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

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

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.

A comprehensive examination of the economic impact of out-of-pocket health expenditures in India.

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

Effectiveness of interventions to contain out-of-pocket-expenditure in lower-middle income countries: A systematic review and synthesis.

The extant literature on myriad interventional strategies to contain the adverse financial impacts of soaring out-of-pocket expenditures commands systematic auditing and knowledge synthesis. The purpose of this study is to answer these specific questions. What are the interventions present in lower-middle-income countries? How effective are those interventions in reducing the household's out-of-pocket expenditure? Are the studies suffering from any methodological bias? The imprints for this systematic review are obtained from Scopus, PubMed, Web of Science, ProQuest and CINAHL. These manuscripts are identified in full compliance with PRISMA guidelines. The documents identified have undergone quality assessment checks using the 'Effective Public Health Practice Project'. The review identified Interventions that are found to reduce out-of-pocket expenditure are patient educational programs, a combination of financial assistance, healthcare facility quality upgrade measures, and early disease detection strategies. However, these reductions represented marginal changes in the total health expenditure of patients. The role of non-health insurance interventions and the combination of health insurance and non-health insurance measures are highlighted. This review concludes by emphasising the need for further research to fill the knowledge gap by building on the suggestions put forward.

Income-related inequality in out-of-pocket health-care expenditures under Taiwan's national health insurance system: An international comparable estimation based on A System of Health Accounts.

National estimates of out-of-pocket health-care expenditures (OOP-HCEs) that use comparable international guidelines based on A Systems of Health Accounts (SHA) are generally unavailable in Taiwan. International comparable OOP are essential for designing universal health-coverage (UHC) policy. We designed an SHA-based household OOP questionnaire. A nationally representative cross-sectional survey was then conducted from January to August 2022. The final questionnaire was completed by 657 households and 1969 individuals. The total OOPs were divided into expenditures related to curative care (HC.1), rehabilitative care (HC.2), long-term care (HC.3), ancillary services (HC.4), and medical goods (HC.5). National estimates were calculated by accounting for the complex survey design. Variance was estimated through Taylor series linearization. The concentration index was calculated using household income as the ranking variable. We then identified factors contributing to the inequality in OOP distribution by household income. National estimates revealed an OOP of NT$424 billion, which accounted for 29.6% of Taiwan's national health expenditure in 2021. Private health insurance (PHI) reimbursements accounted for 9.0% of the total OOP. The OOPs for curative care and medical goods accounted for 50.1% and 39.0% of the total OOP, respectively. The OOPs after PHI reimbursements were progressive (concentration index = 0.103, P = 0.012). The frequency of medical-care use and the number of medical visits negatively affected progressive OOPs. International comparable OOPs revealed that under the Taiwanese National Health Insurance (NHI), OOPs can still be high. However, the NHI might have caused OOPs to be progressive from the perspective of income but regressive from the perspective of health status. Countries striving for UHC should consider the redistribution effect of public health insurance and possible inequalities in health.

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

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

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

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

Household financial burden associated with healthcare for older people in Viet Nam: a cross-sectional survey.

BACKGROUND: Population ageing and the associated increase in the healthcare needs of older people are putting pressure on the healthcare system in Viet Nam. The country prioritizes healthcare for older people and has developed financial protection policies to mitigate financial hardship due to out-of-pocket health expenditures (OOPHEs) borne by their households. This study examines the level and determinants of the financial burden of OOPHE among households with people aged ≥ 60 years in Viet Nam. METHODS: A cross-sectional household survey was conducted among a sample of 1536 older people living in 1477 households in three provinces representing the North, Central and South regions of Viet Nam during 2019-2020. The financial outcomes were catastrophic health expenditure (CHE), using WHO's definition, and financial distress due to OOPHE. Multivariate binary logistic regression analysis was employed to determine the factors associated with these outcomes. RESULTS: OOPHE for older household members accounted for 86.3% of total household health expenditure. Of households with older people, 8.6% (127) faced CHE, and 12.2% (181) experienced financial distress due to OOPHE. Households were at a higher risk of incurring financial burdens related to health expenditures if they had fewer household members; included only older people; were in rural or remote, mountainous areas; and had older members with noncommunicable diseases. There was no significant association between health insurance coverage and financial burden. However, when older people sought tertiary care or private care, the possibility of a household facing CHE increased. Regardless of the type and level of care, health service utilization by older people results in a higher likelihood of a household encountering financial distress. CONCLUSIONS: This study reveals that OOPHE for older people can impose substantial financial burdens on households, leading them to face CHE and financial distress. This study provides evidence to justify reforming financial protection policies and introducing policy interventions targeted at better protecting older people and their households from the financial consequences of OOPHE. There is also the need to strengthen the grassroots health facilities to provide primary care closer to home at lower costs, particularly for the management of noncommunicable diseases.

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

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

Sensitivity analysis and methodological choices on health-related impoverishment estimates in Cambodia, 2009-17.

The measurement of health expenditure-related impoverishment as a proxy of financial risk protection is regularly used as an indicator of progress towards universal health coverage. However, the use of this indicator is greatly sensitive to analysts' choices and data sources, making comparisons across time and countries challenging. We report the results of a sensitivity analysis of critical methodological choices in estimating health-related financial impoverishment in Cambodia from 2009 to 2017. We include the following in our analysis: the construction and data sources for consumption aggregates and out-of-pocket health estimates; the use of international and national absolute and relative poverty thresholds (defined by the share of household food consumption); time and regional price adjustment methods and index sources. Marginal changes substantially affected estimates at the national and regional levels among households. In most cases, the choice of poverty thresholds and temporal and regional deflators had a significant effect. An increase of 0.01 USD in the average daily per capita poverty line resulted in relative increases in impoverished incidences of 2.90-2.62% for 2009 and 3.06-2.95% for 2014. From 2013 onwards, estimates for impoverishment in rural areas based on median food consumption were often significantly higher than estimates using official poverty lines. The high sensitivity of the impoverishment indicator cautions against its use in assessing health-related financial hardship and protection, especially with low and absolute poverty lines. In the context of low- and middle-income countries, assessing financial hardship in relative terms by using measures such as catastrophic health expenditure, complemented with research on coping strategies and their socio-economic effects on households, may be more conducive to policymaking goals and progress towards achieving universal health coverage.

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

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

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

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

Effects of a new health financing scheme on out-of-pocket health expenditure: findings from a longitudinal household study in Yangon, Myanmar.

Since 2017, Population Services International Myanmar (PSI/Myanmar) has been running Strategic Purchasing (SP) clinics in Hlegu and Shwepyithar townships in Yangon, Myanmar. In the project, Population Services International Myanmar simulated the role of a purchaser and contracted SP clinics through a capitation payment scheme. The project aimed to reduce the health-related financial burden of poor populations in the catchment area, by having them registered under respective SP clinics for access to a package of essential health services for a minimal fixed co-payment, as a replacement for usual fee-for-service payments. Four longitudinal surveys of households registered under SP clinics were conducted in 2017, 2018 and 2019. Among 2506 registered households, 867 households sought some health care in all surveys, resulting in 3468 observations. Multivariable linear mixed-effect regression model was used to analyse the changes in out-of-pocket expenditure for health care in relation to household capacity to pay (OOPCTP). The utilization of SP clinics increased over time, and the rates were much higher in Hlegu (20.5% in baseline to 61.9% in round three) compared with those in Shwepyithar (0.2 to 7.9%). Compared with the baseline assessment, household OOPCTP decreased significantly during and after the implementation (0.76 times in round one, 0.80 in round two and 0.82 in round three; P < 0.001). Households in Shwepyithar with less utilization of SP clinics had 1.8 times higher OOPCTP compared with those in Hlegu (1.82, 95% CI 1.58, 2.09; P < 0.001). Household direct expenditures on care-seeking and family planning were up to 50% lower among those who used SP clinics. Our study highlighted that capitation-based health financing schemes could successfully lower out-of-pocket health expenditures among the poor. Optimal utilization of services was paramount in the successful implementation of such programmes. Therefore, for the effective scale-up of new health financing schemes, service utilization rates should be carefully monitored as one of the critical indicators.

Spatiotemporal variation and socioeconomic factors of financial hardships of out-of-pocket health expenditure in Pakistan.

BACKGROUND: Financial hardships of out-of-pocket health expenditure (OPHE) is a growing concern for health policy makers in many low and middle-income countries. Spatiotemporal variation between Pakistan's four provinces over 2001-2015 is discussed, which would help comparing existing health services delivery and financial risk protection plans. AIMS: In this paper, we estimate financial hardship of OPHE in Pakistan. METHODS: We use the data sets of the household integrated economic surveys 2001-02, 2005-06, 2010-11 and 2015-16. We estimate OPHE share in household total and non-subsistence expenditure, catastrophic headcount at the threshold of OPHE ≥ 10% of total expenditure or OPHE ≥ 25% of non-subsistence expenditure. We estimate impoverishment of OPHE using national poverty lines. Finally, we explore socioeconomic factors of financial hardships of OPHE. RESULTS: Over the years, catastrophic headcount and impoverishment of OPHE had decreased at national level (-1.3% points) and in the provinces of Sindh (-7.8% points) and Khyber Pukhtoonkhawa (KPK), (-2.8% points). The province of KPK and the year 2005-06 witnessed the highest incidence of financial catastrophe (26.89% points) and impoverishment (4.8% points) of OPHE. Households in rural areas, in the middle and rich quintiles and those headed by a male were more likely to encounter financial catastrophe and impoverishment due to OPHE. CONCLUSION: Inter-provincial variation in financial hardships of OPHE provide aide to provincial level priority setting. The high impact of OPHE in the non-poor, in rural areas, and in KPK calls for enhanced targeting of financial risk protection plans.

Does social capital increase healthcare financing's projection? Results from the rural household of Uttar Pradesh, India.

In the absence of adequate social security, out-of-pocket health expenditure compels households to adopt coping strategies, such as utilizing savings, selling assets, or acquiring external financial support (EFS) by borrowing with interest. Households' probability of acquiring EFS and its amount (intensity) depends on its social capital - the nature of social relationships and resources embedded within social networks. This study examines the effect of social capital on the probability and intensity of EFS during health events in Uttar Pradesh (UP), India. The analysis used data from a cross-sectional survey of 6218 households, reporting 3066 healthcare events, from two districts of UP. Household heads (HH) reported demographic, socioeconomic, and health-related information, including EFS, for each household member. Self-reported data from Shortened and Adapted Social Capital Assessment Tool in India (SASCAT-I) was used to generate four unique social capital measures (organizational participation, social support, trust, and social cohesion) at HH and community-level, using multilevel confirmatory factor analysis. After descriptive analysis, two-part mixed-effect models were implemented to estimate the probability and intensity of EFS as a function of social capital measures, where multilevel mixed-effects probit regression was used as the first-part and multilevel mixed-effects linear model with log link and gamma distribution as the second-part. Controlling for all covariates, the probability of acquiring EFS significantly increased (p = 0.04) with higher social support of the HH and significantly decreased (p = 0.02) with higher community social cohesion. Conditional to receiving any EFS, higher social trust of the HH resulted in higher intensity of EFS (p = 0.09). Social support and trust may enable households to cope up with financial stress. However, controlling for the other dimensions of social capital, high cohesiveness with the community might restrict a household's access to external resources demonstrating the unintended effect of social capital exerted by formal or informal social control.

Improving access to medicines for non-communicable diseases in rural primary care: results from a quasi-randomized cluster trial in a district in South India.

BACKGROUND: A large proportion of non-communicable diseases (NCDs) are treatable within primary health care (PHC) settings in a cost-effective manner. However, the utilization of PHCs for NCD care is comparatively low in India. The Access-to-Medicines (ATM) study examined whether (and how) interventions aimed at health service optimization alone or combined with community platform strengthening improve access to medicines at the primary health care level within the context of a local health system. METHOD: A quasi-randomized cluster trial was used to assess the effectiveness of the intervention (18 months) implemented across 39 rural PHCs (clusters) of three sub-districts of Tumkur in southern India. The intervention was allocated randomly in a 1:1:1 sequence across PHCs and consisted of three arms: Arm A with a package of interventions aimed at health service delivery optimization; B for strengthening community platforms in addition to A; and the control arm. Group allocation was not blinded to providers and those who assessed outcomes. A household survey was used to understand health-seeking behaviour, access and out-of-pocket expenditure (OOP) on key anti-diabetic and anti-hypertension medicines among patients; facility surveys were used to assess the availability of medicines at PHCs. Primary outcomes of the study are the mean number of days of availability of antidiabetic and antihypertensive medicines at PHCs, the mean number of patients obtaining medicines from PHC and OOP expenses. RESULT: The difference-in-difference estimate shows a statistically insignificant increase of 31.5 and 11.9 in mean days for diabetes and hypertension medicines availability respectively in the study arm A PHCs beyond the increase in the control arm. We further found that there was a statistically insignificant increase of 2.2 and 3.8 percentage points in the mean proportion of patients obtaining medicines from PHC in arm A and arm B respectively, beyond the increase in the control arm. CONCLUSION: There were improvements in NCD medicine availability across PHCs, the number of patients accessing PHCs and reduction in OOP expenditure among patients, across the study arms as compared to the control arm; however, these differences were not statistically significant. TRIAL REGISTRATION: Trial registration number CTRI/2015/03/005640 . This trial was registered on 17/03/2015 in the Clinical Trial Registry of India (CTRI) after PHCs were enrolled in the study (retrospectively registered). The CTRI is the nodal agency of the Indian Council of Medical Research for registration of all clinical, experimental, field intervention and observation studies.

Out-of-Pocket Health Expenditure and Poverty: Evidence from a Dynamic Panel Threshold Analysis.

The current study investigated the association between out-of-pocket health expenditure and poverty using macroeconomic data from a sample of 145 countries from 2000 to 2017. In particular, it was examined whether the relationship between out-of-pocket health expenditure and poverty was contingent on a certain threshold level of out-of-pocket health spending. The dynamic panel threshold method, which allows for the endogeneity of the threshold regressor (out-of-pocket health expenditure), was used. Three indicators were adopted as poverty measures, namely the poverty headcount ratio, the poverty gap index, and the poverty gap squared index. At the same time, out-of-pocket health expenditure was measured as a percentage of total health expenditure. The results showed the validity of the estimated threshold models, indicating that only beyond the turning point, which was about 29 percent, that out-of-pocket health spending led to increased poverty. When heterogeneity was controlled for in the sample, using the World Bank income classification, the findings showed variations in the estimated threshold, with higher values for the low- and lower-middle-income groups, as compared to the high-income group. For the lower-income groups, below the threshold for out-of-pocket health expenditure, it had a positive or insignificant effect on poverty reduction, while it led to higher poverty above the threshold. Further, the sampled countries were divided into regions, according to the World Health Organization. Generally, improving health care systems through tolerable levels of out-of-pocket health expenditure is an inevitable step toward better health coverage and poverty reduction in many developing countries.

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

Health services utilization and out-of-pocket (OOP) expenditures in public and private facilities in Pakistan: an empirical analysis of the 2013-14 OOP health expenditure survey.

BACKGROUND: As low- and middle-income countries progress toward Universal Health Coverage, there is an increasing focus on measuring out-of-pocket (OOP) expenditure and health services utilization within countries. While there have been several reforms to improve health services coverage and financial protection in Pakistan, there is limited empirical research comparing OOP expenditure and health services utilization between public and private facilities and exploring their determinants, a knowledge gap addressed in this study. METHODS: We used data from 2013 to 14 OOP Health Expenditure Survey, a population-based household survey carried out for Pakistan's National Health Accounts. The analysis included 7969 encounters from 4293 households. We conducted bivariate analyses to describe patterns of care utilization, estimated annualized expenditures by type and sector of care, and assessed expenditure composition. We used multivariable logistic regression modeling to identify factors associated with sector of care and generalized linear model (GLM) with log link and gamma distribution to identify determinants of OOP expenditures stratified by type of care (inpatient and outpatient). RESULTS: Most encounters (82.5%) were in the private sector and were for outpatient visits (85%). Several public-private differences were observed in annualized expenditures and expenditure components. Logistic regression results indicate males, wealthier individuals, Punjab and Sindh residents, and those in smaller households were more likely to access private outpatient care. In the inpatient model, rural residents were more likely to use a private provider, while Khyber Pakhtunkhwa residents were less likely to use private care. GLM results indicate private sector inpatient expenditures were approximately PKR 6660 (USD 61.8) higher than public sector expenditures, but no public-private differences were observed for outpatient expenditures. Several demographic factors were significantly associated with outpatient and inpatient expenditures. Of note, expenditures increased with increasing wealth, decreased with increasing household size, and differed by province and region. CONCLUSIONS: This is the first study comprehensively investigating how healthcare utilization and OOP expenditures vary by sector, type of care, and socio-economic characteristics in Pakistan. The findings are expected to be particularly useful for the next phase of social health protection programs and supply side reforms, as they highlight sub-populations with higher OOP and private sector utilization.

Effect of health insurance program for the poor on out-of-pocket inpatient care cost in India: evidence from a nationally representative cross-sectional survey.

BACKGROUND: In India, Out-of-pocket expenses accounts for about 62.6% of total health expenditure - one of the highest in the world. Lack of health insurance coverage and inadequate coverage are important reasons for high out-of-pocket health expenditures. There are many Public Health Insurance Programs offered by the Government that cover the cost of hospitalization for the people below poverty line (BPL), but their coverage is still not complete. The objective of this research is to examine the effect of Public Health Insurance Programs for the Poor on hospitalizations and inpatient Out-of-Pocket costs. METHODS: Data from the recent national survey by the National Sample Survey Organization, Social Consumption in Health 2014 are used. Propensity score matching was used to identify comparable non-enrolled individuals for individuals enrolled in health insurance programs. Binary logistic regression model, Tobit model, and a Two-part model were used to study the effects of enrolment under Public Health Insurance Programs for the Poor on the incidence of hospitalizations, length of hospitalization, and Out-of- Pocket payments for inpatient care. RESULTS: There were 64,270 BPL people in the sample. Individuals enrolled in health insurance for the poor have 1.21 higher odds of incidence of hospitalization compared to matched poor individuals without the health insurance coverage. Enrollment under the poor people health insurance program did not have any effect on length of hospitalization and inpatient Out-of-Pocket health expenditures. Logistic regression model showed that chronic illness, household size, and age of the individual had significant effects on hospitalization incidence. Tobit model results showed that individuals who had chronic illnesses and belonging to other backward social group had significant effects on hospital length of stay. Tobit model showed that days of hospital stay, education and age of patient, using a private hospital for treatment, admission in a paying ward, and having some specific comorbidities had significant positive effect on out-of-pocket costs. CONCLUSIONS: Enrolment in the public health insurance programs for the poor increased the utilization of inpatient health care. Health insurance coverage should be expanded to cover outpatient services to discourage overutilization of inpatient services. To reduce out-of-pocket costs, insurance needs to cover all family members rather than restricting coverage to a specific maximum defined.