재난적 의료비 발생과 재발생이 빈곤화와 빈곤지속에 미치는 영향

The objective of this study was to estimate catastrophic healthcare expenditure in Brazil, using different definitions, and to identify vulnerability indicators. Data from the 2002-2003 Brazilian Household Budget Survey were used to derive total household consumption, health expenditure and household income. Socioeconomic position was defined by quintiles of the National Economic Indicator using reference cut-off points for the country. Analysis was restricted to urban households. Catastrophic health expenditure was defined as expenditure in excess of 10% and 20% of total household consumption, and in excess of 40% of household capacity to pay. Catastrophic health expenditure varied from 2% to 16%, depending on the definition. For most definitions, it was highest among the poorer. The highest proportions of catastrophic health expenditure were found to be in the Central region of Brazil, while the South and the Southeast had the lowest. Presence of an elderly person, health insurance and socioeconomic position were associated with the outcome, and coverage by health insurance did not protect from catastrophic health expenditure.

Financial protection should be the principal objective of any health system. Commonly used indicators for financial protection are out-of-pocket (OOP) payments as a share of total health expenditure and the amount of households driven into poverty by catastrophic health expenditures (CHEs). In the last decade, OOP health payments consisted of approximately one-fifth of the health finance resources in Turkey. Until the year 2008, Turkish health system covered different public and private financing programmes as well as different types of service provision. After 2008, universal financial coverage became a part of the Health Transformation Programme (HTP). This study aimed to evaluate the financial protection in health in the era of health reforms in Turkey between 2003 and 2009. Household expenditures were derived from nationally representative Turkish Household Budget Surveys (HBSs), 2003, 2006 and 2009. Proportion of households facing CHE and impoverishment are calculated by using the methodology proposed by Ke Xu. Probability of incurring and volume of OOP spending were assessed across the health insurance groups by two-part model approach using logistic and OLS regression methods. Our findings showed that the probability of incurring and volume of OOP spending increased gradually in publicly insured households between 2003 and 2009. However, there was a diminishing trend in CHE in Turkey during the period under consideration. The official data showing an ∼3-fold increase in per capita health care use since 2003 and our study findings on decreasing CHE in this period can be interpreted as positive impact of HTP. On the other hand, increased household consumption as a share of OOP health payment and the deterioration in the progressivity of OOP spending in this period should be monitored closely.

BackgroundMauritius embraces principles of a welfare state with free health care at point of use in any public facilities. However, the health financing landscape changed in 2007 when Private Health Expenditure (PvtHE) surpassed General Government Health Expenditure. PvtHE is predominately out of pocket (OOP) with only 3.4% related to premiums for private insurance. In 2014, Household OOP Expenditure on health accounted for 52.8% of total health expenditure. OOP is known to be regressive and to impact negatively on households’ living standards.ObjectivesThis paper aims to examine trends in OOP in Mauritius, to assess its impacts through an analysis of key indicators of financial protection, namely catastrophic health expenditure (CHE) and impoverishment due to OOP health expenditure. It also aims to predict core determinants of CHEs.MethodsHousehold Budget Surveys (HBS) of 2001/2002, 2006/2007 and 2012 were the primary source data. CHE and impoverishment were used to assess financial hardships resulting from OOP health payments. The incidence of CHE was estimated at three threshold levels (10,25 and 40%), using the budget share and the capacity to pay approaches. Impoverishment due to OOP was measured by changes in the incidence of poverty and intensity of poverty using the US$ 3.1 international poverty line. Logistic regression analysis was used to identify determinants of CHE.FindingsHousehold CHE increased from 5.78% in 2001/02 to 8.85% in 2012 and 0.61% in 2001/02 to 1.25% in 2012, for 10 and 40% thresholds, respectively. The incidence of CHE was significantly higher in urban areas compared to rural areas. The highest levels of CHEs were among households’ heads, who are retired rising from 1.62% in 2001/02 to 3.71% in 2012, followed by households’ head who are widowed from 2.29% in 2001/02 to 2.63% in 2012 and homemakers from 2.12% in 2001/02 to 2.57% in 2012 at the 40% threshold. The share of households pushed below the poverty line due to OOP dropped from 0.4% in 2001/02 to 0.2% in 2006/07 before rising to 0.34% in 2012. In 2012, poverty gap occurred only among households under poorest quintile 1 (0.24%) and quintile 2 (0.03%). Overall poverty gap dropped from 0.08% in 2001/02 to 0.05% in 2012. Logistic regression analysis revealed that the odds ratio of facing CHE were significant only among households with heads being retired and with a presence of an elderly member in the household.ConclusionDespite the rise in incidence of CHE between 2001 and 2012 the impact of OOP on the level of impoverishment and poverty gap has not been significant.

Health policy makers are concerned about protecting people from catastrophic health expenditures and subsequent impoverishment. This study aimed to describe the magnitude and distribution of catastrophic health expenditures in Kermanshah western Iran. In this descriptive study, during May 2008, 189 households were chosen by "Systematic Random sampling" among the community of Maskan in Maskan Center for Population. After getting the informed consent forms signed, data ere collected using a questionnaire by interviewing the head of the families. The cut-off point for catastrophic expenditure was defined as health expenditures over 40% of household's capacity to pay. From a total of 189 households, 22.2% (42) households (95% CI 16.3%- 28.1%) incurred catastrophic health expenditures. Out of 42 households, for 11.9%, the head of family was female. 40.5 % had one member younger than 12 years old, 26.2% had one member older than sixty years old, and 9.5% were households with at least one member with chronic condition. In addition, 19% were uninsured. In addition, because of financial burden of health expenditures 21.4% of the households sold their jewels, 16.7% used up their savings and 47.6% were in debt. Compared to 2% of general population facing catastrophic health expenditure, 22.2% was a high proportion. Our study revealed the importance of protecting households against the cost of ill-health.

INTRODUCTION Non-communicable diseases (NCDs) are increasingly becoming important causes of illness and premature deaths globally, causing up to 41 million deaths annually, mostly occurring in Low and Middle-Income Countries. However, NCD treatment is lengthy and expensive forcing households to incur catastrophic expenditure. Thus, NCDs deepen inequality and are major drivers of unending poverty due to their lengthy treatment. Kenya successively reformed the National Health Insurance Fund to include a package that covers the plight of NCDs and transform it into a primary enabler for achieving Universal Health Coverage. This study examined whether health insurance affects catastrophic health expenditure among households of people with NCDs. METHODOLOGY A quasi-experimental design was conducted among eligible households with health insurance and those without, involving a representative sample of 350 households. Trained interviewers conducted interviews at baseline and after one year with household heads. RESULTS Households without cover spent a higher proportion of their total income (23%) on NCD care compared to households with insurance (11.7%). The mean total expenditure on NCD care for insured households was Ksh. 8,657.37 (95% CI 7,061.6 - 10,253.1) while that for non-insured was Ksh. 16,851.20 (95% CI 15,255.4 - 18,445.0), p = 0.000. Although the proportion of un-insured households that incurred catastrophic health expenditure (CHE) was higher than that of insured households, the study failed to establish that the incidence of CHE was different for non-insured and insured households (χ2= 33.89, df =1, p = 0.062). CONCLUSION NHIF cover was unable to protect Households of People with NCDs from CHE. The study recommends that NHIF's benefits package be further reformed to adequately cover all NCD's care needs. County government to strengthen the health system and boost capacity at lower levels of care to enhance NHIF coverage.

Can Insurance Reduce Catastrophic Out-of-Pocket Health Expenditure?

Subnational variation in catastrophic health expenditure and its determinants in China: a cross-sectional analysis of five provinces in 2014

Catastrophic health expenditure is one of the challenges Indonesia faces in achieving Universal Health Coverage. Aside from being a financial disaster, the incident caused by out-of-pocket health expenditure exceeding a fixed limit can drive people into poverty. Unfortunately, the availability of the data causes the limitation of the study in Indonesia. This study aims to analyze the association between catastrophic health expenditure and several social-economic factors by using the latest data of out-of-pocket expenditure collected at the individual level from the 2019 Susenas Module of Health and Housing. Using the Chi-square test, this study confirms a significant association between catastrophic health expenditures and the following social-economic factors: outpatient and inpatient service use, health insurance ownership, age, sex, marital status, educational level, work status, welfare status, type of area, and geographic location. From the logistic regression, the probability of the population to experience catastrophic health expenditure is higher for people in the following categories: use inpatient or outpatient services, do not have health insurance, are elderly, ever-married, not working, not poor, and live in the rural areas or Java island. Disaggregation by outpatient and inpatient service use shows the large gap in the probability of falling into catastrophic health expenditures. The probability for people who used inpatient service is more than four times people who never used the service. Meanwhile, for outpatient service, the probability is almost three times. Therefore, people can strengthen preventive care, especially those with low or no cost, to avoid falling into catastrophic health expenditure.

The purpose of the study was to examine the effect of catastrophic Out-of-Pocket health expenditure on household poverty in Uganda and propose measures that can guard against it so as to improve health outcomes as specified in the Millennium Development Goals. Specifically, the study aimed at establishing the effect of Out-of-Pocket health expenditure on welfare/poverty and based on the hypothesis that the country experiences catastrophic health expenditure. The study utilized the Uganda National Household Survey data of 2005/06 and change in Poverty Headcount Ratios computed using gross and net household expenditures as a proxy for income. The national catastrophic headcount ratio was found to be 19.33% (28.08% after adjusting for zero expenditure) and catastrophic health expenditure was found to exist among all socioeconomic groups although it was more among rural households and the non-poor. Direct Out-of-Pocket health expenditure increases household poverty by 5.81% or reduces welfare by the same percentage. The poverty gap was increased by Uganda Shillings 432 on average and this was 7,146 at the maximum representing more than 10% increase in some instances. The paper argues for government plans to protect the population against catastrophic expenditure through provision of free health care for all or at worst facilitate the establishment of prepaid schemes at all levels if it cannot speed up the National Social Health Insurance Scheme. The methodology for computing poverty numbers should always address health expenditure since it is not welfare maximizing.

BackgroundIn 2003, the Mexican Congress approved a major reform to provide health care services to the poor population through the public insurance scheme Seguro Popular. This program was dismantled in 2019 as part of a set of health system reforms and substituted with the Health Institute for Welfare (INSABI). These changes were implemented during the initial phases of the coronavirus (COVID-19) pandemic. We aimed to examine the impact of these reforms and the COVID-19 pandemic on financial risk protection in Mexico between 2018 and 2020.MethodsWe performed a population-based analysis using cross-sectional data from the 2018 and 2020 rounds of the National Household Income and Expenditures Survey. We used a pooled fixed-effects multivariable two-stage probit model to determine the likelihood of catastrophic health expenditure (CHE), impoverishing health expenditure (IHE), and excessive health expenditure (EHE) among Mexican households. We also mapped the quintiles of changes in EHE in households without health insurance by state.ResultsThe percentage of households without health insurance almost doubled from 8.8% (three million households) in 2018 to 16.5% (5.8 million households) in 2020. We also found large increases in the proportion of households incurring in CHE (18.4%; 95% confidence interval (CI) = 6.1, 30.7) and EHE (18.7%; 95% CI = 7.9, 29.5). Significant increases in CHE, IHE, and EHE were only observed among households without health insurance (CHE: 90.7%; 95% CI = 31.6, 149.7, EHE: 73.5%; 95% CI = 25.3, 121.8). Virtually all Mexican states (n/N = 31/32) registered an increase in EHE among households without health insurance. This increase has a systematic territorial component affecting mostly central and southern states (range = -1.0% to 194.4%).ConclusionsThe discontinuation of the Seguro Popular Program and its substitution with INSABI during the first stages of the COVID-19 pandemic reduced the levels of health care coverage in Mexico. This reduction and the pandemic increased out-of-pocket expenditure in health and the portion of CHE and EHE in the 2018-2020 period. The effect was higher in households without health insurance and households in central and southern states of the country. Further studies are needed to determine the specific effect both of recent policy changes and of the COVID-19 pandemic on the levels of financial protection in health in Mexico.

This paper was aimed to investigate the mixed empirical results on the effect of health insurance in reducing the risk of catastrophic health expenditure (CHE). We investigated a wide range of factors affecting the risk of CHE among patients admitted to hospitals in Tehran. We categorized hospitals into five groups from private hospitals to charity ones. The data used herein was extracted from the second round of Urban Health Equity Assessment and Response Tool. Determinants of CHE were identified using logistic regression. We found that the significant effect of insurance on aggregate data was solely determined by its effect on reducing the risk of CHE in social security organization hospitals. Insured people by this organization allocate a higher proportion of their salaries to the health insurance and are admitted to the organizational hospitals free of charge. This finding shows the bias inherited in the aggregation and provides support for full pre-payments mechanisms. Our findings suggest that individuals relate CHE to the chosen hospitals, which, in turn, needs to be based on individuals’ health insurance and socio-economic conditions.

BackgroundOut-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 MaterialHospital-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.ResultsThe 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.ConclusionThe 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.

BackgroundThe extent of catastrophic health expenditure and impoverishment associated with depression in low-and middle-income countries is not known. The aim of this study was to estimate the incidence and intensity of catastrophic out-of-pocket (OOP) health expenditure, level of impoverishment and coping strategies used by households of persons with and without depression in a rural Ethiopian district.MethodsA comparative cross-sectional survey was conducted, including 128 households of persons with depression and 129 households without. Depression screening was conducted using the Patient Health Questionnaire, nine item version (PHQ-9). People in the depression group were classified into high and low disability groups based on the median value on the World Health Organization Disability Assessment Schedule (WHODAS) polytomous summary score.Health expenditure greater than thresholds of 10 and 25% of total household consumption was used for the primary analyses. The poverty headcount, poverty gap and normalized poverty gap were estimated using retrospective recall of total household expenditure pre- and post-OOP payments for health care. Linear probability model using binreg command in STATA with rr option was used to estimate risk ratio for the occurrence of outcomes among households with and without depression based on level of disability.ResultsCatastrophic OOP payments at any threshold level for households with depression and high disability were higher than control households. At the 10% threshold level, 24.0% of households of persons with depression and high disability faced catastrophic payments compared with 15.3% for depression and low disability and 12.1% for control households (p = 0.041). Depression and high disability level was an independent predictor of catastrophic OOP payments: RR 2.1; 95% CI:1.1, 4.6.An estimated 5.8% of households of persons with depression and high disability were pushed into poverty because of paying for health care compared with 3.5% for households of persons with depression and low disability and 2.3% for control households (p = 0.039).ConclusionsHouseholds of people with depression and high disability were more likely to face catastrophic expenditures and impoverishment from OOP payments. Financial protection interventions through prepayment schemes, exemptions and fee waiver strategies need to target households of persons with depression.

IntroductionMultimorbidity is common among patients with diabetes and can lead to catastrophic health expenditure (CHE) for their families. This study aims to investigate the prevalence of multimorbidity and CHE among...

The Government of Vietnam has set the goal of achieving universal health coverage (UHC) by 2025. Health insurance (HI) is being considered a tool to achieve this goal. However, out-of-pocket spending and catastrophic health expenditure (CHE) remain high. Research evidence on how to reduce these expenditures to achieve UHC is essential. Therefore, this study examines the determinants of CHE, especially the HI factor. To identify HI participation status and other factors associated with CHE, we use logistic regression on a dataset from the 2016 Vietnam Household Living Standards Survey. The study finds that HI is a protective factor against CHE, although this result is not always statistically significant across different subsamples. Moreover, the household head's age and employment status, household size, share of the elderly above 60 years, income, illness status, healthcare utilisation, availability of hospitals, commune health stations with medical doctors and place of residence all correlate with household CHE. Although there has been a rise in HI coverage, the financial protection capacity of HI schemes in Vietnam remains inadequate, particularly for households living in rural areas. Further investigations of the causal effect of HI, other health system factors and CHE in rural settings are necessary to reduce the incidence of CHE. Additionally, policies aimed at groups vulnerable to CHE, such as those with higher incidences of severe illness or inpatient admissions, low income, and higher age, should be considered.