Gasto de bolsillo en salud durante el último año de vida de adultos mayores mexicanos: análisis del Enasem / Out of pocket expenditure on health during the last year of life of Mexican elderly: analysis of the Enasem

Resumen: Objetivo: Estimar el gasto de bolsillo (GB) durante el último año de vida en adultos mayores (AM) mexicanos. Material y métodos: Estimación del GB del último año de vida de AM, ajustando por tipo de manejo, afiliación y causa de muerte. Se emplearon datos del Estudio Nacional de Salud y Envejecimiento en México (2012). Los gastos en medicamentos, consultas médicas y hospitalización durante el año previo a la muerte conforman el GB. El GB se ajustó por inflación y se reporta en dólares americanos 2018. Resultados: La media de GB fue $6 255.3±18 500. En el grupo de atención ambulatoria el GB fue $4 134.9±13 631.3. El GB en hospitalización fue $7 050.6±19 971.0. Conclusiones: La probabilidad de incurrir en GB es menor cuando no se requiere hospitalización. Con hospitalización, la afiliación a la seguridad social y atenderse en hospitales públicos juega un papel protector.

Abstract: Objective: To estimate the out-of-pocket expenses (OOPE) during the last year of life in Mexican older adults (OA). Materials and methods: Estimation of the OOPE corresponding to the last year of life of OA, adjusting by type of management, affiliation and cause of death. Data from the National Health and Aging Study in Mexico (2012) were used. To calculate the total OOPE, the expenses in the last year were used in: medications, medical consultations and hospitalization. The OOPE was adjusted for inflation and is reported in US dollars 2018. Results: The mean OOPE was $6 255.3±18 500. In the ambulatory care group, the OOPE was $4 134.9±13 631.3. The OOPE in hospitalization was $7 050.6±19 971.0. Conclusions: The probability of incurre in OOPE is lower when hospitalization is not required. With hospitalization, affiliation to social security and attending to public hospitals plays a protective role.

Custos não médicos diretos e indiretos relacionados ao glaucoma primário de ângulo aberto no Brasil / Non-medical direct and indirect costs related to primary open-angle glaucoma in Brazil

RESUMO Objetivo: Identificar os custos não médicos diretos e indiretos em uma população de pacientes portadores de glaucoma primário de ângulo aberto (GPAA) em tratamento no Brasil. Métodos: A pesquisa dos custos neste estudo transversal foi realizada através de entrevista a uma população de pacientes portadores de GPAA em acompanhamento em um centro de referência para o tratamento do glaucoma na cidade de Juiz de Fora - MG. Para avaliação dos custos não médicos diretos, as seguintes variáveis foram investigadas: gasto com transporte, hospedagem, alimentação e acompanhante para cada consulta. Já na análise dos custos indiretos, avaliou-se: recebimento ou não de benefício social por causa do glaucoma (aposentadoria ou auxílio-doença) e qual o valor anual e perda de dias trabalhados pelo paciente e/ou pelo acompanhante. Os valores médios anuais foram calculados para todo o grupo e para cada estágio evolutivo do glaucoma. Resultados: Setenta e sete pacientes foram incluídos nesta análise (GPAA inicial: 26,0%; GPAA moderado: 24,7% e GPAA avançado: 49,3%). A média do custo não médico direto foi (em reais): 587,47; 660,52 e 708,54 para os glaucomas iniciais, moderados e avançados, respectivamente. Já a média do custo indireto foi: 20.156,75 (GPAA inicial); 26.988,16 (moderado) e 27.263,82 (avançado). Conclusão: Os custos não médicos diretos e indiretos relacionados ao GPAA no Brasil foram identificados. Os custos indiretos são superiores aos custos não médicos diretos e ambos tendem a aumentar com o avanço da doença.

ABSTRACT Objective: To identify direct and indirect non-medical costs in a population of patients with primary open-angle glaucoma (POAG) receiving treatment in Brazil. Methods: In this cross-sectional study, we obtained the costs through an interview with a population of patients with POAG at a glaucoma referral clinic in the city of Juiz de Fora - MG. In order to assess the direct non-medical costs, we investigated the following variables transportation expenses, lodging expenses, food and companion expenses for each visit. In the indirect costs analysis, we assessed the following variables: whether or not social benefits were received because of glaucoma (retirement or sickness benefit) and the annual value and loss of days worked by the patient and/or the companion. We calculated the mean annual values for the whole group and for each glaucoma stage. Results: Seventy-seven patients were included in this analysis (initial POAG: 26.0%, moderate POAG: 24.7% and advanced POAG 49.3%). The mean non-medical direct cost was (in reais): 587.47; 660.52 and 708.54 for the initial, moderate and advanced glaucomas, respectively. The mean indirect cost was: 20,156.75 (initial POAG); 26,988.16 (moderate POAG) and 27,263.82 (advanced POAG). Conclusion: We identified the direct and indirect non-medical costs related to POAG in Brazil. Indirect costs are higher than non-medical direct costs and both tend to increase with disease progression.

Protección financiera en salud: evolución y comparación del gasto de bolsillo de los hogares chilenos / Financial protection for health care expenses provided by public and private systems in Chile

Background: People need a financial protection system to face the high costs of health care. Aim: To compare the financial protection between households affiliated to the Chilean public health financing system (FONASA) or to a private health financing system (ISAPRE). To describe the evolution of protection at the national level between 2007 and 2012. Material and Methods: As proposed by the World Bank, impact indicators to measure the equity and efficiency of the insurance systems were generated. Namely, average out-of-pocket expenses by insurance and average out-of-pocket spending as a percentage of expenditure. Also, the evolution of out-of-pocket spending by quintiles and Gini Coefficient were measured as measure of equity. To determine these, Family Budget Surveys for 2007 and 2012 were used. Results: Household out-of-pocket spending increased by 14.12%. When expressed as a percentage of total expenditure, it grew from 5.6% to 6.2%. Household Gini coefficient and per capita out-of-pocket spending decreased and the ratio between the highest and lowest quintile out-of-pocket increased at both analysis levels. Pocket expense in absolute values or expressed as a percentage of total expenses was higher among persons insured in private systems than those affiliated to the public financing service. Conclusions: Out-of-pocket spending increased for all income groups and people insured in the public system had a lower absolute and relative spending than those insured in private systems.

Desigualdades no comprometimento da renda domiciliar dos brasileiros com gastos privados em assistência odontológica / Inequalities in Brazilian families' income commitment to out-of-pocket spending on dental care / Desigualdades respecto a la renta domiciliaria en el desembolso de los brasileños con gastos privados de asistencia odontológica

O objetivo foi investigar as desigualdades no comprometimento da renda domiciliar com gastos privados em assistência odontológica no Brasil. Foram analisados dados de 55.970 domicílios brasileiros que participaram da Pesquisa de Orçamentos Familiares, de abrangência nacional, no período de 2008-2009. O comprometimento dos gastos privados com assistência odontológica na renda familiar foi calculado pela divisão do gasto médio domiciliar per capita anual pela renda familiar per capita anual e estimado segundo quatro categorias: > 0%, ≥ 5%, ≥ 10% e ≥ 20%. A análise do comprometimento na renda foi realizada apenas para os domicílios com gasto positivo. Apenas 2.961 (7%) dos domicílios reportaram gastos positivos com assistência em odontologia. No geral, o gasto médio per capita anual foi de R$ 42,19 e, de R$ 602,47 entre aqueles com gasto positivo. Os domicílios que possuem os maiores gastos absolutos com assistência odontológica são aquelas pertencentes à área urbana e ao quinto mais rico. Em contrapartida, os domicílios com maior comprometimento na renda pertencem à área rural e ao quinto mais pobre. Entre os que informaram gasto positivo, 55% dos domicílios do quinto mais pobre comprometeram ≥ 20% de sua renda com assistência odontológica. O percentual é de apenas 6% no grupo mais rico da população. Os domicílios mais pobres das regiões mais ricas (Centro-oeste, Sul e Sudeste) apresentaram os maiores comprometimentos de renda. As desigualdades socioeconômicas nos gastos e no comprometimento de renda com assistência odontológica são evidentes. A avaliação dessas desigualdades torna-se relevante para avaliação e orientação de políticas públicas em saúde.

The study aimed to investigate inequalities in the commitment of family income to private expenditures on dental care in Brazil. Data were analyzed from 55,970 Brazilian households that participated in the nationwide Family Budgets Survey in 2008-2009. The commitment of family income to private spending on dental care was calculated by dividing the mean annual per capita household spending on dental care by the mean annual per capita income, classified in four categories: > 0%, ≥ 5%, ≥ 10%, and ≥ 20%. Analysis of income commitment only included households with positive spending. Only 2,961 households (7%) reported positive spending on dental care. Mean annual per capita spending was BRL 42.19 (USD 12.78) overall and BRL 602.47 (USD 182.57) among those with positive spending. Households with the highest absolute expenditures on dental care were those from urban areas and the wealthiest quintile. Meanwhile, households with the highest proportional income commitment were from rural areas and the poorest quintile. Among those that reported positive spending, 55% of the households in the poorest quintile committed ≥ 20% of their income to dental care. The proportion was only 6% in the wealthiest quintile of the population. The poorest households in the wealthiest regions of Brazil (Central, South, and Southeast) showed the highest income commitments. There were striking socioeconomic inequalities in spending and income commitment to dental care. The evaluation of these inequalities is relevant for the evaluation and orientation of public health policies.

El objetivo de este trabajo fue investigar las desigualdades en el desembolso de renta domiciliaria con gastos privados en asistencia odontológica en Brasil. Se analizaron datos de 55.970 domicilios brasileños que participaron en la Encuesta de Presupuestos Familiares, de alcance nacional, durante el período de 2008-2009. El desembolso económico privado en asistencia odontológica, respecto a la renta familiar, se calculó mediante la división del gasto medio domiciliario per cápita anual por la renta familiar per cápita anual y estimado según cuatro categorías: > 0%, ≥ 5%, ≥ 10% y ≥ 20%. El análisis del desembolso económico se realizó sólo para los domicilios con gasto positivo. Sólo 2.961 (7%) de los domicilios informaron de gastos positivos con asistencia en odontología. En general, el gasto medio per cápita anual fue BRL 42,19 y, BRL 602,47 entre quienes contaban con un gasto positivo. Los domicilios que cuentan con los mayores gastos absolutos respecto a la asistencia odontológica son los pertenecientes al área urbana y a la quinta parte más rica. En contrapartida, los domicilios con mayor desembolso de renta pertenecen al área rural y a la quinta parte más pobre. Entre los que informaron de gasto positivo, un 55% de los domicilios de la quinta parte más pobre desembolsaron un ≥ 20% de su renta en asistencia odontológica. El porcentaje es de apenas un 6% en el grupo más rico de la población. Los domicilios más pobres de las regiones más ricas (Centro-oeste, Sur y Sudeste) presentaron los mayores desembolsos de renta. Las desigualdades socioeconómicas en los gastos y en el desembolso de renta con la asistencia odontológica son evidentes. La evaluación de estas desigualdades es relevante para la evaluación y orientación de las políticas públicas en salud.

Gastos privados com saúde bucal no Brasil: análise dos dados da Pesquisa de Orçamentos Familiares, 2008-2009 / Private spending on oral health in Brazil: analysis of data from the Family Budgets Survey, 2008-2009 / Gastos privados con la salud bucal en Brasil: análisis de datos de la Encuesta de Presupuestos Familiares, 2008-2009

Resumo: O objetivo foi analisar os gastos privados com assistência odontológica e produtos de higiene bucal dos brasileiros. Foram analisados dados de 55.970 domicílios pesquisados na Pesquisa de Orçamentos Familiares de 2008-2009. Os gastos foram descritos segundo macrorregiões, estados e capitais do Brasil e de acordo com características socioeconômicas e demográficas dos domicílios (sexo, idade, cor da pele e escolaridade do chefe, renda domiciliar per capita e presença de idoso no domicílio). Os brasileiros gastaram em média no ano R$ 42,19 com serviços de assistência odontológica e R$ 10,27 com produtos de higiene bucal. Desigualdades sociais na distribuição desses gastos segundo as características dos moradores dos domicílios e segundo as diferentes macrorregiões, estados e capitais do país foram encontradas. O presente estudo evidenciou com detalhes quanto e com o que gastam os brasileiros com assistência odontológica e com produtos de higiene bucal. O monitoramento e avaliação desses gastos são condições fundamentais para avaliação e orientação de políticas públicas em saúde bucal.

Abstract: The aim was to analyze Brazilians' private spending on dental care and oral hygiene products. Data were analyzed from 55,970 households in the Family Budgets Survey, 2008-2009. Expenditures were analyzed by major geographic region, state, state capital, and household socioeconomic and demographic characteristics (sex, age, head-of-household's skin color and schooling, per capita household income, and presence of elderly in the household). Brazilians spent an average of BRL 42.19 per year on dental care and BRL 10.27 on oral hygiene products. The study detected social inequalities in the distribution of these expenditures according to household residents' characteristics and the different geographic regions, states, and state capitals. The current study evidenced quantitative and specific details on Brazilians' spending on dental care and oral hygiene products. Monitoring and assessment of these expenditures are fundamental for evaluating and orienting public policies in oral health.

Resumen: El objetivo fue analizar los gastos privados con asistencia odontológica y productos de higiene bucal de los brasileños. Se analizaron datos de 55.970 domicilios seleccionados en la Encuesta de Presupuestos Familiares de 2008-2009. Los gastos fueron descritos según macrorregiones, estados y capitales do Brasil, y de acuerdo con características socioeconómicas y demográficas de los domicilios (sexo, edad, color de piel y escolaridad del cabeza de familia, renta domiciliaria per cápita y presencia del anciano en el domicilio). Los brasileños gastaron de media durante el año R$ 42,19 en servicios de asistencia odontológica y R$ 10,27 con productos de higiene bucal. Se hallaron desigualdades sociales en la distribución de esos gastos, según las características de los residentes de los domicilios, y conforme las diferentes macrorregiones, estados y capitales del país. El presente estudio evidenció con detalle cuánto y en qué gastan los brasileños respecto a la asistencia odontológica y productos de higiene bucal. El monitoreo y evaluación de estos gastos son condiciones fundamentales para la evaluación y orientación de políticas públicas en salud bucal.

Equity in out-of-pocket payment in Chile

ABSTRACT OBJECTIVE To assess the distribution of financial burden in Chile, with a focus on the burden and progressivity of out-of-pocket payment. METHODS Based on the principle of ability to pay, we explore factors that contribute to inequities in the health system finance and issues about the burden of out-of-pocket payment, as well as the progressivity and redistributive effect of out-of-pocket payment in Chile. Our analysis is based on data from the 2006 National Survey on Satisfaction and Out-of-Pocket Payments. RESULTS Results from this study indicate evidence of inequity, in spite of the progressivity of the healthcare system. Our analysis also identifies relevant policy variables such as education, insurance system, and method of payment that should be taken into consideration in the ongoing debates and research in improving the Chilean system. CONCLUSIONS In order to reduce the detected disparities among income groups, healthcare priorities should target low-income groups. Furthermore, policies should explore changes in the access to education and its impact on equity.

The influence of health expenditures on household impoverishment in Brazil / Influência dos gastos em saúde no empobrecimento de domicílios no Brasil

OBJECTIVE To analyze the variation in the proportion of households living below the poverty line in Brazil and the factors associated with their impoverishment. METHODS Income and expenditure data from the Household Budget Survey, which was conducted in Brazil between 2002-2003 (n = 48,470 households) and 2008-2009 (n = 55,970 households) with a national sample, were analyzed. Two cutoff points were used to define poverty. The first cutoff is a per capita monthly income below R$100.00 in 2002-2003 and R$140.00 in 2008-2009, as recommended by the Bolsa Família Program. The second, which is proposed by the World Bank and is adjusted for purchasing power parity, defines poverty as per capita income below US$2.34 and US$3.54 per day in 2002-2003 and 2008-2009, respectively. Logistic regression was used to identify the sociodemographic factors associated with the impoverishment of households. RESULTS After subtracting health expenditures, there was an increase in households living below the poverty line in Brazil. Using the World Bank poverty line, the increase in 2002-2003 and 2008-2009 was 2.6 percentage points (6.8%) and 2.3 percentage points (11.6%), respectively. Using the Bolsa Família Program poverty line, the increase was 1.6 (11.9%) and 1.3 (17.3%) percentage points, respectively. Expenditure on prescription drugs primarily contributed to the increase in poor households. According to the World Bank poverty line, the factors associated with impoverishment include a worse-off financial situation, a household headed by an individual with low education, the presence of children, and the absence of older adults. Using the Bolsa Família Program poverty line, the factors associated with impoverishment include a worse-off financial situation and the presence of children. CONCLUSIONS Health expenditures play an important role in the impoverishment of segments of the Brazilian population, especially among the most disadvantaged. .

OBJETIVO Analisar a variação na proporção de domicílios vivendo abaixo da linha de pobreza no Brasil e os fatores associados ao empobrecimento. MÉTODOS Foram analisados os dados de despesa e renda das Pesquisas de Orçamentos Familiares conduzidas no Brasil em 2002-2003 (n = 48.470 domicílios) e 2008-2009 (n = 55.970 domicílios) com amostra representativa nacional. Foram utilizados dois pontos de corte para definir pobreza. O primeiro, recomendado pelo Programa Bolsa-Família, considerou pobreza rendimento per capita mensal inferior a R$100,00 em 2002-2003 e a R$140,00 em 2008-2009. O segundo, proposto pelo Banco Mundial, incorpora a correção pela paridade do poder de compra, resultando em US$2,34 por dia, em 2002-2003, e US$3,54, em 2008-2009. Para identificar os fatores sociodemográficos associados ao empobrecimento dos domicílios foi utilizada regressão logística. RESULTADOS Houve acréscimo de domicílios vivendo abaixo da linha de pobreza no Brasil após subtração dos gastos em saúde. Considerando-se a linha de pobreza recomendada pelo Banco Mundial, em 2002-2003 o acréscimo foi 2,6 pontos percentuais (ou 6,8%) e, em 2008-2009, 2,3 pontos percentuais (ou 11,6%). Considerando-se a linha de pobreza utilizada pelo Programa Bolsa-Família, a variação foi 1,6 (11,9%) e 1,3 (17,3%), respectivamente. Gastos com medicamentos foram os que mais contribuíram para o aumento de domicílios pobres. Os fatores associados ao empobrecimento, segundo a linha de pobreza do Banco Mundial, foram apresentar pior situação econômica, ser chefiado por indivíduo com baixa escolaridade, presença de crianças e ausência de idosos. Utilizando-se a linha de pobreza do Bolsa-Família, os fatores associados foram apresentar pior situação econômica e presença de crianças. ...

Disposición a pagar por vacunas contra el virus papiloma humano en la Región Metropolitana de Santiago de Chile / Willingness to pay for human papillomavirus vaccine in Metropolitan Santiago, Chile

Background: Human papillomavirus (HPV) infection is a risk factor for cervical cancer and can be prevented with the HPV vaccine. Aim: To explore the willingness of parents to pay for HPV vaccine for their offspring. Material and Methods: A survey about the willingness to pay for HPV vaccine was answered by 386 individuals of the highest socioeconomic level who had a daughter aged between 12 and 18 years. The survey included information about the risks of HPV infection. Results: Parents would pay a mean of US$ 758 for the vaccine. Twenty five percent of parents were not willing to pay for it. If the cost of the vaccine would be reduced by 50%, only 4% of parents would not pay for it. The willingness to pay is associated with the price of the vaccine, the income level of respondents and the size of the family. Conclusions: Most respondents would pay for HPV vaccine for their daughters, despite the relatively high cost.