise the provision of adequate services to the population. For better control and transparency in the use of these resources, the Ministry of Health created the Information System on Public Health Budgets (SIOPS). This work is motivated to demonstrate the evolution of public health expenditures in the municipalities of Pernambuco, as well as, we want to identify the factors that had greater participation in health expenditures in these municipalities in the period from 2008 to 2018. It is based on a quantitative study, descriptive, retrospective and longitudinal, which analyzed data from SIOPS, IBGE and e-Manager Primary Care. The analysis showed an increasing trend, with an 11.63% increase in the region's population average, a real increase of 179.8% in the average of total municipal health expenditures, a real increase of 122.76% in the average of per capita spending from own funds, an increase of 3.9 percentage points in the average of investments in health, an increase of 6.26 percentage points in the average participation of outsourced services by legal entities, a reduction of 2.29 percentage points in the average expenditure on medication and a reduction of 3.4 percentage points in the average expenditure on health personnel. The average coverage of the family health strategy and primary care also followed an increasing trend, leaving 87.78% and 88.35%, respectively in 2008, and reaching an average of 92.11% and 92.99% of coverage, respectively in 2018. The results show a substantial increase in health expenditures, the increasing participation of municipal treasury resources for the maintenance and expansion of primary health care and better infrastructure for family health

Análisis del gasto de bolsillo ante la enfermedad de personas de 60 y más años según su condición de pobreza en Paraguay

Introducción: Reducir la pobreza y lograr cobertura universal de salud con protección financiera para las personas de todas las edades son parte de los Objetivos de Desarrollo Sostenible. Objetivo: Determinar el gasto de bolsillo de salud (GBS) ante la enfermedad de personas de 60 y más años (≥ 60 años) y su incidencia económica en los hogares según su condición de pobreza en Paraguay. Material y Método: Se analizó la Encuesta Permanente de Hogares del 2014, considerando la definición oficial de pobreza y la referencia de enfermedad o accidente en un trimestre. Se calculó el promedio de GBS por hogar, la incidencia sobre el ingreso monetario trimestral (IM) y sobre los subsidios estatales por pensión alimentaria para adultos mayores (IPa). Resultados: De los 1.621.525 hogares del país 435.448 tenía al menos 1 persona ≥ 60 años, de los cuales 188.715 tenía al menos 1 de ellos enfermo o accidentado y 144.554 reportó GBS. Entre los hogares no pobres: 11,6% (IC 10,5 a 12,9) tuvo al menos 1 enfermo ≥ 60 años, de los cuales 75,8% (IC 71,2 a 79,8) tuvo GBS, siendo en promedio 547.931 Gs. (DE 58.251). Los medicamentos fueron 53,3% (IC 45,2 a 61,5) del total. La IM fue 5,7% (IC 4,6 a 6,9). Entre los hogares pobres: 11,6% (IC 9,6 a 14,0) tuvo al menos 1 enfermo ≥ 60 años, de los cuales 79,5% (IC 70,7 a 86,2) tuvo GBS, siendo en promedio 341.542 Gs. (DE 49.101). Los medicamentos fueron 71,3% (IC 61,9 a 80,7) del total. La IM fue 11,5% (IC 7,0 a 16,0), la IPa fue de 16,9% (IC 4,4 a 29,4). El GBS fue el equivalente a 19 días de alimentación en promedio (DE 3,71). Conclusión: Paraguay requiere de mayor protección financiera para adultos mayores mediante sinergias de las políticas de reducción de pobreza y de salud.

Introduction: Reducing poverty and achieving universal health coverage for people of all ages are part of the Sustainable Development Goal. Objective: determine the Out-of-pocket Health Expenditure (GBS) for people 60 and older (≥ 60 years) who are sick and its economic impact on households according to their poverty status in Paraguay. Material and Method: the 2014 Permanent Household Survey was analyzed, considering the official definition of poverty and the reference of illness or accident in a quarter. The average of GBS per household, the impact on quarterly monetary risk (IM) and on state subsidies for food pensions for the elderly (IPa). Results: Of 1,621,525 homes in the country 435,448 had at least 1 person 60 years, of which 188,715 had at least 1 of them ill or injured and 144,554 reported GBS. Among the non-poor households: 11.6% (IC 10.5 to 12.9) had at least 1 ill person ≥ 60 years, of which 75.8% (IC 71.2 to 79.8) had GBS, being on average 547,931 Gs. (DE 58,251). The medications were 53.3% (IC 45.2 to 61.5) from total. There was an IM of 5,7% (IC 4.6 to 6.9). Among the poor households: 11.6% (IC 9.6 to 14.0) had at least 1 ill person ≥ 60 years, of which 79.5% (IC 70.7 to 86,2) had GBS, being on average 341,542 Gs. (DE 40,101). The medications were 71.3 % (IC 61.9 to 80.7) from total. There was an IM of 11.5% (IC 7.0 to 16.0). There was an IPa of 16.9% (IC 4.4 to 29.4). The GBS was the equivalent to 19 days of feeding on average (DE 3.71). Conclusion: Paraguay requires more financial protection for older adults through synergies of poverty reduction and health policies.

Austerity, and funding cuts: Implications for sustainability of the response to the Caribbean HIV/AIDS epidemic.

The Caribbean, accessed significant external funding over the first three decades of the epidemic, which provided local authorities the opportunity to defer their responsibility in leading or matching the support provided from the external agencies. The reduction in external support has placed increased pressure on the response to the epidemic, with some countries more likely to be affected than others. This paper undertakes a review of the expenditure and funding landscape for HIV programs in the Caribbean. The findings confirm that despite the dwindling number of funding sources, some countries continue to display a significant degree of dependency on external funding sources. It is noteworthy that Treatment and Care accounted for the largest share of HIV expenditure in those countries, which displayed the highest degree of dependency on external funding. While, HIV spending was a relatively small percentage of both total health expenditure and gross domestic product, expenditure levels were noticeably higher in Haiti. These averages however conceal significant differences across countries, which should inform the magnitude and direction of any spending expansion by these countries if they are to achieve financial sustainability. Some recommendations are provided on the way forward to facilitate building a sustainable response to the epidemic.

Out-Of-Pocket Expenditures on Dental Care for Schoolchildren Aged 6 to 12 Years: A Cross-Sectional Estimate in a Less-Developed Country Setting.

Aim: The objective of this study was to estimate the Out-Of-Pocket Expenditures (OOPEs) incurred by households on dental care, as well as to analyze the sociodemographic, economic, and oral health factors associated with such expenditures. Method: A cross-sectional study was conducted among 763 schoolchildren in Mexico. A questionnaire was distributed to parents to determine the variables related to OOPEs on dental care. The amounts were updated in 2017 in Mexican pesos and later converted to 2017 international dollars (purchasing power parities-PPP US $). Multivariate models were created: a linear regression model (which modeled the amount of OOPEs), and a logistic regression model (which modeled the likelihood of incurring OOPEs). Results: The OOPEs on dental care for the 763 schoolchildren were PPP US $53,578, averaging a PPP of US $70.2 ± 123.7 per child. Disbursements for treatment were the principal item within the OOPEs. The factors associated with OOPEs were the child's age, number of dental visits, previous dental pain, main reason for dental visit, educational level of mother, type of health insurance, household car ownership, and socioeconomic position. Conclusions: The average cost of dental care was PPP US $70.2 ± 123.7. Our study shows that households with higher school-aged children exhibiting the highest report of dental morbidity-as well as those without insurance-face the highest OOPEs. An array of variables were associated with higher expenditures. In general, higher-income households spent more on dental care. However, the present study did not estimate unmet needs across the socioeconomic gradient, and thus, future research is needed to fully ascertain disease burden.