From the local disparities to national realities: Mapping and multilevel modeling of catastrophic health expenditure in Bangladesh using HIES 2016.

In developing nations, catastrophic health expenditures have become an all-too-common occurrence, threatening to push households into impoverishment and poverty. By analyzing the Household Income and Expenditure Survey 2016, which features a sample of 46,080 households, this study provides a comprehensive district-by-district analysis of the variation in household catastrophic health expenditures and related factors. The study utilizes a multilevel logistic regression model, which considers both fixed and random effects to identify factors associated with catastrophic health expenditure. The findings of the study indicate that districts located in the eastern and southern regions are at a significantly higher risk of experiencing catastrophic health expenditures. A potential explanation for this trend may be attributed to the high prevalence of chronic diseases in these districts, as well as their economic conditions. The presence of chronic diseases (AOR 5.45 with 95% CI: 5.14, 5.77), presence of old age person (AOR 1.50 with 95% CI: 1.39, 1.61), place of residence (AOR 1.40 with 95% CI: 1.14, 1.73) are found to be highly associated factors. Additionally, the study reveals that the thresholds used to define catastrophic health expenditures exhibit substantial variation across different regions, and differ remarkably from the threshold established by the WHO. On average, the thresholds are 23.12% of nonfood expenditure and 12.14% of total expenditure. In light of these findings, this study offers important insights for policymakers and stakeholders working towards achieving universal health coverage and sustainable development goals in Bangladesh.

Prevalence and Determinants of Catastrophic Healthcare Expenditures in Iran From 2013 to 2019.

OBJECTIVES: Protecting people against financial hardship caused by illness stands as a fundamental obligation within healthcare systems and constitutes a pivotal component in achieving universal health coverage. The objective of this study was to analyze the prevalence and determinants of catastrophic health expenditures (CHE) in Iran, over the period of 2013 to 2019. METHODS: Data were obtained from 7 annual national surveys conducted between 2013 and 2019 on the income and expenditures of Iranian households. The prevalence of CHE was determined using a threshold of 40% of household capacity to pay for healthcare. A binary logistic regression model was used to identify the determinants influencing CHE. RESULTS: The prevalence of CHE increased from 3.60% in 2013 to 3.95% in 2019. In all the years analyzed, the extent of CHE occurrence among rural populations exceeded that of urban populations. Living in an urban area, having a higher wealth index, possessing health insurance coverage, and having employed family members, an employed household head, and a literate household head are all associated with a reduced likelihood of CHE (p<0.05). Conversely, the use of dental, outpatient, and inpatient care, and the presence of elderly members in the household, are associated with an increased probability of facing CHE (p<0.05). CONCLUSIONS: Throughout the study period, CHE consistently exceeded the 1% threshold designated in the national development plan. Continuous monitoring of CHE and its determinants at both household and health system levels is essential for the implementation of effective strategies aimed at enhancing financial protection.

Regional catastrophic health expenditure and health inequality in China.

Background: Catastrophic health expenditures (CHE) can trigger illness-caused poverty and compound poverty-caused illness. Our study is the first regional comparative study to analyze CHE trends and health inequality in eastern, central and western China, exploring the differences and disparities across regions to make targeted health policy recommendations. Methods: Using data from China's Household Panel Study (CFPS), we selected Shanghai, Henan and Gansu as representative eastern-central-western regional provinces to construct a unique 5-year CHE unbalanced panel dataset. CHE incidence was measured by calculating headcount; CHE intensity was measured by overshoot and CHE inequality was estimated by concentration curves (CC) and the concentration index (CI). A random effect model was employed to analyze the impact of household head socio-economic characteristics, the household socio-economic characteristics and household health utilization on CHE incidence across the three regions. Results: The study found that the incidence and intensity of CHE decreased, but the degree of CHE inequality increased, across all three regions. For all regions, the trend of inequality first decreased and then increased. We also revealed significant differences across the eastern, central and western regions of China in CHE incidence, intensity, inequality and regional differences in the CHE influencing factors. Affected by factors such as the gap between the rich and the poor and the uneven distribution of medical resources, families in the eastern region who were unmarried, use supplementary medical insurance, and had members receiving outpatient treatment were more likely to experience CHE. Families with chronic diseases in the central and western regions were more likely to suffer CHE, and rural families in the western region were more likely to experience CHE. Conclusions: The trends and causes of CHE varied across the different regions, which requires a further tilt of medical resources to the central and western regions; improved prevention and financial support for chronic diseases households; and reform of the insurance reimbursement policy of outpatient medical insurance. On a regional basis, health policy should not only address CHE incidence and intensity, but also its inequality.

Association of Catastrophic Health Expenditure With the Risk of Depression in Chinese Adults: Population-Based Cohort Study.

BACKGROUND: Depression is one of the most common mental illnesses, and it may have a lasting effect on one's whole life. As a form of financial hardship, catastrophic health expenditure (CHE) may be associated with depression. However, current evidence about the relationship between CHE and the risk of depression is insufficient. OBJECTIVE: This study aimed to explore the relationship between CHE and the risk of depression among Chinese adults. METHODS: In this study, we used 3 waves of the China Family Panel Studies (CFPS) from 2012, 2016, and 2018. The CFPS are a nationally representative study covering 25 of 31 provinces in Chinese mainland and representing nearly 94.5% of the total population. We selected eligible household heads as participants, divided them into 2 groups by CHE events at baseline (exposed group: with CHE; unexposed group: without CHE), and followed them up. Households with CHE were defined as having out-of-pocket medical expenditures exceeding 40% of the total household nonfood expenditure, and people with depression were identified by the 8-item Centre for Epidemiological Studies Depression Scale (CES-D). We first described the baseline characteristics and used logistical regression to estimate their effects on CHE events. Then, we used Cox proportional hazard models to estimate adjusted hazard ratios and 95% CIs of depression among participants with CHE compared with those without CHE. Finally, we analyzed the subgroup difference in the association between CHE and depression. RESULTS: Of a total of 13,315 households, 9629 were eligible for analysis. Among them, 6824 (70.9%) were men. The mean age was 50.15 (SD 12.84) years. Only 987 (10.3%) participants had no medical insurance. The prevalence of CHE at baseline was 12.9% (1393/9629). Participants with a higher family economic level (adjusted odds ratio [aOR] 1.15, 95% CI 1.02-1.31) and with the highest socioeconomic development level (aOR 1.18, 95% CI 1.04-1.34) had a higher prevalence of CHE than reference groups. During a median of 71 (IQR 69-72) person-months of follow-up, the depression incidence of participants with CHE (1.41 per 1000 person-months) was higher than those without CHE (0.73 per 1000 person-months). Multivariable models revealed that the adjusted hazard ratio for the incidence of depression in participants with CHE was 1.33 (95% CI 1.08-1.64), and this association appeared to be greater in participants without outpatient services (for interaction, P=.048). CONCLUSIONS: CHE was significantly associated with increased risk of depression among Chinese adults. Concentrated work should be done to monitor CHE, and more efforts to ensure financial protection need to be made to prevent depression, especially for people with high health care needs.

Catastrophic health expenditure and the risk of depression among middle-aged and old people in China: a national population-based longitudinal study.

AIMS: To estimate the association of catastrophic health expenditure (CHE) with the risk of depression in middle-aged and old people in China. METHODS: We used data of 2011, 2013, 2015 and 2018 from the China Health and Retirement Longitudinal Study, which covered 150 counties of 28 provinces in China. CHE was calculated as out-of-pocket health expenditure exceeding 40% of a household's capacity to pay. Depression was measured by a 10-item Centre for Epidemiological Studies Depression Scale. We evaluated CHE prevalence and applied Cox proportional hazard models to estimate adjusted hazard ratios (aHRs) and 95% confident intervals (CIs) for the risk of depression among participants with CHE after controlling potential confounders, compared with those without CHE. RESULTS: Among 5765 households included in this study, CHE prevalence at baseline was 19.24%. The depression incidence of participants with CHE (8.00 per 1000 person-month) was higher than that of those without CHE (6.81 per 1000 person-month). After controlling confounders, participants with CHE had a 13% higher risk (aHR = 1.13, 95% CI: 1.02-1.26) of depression than those without CHE. In subgroup analysis, the association of CHE with depression was significant in males and in people with chronic diseases, of younger age, living in rural areas and of lowest family economic level (all P < 0.05). CONCLUSIONS: Nearly one of five middle-aged and old people in China incurred CHE, and CHE was associated with the risk of depression. Concerted efforts should be made to monitor CHE and related depression episode. Moreover, timely interventions about CHE and depression need to be implemented and strengthened among middle-aged and old people.

Associations among socioeconomic status, multimorbidity of non-communicable diseases, and the risk of household catastrophic health expenditure in China: a population-based cohort study.

BACKGROUND: Multimorbidity of non-communicable diseases (NCDs) is increasingly prevalent among older adults around the world, leading a higher risk of household catastrophic health expenditure (CHE). As current powerful evidence was insufficient, we aimed to estimate the association between multimorbidity of NCDs and the risk of CHE in China. METHODS: We designed a cohort study using data investigated in 2011-2018 from the China Health and Retirement Longitudinal Study, which is a nationally-representative study covering 150 counties of 28 provinces in China. We used mean ± standard deviation (SD) and frequencies and percentages to describe baseline characteristics. Person χ2 test was employed to compare the differences of baseline characteristics between households with and without multimorbidity. Lorenz curve and concentration index were used to measure the socioeconomic inequalities of CHE incidence. Cox proportional hazards models were applied to estimate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for the association between multimorbidity and CHE. RESULTS: Among 17,708 participants, 17,182 individuals were included for the descriptive analysis of the prevalence of multimorbidity in 2011, and 13,299 individuals (8029 households) met inclusion criteria and were included in the final analysis with a median of 83 (interquartile range: 25-84) person-months of follow-up. 45.1% (7752/17,182) individuals and 56.9% (4571/8029) households had multimorbidity at baseline. Participants with higher family economic level (aOR = 0.91, 95% CI: 0.86-0.97) had lower multimorbidity prevalence than those with lowest family economic level. 82.1% of participants with multimorbidity did not make use of outpatient care. The CHE incidence was more concentrated among participants with higher socioeconomic status (SES) with a concentration index of 0.059. The risk of CHE was 19% (aHR = 1.19, 95% CI: 1.16-1.22) higher for each additional NCD. CONCLUSIONS: Approximately half of middle-aged and older adults in China had multimorbidity, causing a 19% higher risk of CHE for each additional NCD. Early interventions for preventing multimorbidity among people with low SES could be intensified to protect older adults from financial hardship. In addition, concerted efforts are needed to increase patients' rational healthcare utilization and strengthen current medical security for people with high SES to reduce economic disparities in CHE.

Factors influencing catastrophic health expenditure of households with people with diabetes in Northwest China-an example from Gansu Province.

BACKGROUND: Diabetes is a chronic non-communicable disease that causes a substantial economic burden on diabetic suffers and their households. The aim of this study was to explore the prevalence, equity, and determinants of catastrophic health expenditure (CHE) among households with people with diabetes in Northwest China. METHODS: A total of 3,000 households were included in the 6th Health services survey in Gansu Province, China of which 270 households with people with diabetes. The equity of CHE was evaluated by concentration curve and concentration index (CI). We adopted the Pareto chart to analyze the main economic intervals of the occurrence of CHE. Finally, we combined the decision tree and logistic model and analyzed the determinants of the occurrence of CHE. RESULTS: The incidence of CHE at 15%, 25% and 40% were 75.19%, 58.89% and 35.19%, respectively. CHE tended to occur in households with a lower economic level, with the phenomenon being more pronounced at Z = 40%. The Pareto chart showed that households in the group with an annual per capita income of 0-740 USD (0-5,000 Chinese Yuan) were most likely to experience CHE. Both decision tree and logistic models suggested that economic level, comorbidities, and small household size were potential risk factors. In addition, the decision tree model also suggested the interaction between the influencing factor of health checks in the past 12 months and the number of chronic diseases. CONCLUSIONS: In summary, Households with people with diabetes were more likely to incur CHE. It is essential to focus on low- and middle-income households with people with diabetes, strengthen the management of patients with diabetes, and provide timely health interventions to reduce the occurrence of chronic comorbidity and the risk of CHE in households.

Household catastrophic health expenditure for COVID-19 during March-August 2021, in South India: a cross-sectional study.

BACKGROUND: The Coronavirus disease 2019 (COVID-19) pandemic increased the utilisation of healthcare services. Such utilization could lead to higher out-of-pocket expenditure (OOPE) and catastrophic health expenditures (CHE). We estimated OOPE and the proportion of households that experienced CHE by conducting a cross-sectional survey of 1200 randomly selected confirmed COVID-19 cases. METHODS: A cross-sectional survey was conducted by telephonic interviews of 1200 randomly selected COVID-19 patients who tested positive between 1 March and 31 August 2021. We collected household-level information on demographics, income, expenditure, insurance coverage, direct medical and non-medical costs incurred toward COVID-19 management. We estimated the proportion of CHE with a 95% confidence interval. We examined the association of household characteristics; COVID-19 cases, severity, and hospitalisation status with CHE. A multivariable logistic regression analysis was conducted to ascertain the effects of variables of interest on the likelihood that households face CHE due to COVID-19. RESULTS: The mean (95%CI) OOPE per household was INR 122,221 (92,744-1,51,698) [US$1,643 (1,247-2,040)]. Among households, 61.7% faced OOPE, and 25.8% experienced CHE due to COVID-19. The odds of facing CHE were high among the households; with a family member over 65 years [OR = 2.89 (2.03-4.12)], with a comorbid individual [OR = 3.38 (2.41-4.75)], in the lowest income quintile [OR = 1.82 (1.12-2.95)], any member visited private hospital [OR = 11.85 (7.68-18.27)]. The odds of having CHE in a household who have received insurance claims [OR = 5.8 (2.81- 11.97)] were high. Households with one and more than one severe COVID-19 increased the risk of CHE by more than two-times and three-times respectively [AOR = 2.67 (1.27-5.58); AOR = 3.18 (1.49-6.81)]. CONCLUSION: COVID-19 severity increases household OOPE and CHE. Strengthening the public healthcare and health insurance with higher health financing is indispensable for financial risk protection of households with severe COVID-19 from CHE.

Multimorbidity and catastrophic health expenditure: Evidence from the China Health and Retirement Longitudinal Study.

Background: Population aging accompanied by multimorbidity imposes a great burden on households and the healthcare system. This study aimed to determine the incidence and determinants of catastrophic health expenditure (CHE) in the households of old people with multimorbidity in China. Methods: Data were obtained from the China Health and Retirement Longitudinal Study (CHARLS) conducted in 2018, with 3,511 old people (≥60 years) with multimorbidity responding to the survey on behalf of their households. CHE was identified using two thresholds: ≥10% of out-of-pocket (OOP) health spending in total household expenditure (THE) and ≥40% of OOP health spending in household capacity to pay (CTP) measured by non-food household expenditure. Logistic regression models were established to identify the individual and household characteristics associated with CHE incidence. Results: The median values of THE, OOP health spending, and CTP reached 19,900, 1,500, and 10,520 Yuan, respectively. The CHE incidence reached 31.5% using the ≥40% CTP threshold and 45.6% using the ≥10% THE threshold. It increased by the number of chronic conditions reported by the respondents (aOR = 1.293-1.855, p < 0.05) and decreased with increasing household economic status (aOR = 1.622-4.595 relative the highest quartile, p < 0.001). Hospital admissions over the past year (aOR = 6.707, 95% CI: 5.186 to 8.674) and outpatient visits over the past month (aOR = 4.891, 95% CI: 3.822 to 6.259) of the respondents were the strongest predictors of CHE incidence. The respondents who were male (aOR = 1.266, 95% CI: 1.054 to 1.521), married (OR = 1.502, 95% CI: 1.211 to 1.862), older than 70 years (aOR = 1.288-1.458 relative to 60-69 years, p < 0.05), completed primary (aOR = 1.328 relative to illiterate, 95% CI: 1.079 to 1.635) or secondary school education (aOR = 1.305 relative to illiterate, 95% CI: 1.002 to 1.701), lived in a small (≤2 members) household (aOR = 2.207, 95% CI: 1.825 to 2.669), and resided in the northeast region (aOR = 1.935 relative to eastern, 95% CI: 1.396 to 2.682) were more likely to incur CHE. Conclusion: Multimorbidity is a significant risk of CHE. Household CHE incidence increases with the number of reported chronic conditions. Socioeconomic and regional disparities in CHE incidence persist in China.

Factors associated with catastrophic health expenditure in sub-Saharan Africa: A systematic review.

OBJECTIVE: A non-negligible proportion of sub-Saharan African (SSA) households experience catastrophic costs accessing healthcare. This study aimed to systematically review the existing evidence to identify factors associated with catastrophic health expenditure (CHE) incidence in the region. METHODS: We searched PubMed, CINAHL, Scopus, CNKI, Africa Journal Online, SciELO, PsycINFO, and Web of Science, and supplemented these with search of grey literature, pre-publication server deposits, Google Scholar®, and citation tracking of included studies. We assessed methodological quality of included studies using the Appraisal tool for Cross-Sectional Studies for quantitative studies and the Critical Appraisal Skills Programme checklist for qualitative studies; and synthesized study findings according to the guidelines of the Economic and Social Research Council. RESULTS: We identified 82 quantitative, 3 qualitative, and 4 mixed-methods studies involving 3,112,322 individuals in 650,297 households in 29 SSA countries. Overall, we identified 29 population-level and 38 disease-specific factors associated with CHE incidence in the region. Significant population-level CHE-associated factors were rural residence, poor socioeconomic status, absent health insurance, large household size, unemployed household head, advanced age (elderly), hospitalization, chronic illness, utilization of specialist healthcare, and utilization of private healthcare providers. Significant distinct disease-specific factors were disability in a household member for NCDs; severe malaria, blood transfusion, neonatal intensive care, and distant facilities for maternal and child health services; emergency surgery for surgery/trauma patients; and low CD4-count, HIV and TB co-infection, and extra-pulmonary TB for HIV/TB patients. CONCLUSIONS: Multiple household and health system level factors need to be addressed to improve financial risk protection and healthcare access and utilization in SSA. PROTOCOL REGISTRATION: PROSPERO CRD42021274830.

Catastrophic health expenditure in the Northern midlands and mountainous areas and its determinants, Vietnam from 2014 to 2020: a cross-sectional study.

OBJECTIVES: The study assesses households' catastrophic health expenditure (CHE) by income group, urban versus rural area, and influencing factors in the Northern midlands and mountainous areas of Vietnam. DESIGN/SETTING: A cross-sectional study with the four waves of data from 2014, 2016, 2018 and 2020 Vietnam household living standards surveys was used. PARTICIPANTS: The number of participants in this study were 1658, 1661, 1659 and 1662 households in 2014, 2016, 2018 and 2020, respectively. We included households residing in the Northern midlands and mountain areas of Vietnam. OUTCOMES MEASURE: We examined out-of-pocket health payments and capacity to pay by income groups and place of residence, the incidence of CHE and impoverishment. A logistic regression model was used to examine the influence of demographic and socioeconomic characteristics on CHE. RESULTS: The findings showed a remarkable decrease in CHE between 2014 and 2016, followed by a considerable increase between 2016 and 2018. The CHE rates in the region were between 3.5% and 5%, with the highest value observed in 2014. In addition, the differences in household CHE rates according to income and place of residence were observed. The results also indicated that medical impoverishment ranged between 3.4% and 3.9%. Overall, factors such as the burden of disease, rural settlements, increasing use of healthcare services, visiting private health facilities and having an old-aged person in the household were significantly and positively associated with CHE. By contrast, households that were wealthier, participated in health insurance, had a household head employed and female-headed households, were negatively associated with CHE. CONCLUSIONS: The findings provide useful information that can guide policy-makers to design policies, and interventions necessary to reduce CHE in the region, narrow the gap between the rich and the poor, the rural and urban settlements, and ensure universal health coverage.

Catastrophic health expenditure among Chinese adults living alone with cognitive impairment: findings from the CHARLS.

BACKGROUND: The catastrophic health expenditure of older adults results in serious consequences; however, the issue of whether cognitive status and living situations contribute to such financial burdens is uncertain. Our aim was to compare the differences in catastrophic health expenditure between adults living alone with cognitive impairment and those adults living with others and with normal cognition. METHODS: We identified 909 observations of participants living alone with cognitive impairment (cases) and 37,432 observations of participants living with others and with normal cognition (comparators) from the 2011/2012, 2013, 2015 and 2018 waves of the China Health and Retirement Longitudinal Study (CHARLS). We used propensity score matching (1:2) to create matched cases and comparators in a covariate-adjusted logistic regression analysis. Catastrophic health expenditure was defined as an out-of-pocket cost for health care ≥40% of a household's capacity to pay. RESULTS: In comparison with participants living with others and with normal cognition, those adults living alone with cognitive impairment reported a higher percentage of catastrophic health expenditure (19.5% vs. 11.8%, respectively, P < 0.001). When controlling for age, sex, education, marital status, residence areas, alcohol consumption, smoking status and disease counts, we found that this subpopulation had significantly higher odds of having catastrophic health expenditure (odds ratio [OR] = 1.89, 95% confidence interval [CI]: 1.40, 2.56). Additional analyses confirmed the robustness of the results. CONCLUSIONS: This study demonstrated that adults living alone with cognitive impairment in the CHARLS experienced a high burden of catastrophic health expenditure. Health care policies on social health insurance and medical assistance should consider these vulnerable adults.

Incidence and determinants of catastrophic health expenditure among low-income Malaysian households.

INTRODUCTION: Catastrophic health expenditure (CHE) incurs when out-of-pocket health expenditure (OOPHE) exceeds a certain threshold, therefore exposing households to financial hardship, with the low-income population being most vulnerable. Data related to the incidence and determinants of CHE among the low-income population in Malaysia are lacking. This study aims to determine the incidence and determinants of CHE among Malaysian lowincome households. METHODOLOGY: This is a cross-sectional study using data from 6,720 low-income households from the national Household Expenditure Survey (HES) 2016 conducted from May 2016 till February 2017. The data were analysed using IBM SPSS software 25.0. OOPHE in this study included all spending on healthcare products and services by the household. CHE was identified in households with OOPHE of at least 10% of total monthly income. RESULTS: The incidence of CHE at the threshold of 10% household income was 1.7% (n=112). The determinants of CHE were households with any accident or medical insurance (p<0.001), having less than five members in a household (p<0.001), presence of elderly (p=0.024), and hospitalisation (p=0.021). In contrast, employment of the head of household (p=0.003) and having a child aged ≤5 years old (p=0.033) protect households from CHE. CONCLUSION: In the context of this study, the incidence of CHE among the low-income Malaysian population was low, indicating that a majority of the low-income population is protected from financial catastrophe. Regardless, the determinants of CHE among low-income population should be considered in future health policies.

Financial risk protection from out-of-pocket health spending in low- and middle-income countries: a scoping review of the literature.

BACKGROUND: Financial risk protection (FRP), defined as households' access to needed healthcare services without experiencing undue financial hardship, is a critical health systems target, particularly in low- and middle-income countries (LMICs). Given the remarkable growth in FRP literature in recent times, we conducted a scoping review of the literature on FRP from out-of-pocket (OOP) health spending in LMICs. The objective was to review current knowledge, identify evidence gaps and propose future research directions. METHODS: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines to conduct this scoping review. We systematically searched PubMed, Scopus, ProQuest and Web of Science in July 2021 for literature published since 1 January 2015. We included empirical studies that used nationally representative data from household surveys to measure the incidence of at least one of the following indicators: catastrophic health expenditure (CHE), impoverishment, adoption of strategies to cope with OOP expenses, and forgone care for financial reasons. Our review covered 155 studies and analysed the geographical focus, data sources, methods and analytical rigour of the studies. We also examined the level of FRP by disease categories (all diseases, chronic illnesses, communicable diseases) and the effect of health insurance on FRP. RESULTS: The extant literature primarily focused on India and China as research settings. Notably, no FRP study was available on chronic illness in any low-income country (LIC) or on communicable diseases in an upper-middle-income country (UMIC). Only one study comprehensively measured FRP by examining all four indicators. Most studies assessed (lack of) FRP as CHE incidence alone (37.4%) or as CHE and impoverishment incidence (39.4%). However, the LMIC literature did not incorporate the recent methodological advances to measure CHE and impoverishment that address the limitations of conventional methods. There were also gaps in utilizing available panel data to determine the length of the lack of FRP (e.g. duration of poverty caused by OOP expenses). The current estimates of FRP varied substantially among the LMICs, with some of the poorest countries in the world experiencing similar or even lower rates of CHE and impoverishment compared with the UMICs. Also, health insurance in LMICs did not consistently offer a higher degree of FRP. CONCLUSION: The literature to date is unable to provide a reliable representation of the actual level of protection enjoyed by the LMIC population because of the lack of comprehensive measurement of FRP indicators coupled with the use of dated methodologies. Future research in LMICs should address the shortcomings identified in this review.

Catastrophic health expenditure in sub-Saharan Africa: systematic review and meta-analysis.

Objective: To estimate the incidence of, and trends in, catastrophic health expenditure in sub-Saharan Africa. Methods: We systematically reviewed the scientific and grey literature to identify population-based studies on catastrophic health expenditure in sub-Saharan Africa published between 2000 and 2021. We performed a meta-analysis using two definitions of catastrophic health expenditure: 10% of total household expenditure and 40% of household non-food expenditure. The results of individual studies were pooled by pairwise meta-analysis using the random-effects model. Findings: We identified 111 publications covering a total of 1 040 620 households across 31 sub-Saharan African countries. Overall, the pooled annual incidence of catastrophic health expenditure was 16.5% (95% confidence interval, CI: 12.9-20.4; 50 datapoints; 462 151 households; I 2 = 99.9%) for a threshold of 10% of total household expenditure and 8.7% (95% CI: 7.2-10.3; 84 datapoints; 795 355 households; I 2 = 99.8%) for a threshold of 40% of household non-food expenditure. Countries in central and southern sub-Saharan Africa had the highest and lowest incidence, respectively. A trend analysis found that, after initially declining in the 2000s, the incidence of catastrophic health expenditure in sub-Saharan Africa increased between 2010 and 2020. The incidence among people affected by specific diseases, such as noncommunicable diseases, HIV/AIDS and tuberculosis, was generally higher. Conclusion: Although data on catastrophic health expenditure for some countries were sparse, the data available suggest that a non-negligible share of households in sub-Saharan Africa experienced catastrophic expenditure when accessing health-care services. Stronger financial protection measures are needed.

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.

Sarcopenia and catastrophic health expenditure by socio-economic groups in China: an analysis of household-based panel data.

BACKGROUND: Sarcopenia was thought to be associated with adverse outcomes and will cause lots of health expenditure. But the relationship between sarcopenia and catastrophic health expenditure (CHE) had been little explored. Here, we examined the distribution of sarcopenia in relation to medical and payment burdens. METHODS: We used data from three waves of China Health and Retirement Longitudinal Study including 14 130 participants from 9077 households aged over 50 years old. Sarcopenia was operationalized according to the Asian Working Group for Sarcopenia 2019. Medical expenditure was obtained by self-reported data, and CHE was identified by WHO definitions. We used the negative binomial regression model and logistic mixed-effects models to examine the associations between sarcopenia and medical and CHE. RESULTS: A total of 14 130 participants [52.2% female, aged 60.8 (SD 9.3)] from 9077 households were included in this study. The prevalence of sarcopenia was 19.8%, 11.9% for moderate sarcopenia, and 7.9% for severe sarcopenia, respectively. We identified 1416 household CHE events in all three waves. Severe sarcopenia was associated with an increase in the number of inpatient visits [incidence rate ratio 1.31, 95% confidence interval (CI): 1.03-1.66, P = 0.03] and the risk of CHE (odds ratio: 1.04, 95% CI: 1.01-1.07, P < 0.01). We saw similar effects in health service use of sarcopenia in different socio-economic groups. Moderate sarcopenia increased the risk of CHE in the lowest socio-economic group (odds ratio 1.03, 95% CI: 1.01-1.06, P = 0.03) and had no statistical significance in other groups. The association between severe sarcopenia and CHE did not attenuate after the adjustment of disease factors. CONCLUSIONS: Severe sarcopenia may increase the risk of CHE. Timely and effective intervention on moderate sarcopenia from severe sarcopenia will contribute to reduce the health burden.

What Policy Approaches Were Effective in Reducing Catastrophic Health Expenditure? A Systematic Review of Studies from Multiple Countries.

BACKGROUND: The United Nations set a goal for universal health coverage in all countries by 2030 and selected the catastrophic health expenditure (CHE) indicator as an assessment tool for this goal. Many countries have strived to reduce household CHE. However, no study has compared countries whose policies have had a remarkable effect on decreasing CHE. Therefore, the purpose of this systematic literature review is to find appropriate methods for measuring CHE that can help us to analyze the impact of health policies and identify countries whose health policies are most effective in reducing CHE. METHOD: PubMed and Web of Science were searched. Studies that measured the incidence or intensity of CHE in multiple years were included. Two independent reviewers screened the literature, extracted the data, and analyzed the studies selected. Thirty-eight studies met the inclusion criteria for the review. We classified the selected research papers to random sampling and quasi-experimental studies. RESULTS: We graphically presented the results of CHE incidence and intensity rates reported in the collected papers as a time series data set. Since most studies did not use sample weights, it was not easy to confirm whether the time series changes of CHE are significant. Therefore, we could find only two countries that had policy effects. Both countries established policies that focus on the poor. CONCLUSION: There are so many studies that analyze CHE, but policies that are effective in reducing CHE are unknown. This study uses a systematic literature review methodology to determine effective policies by comparing CHE time series trends among countries. As a policy implication, it was found that because CHE is defined as the ratio of the ability to pay to medical expenses, a policy of differential medical expenses that is based on income level is effective.

Catastrophic health expenditure in patients with Guillain Barre syndrome: Retrospective study.

INTRODUCTION: Catastrophic health expenditure (CHE) is a reliable measure of the financial unpreparedness of the studied population to meet unexpected health issues. The alarming proportion of patients who incur CHE in the wake of an acute neurological illness like Guillain Barre Syndrome (GBS) is of serious concern in a country like India where a large majority of households are uninsured. METHODOLOGY: Medical records of patients diagnosed with at a tertiary care centre in Delhi were analysed retrospectively to determine the rate of CHE. Clinical details and other contributory variables were also recorded. RESULTS: 53 patients with a median age of 29 years (10.5-46.5) were included in the study. Tow- third of patients were less than 40 years of age and 58.5% were male. 90.6% of patients incurred CHE with a median amount INR 273 300 spent out of pocket. CONCLUSION: The enormous magnitude of financial distress and crisis emerging out of an acute neurological illness needs to be addressed with urgency to prevent impoverishment of already weakened households.

A dominance approach to analyze the incidence of catastrophic health expenditures in Iran.

Financial protection is a health system goal for all countries. Assessing progress on this relies on measuring the incidence of catastrophic health expenditures (proportion of the population whose out-of-pocket (OOP) payments for health surpass a certain threshold of household resources). Standard approaches rely on selective thresholds, however this masks varying intensities of financial hardship and poses a measurement challenge as incidence is sensitive to the choice of the threshold. We address this problem by applying the dominance approach, which tests differences in catastrophic incidence curves over a continuous range of thresholds. Iran is an interesting country for empirical application of the dominance approach given its historically high reliance on OOP payments to finance its health system and its commitment to improving financial protection through several national health policies over the last two decades. Using data from annual Household Income and Expenditure Surveys from 2005 to 2017 (sample size: 26,851-39,088 households), incidence was analyzed following this novel approach. Distribution of incidence across socio-economic status was also analyzed by estimating concentration indices and across health services or products by estimating average shares of each item. Results showed that over time catastrophic health expenditures increased for thresholds lower than 25% and decreased for thresholds higher than 35%. Catastrophic health expenditures were more equally distributed across income levels at lower thresholds, becoming concentrated amongst the rich as the threshold rose. Medicines represented the largest share of catastrophic spending for the poorest; medicines, dentistry, inpatient and ancillary services for the richest. This is the first study to apply dominance methods to analyze catastrophic health expenditures in a country over time. The analysis provides a nuanced picture of who incurs catastrophic health expenditures, to what extent hardship is experienced and what were the drivers of these expenditures - thus providing a better basis for policy responses.