Association of socioeconomic status with financial burden of disease among elderly patients with cardiovascular disease: evidence from the China Health and Retirement Longitudinal Survey

ObjectivesThe prevalence of cardiovascular diseases (CVD) within low-income and middle-income countries has reached epidemic proportions. However, the association between out-of-pocket (OOP) payment and socioeconomic status (SES) of patients with CVD is not well studied. We aimed to understand the financial burden among Chinese middle-aged and older patients with CVD, and whether there was an association with SES.SettingsA nationally representative survey—The China Health and Retirement Longitudinal Survey(CHARLS)—was conducted in 28 provinces of mainland China in 2011 and 2013.ParticipantsOf the over 18 000 CHARLS respondents, eligible participants were those aged 45 years and over who had been previously diagnosed with CVD.Outcome measuresFinancial burden was measured byindividualOOP payment andhouseholdcatastrophic health expenditure (CHE) occurrence (ie, the annual household health expenditure was 40% or more of the total non-food household expenditure). Multilevel regression models were used to explore the association between financial burden and SES.ResultsAmong CHARLS respondents, CVD prevalence increased from 14.7% in 2011 to 16.6% in 2013. Average annual CVD OOP payment increased from 5000 RMB (770 USD) to 6120 RMB (970 USD). Furthermore, CHE occurrence increased from 44.2% to 48.1%. Patients spent almost twice on outpatient as on inpatient services. Two of the three SES indicators (total household expenditure, occupation type) were found to be associated with CVD OOP payment amount, and the likelihood of CHE. Unemployed patients had a higher likelihood of CHE compared with agricultural workers. Rural-urban difference was associated with the likelihood of CHE in 2011 alone.ConclusionThe Chinese health system should use this health expenditure pattern among patients with CVD to create more equitable health insurance schemes that financially balance between outpatient and inpatient care, and provide better financial risk protection to patients with low SES.

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Impact of non-communicable disease multimorbidity on health service use, catastrophic health expenditure and productivity loss in Indonesia: a population-based panel data analysis study

BMJ Open ◽

10.1136/bmjopen-2020-041870 ◽

2021 ◽

Vol 11 (2) ◽

pp. e041870

Author(s):

Tiara Marthias ◽

Kanya Anindya ◽

Nawi Ng ◽

Barbara McPake ◽

Rifat Atun ◽

...

Keyword(s):

Panel Data ◽

Health Service ◽

Low Income ◽

Health Expenditure ◽

Service Use ◽

Financial Burden ◽

Panel Data Analysis ◽

Productivity Loss ◽

Catastrophic Health Expenditure ◽

Health Service Use

ObjectivesTo examine non-communicable diseases (NCDs) multimorbidity level and its relation to households’ socioeconomic characteristics, health service use, catastrophic health expenditures and productivity loss.DesignThis study used panel data of the Indonesian Family Life Survey conducted in 2007 (Wave 4) and 2014 (Wave 5).SettingThe original sampling frame was based on 13 out of 27 provinces in 1993, representing 83% of the Indonesian population.ParticipantsWe included respondents aged 50 years and above in 2007, excluding those who did not participate in both Waves 4 and 5. The total number of participants in this study are 3678 respondents.Primary outcome measuresWe examined three main outcomes; health service use (outpatient and inpatient care), financial burden (catastrophic health expenditure) and productivity loss (labour participation, days primary activity missed, days confined in bed). We applied multilevel mixed-effects regression models to assess the associations between NCD multimorbidity and outcome variables,ResultsWomen were more likely to have NCD multimorbidity than men and the prevalence of NCD multimorbidity increased with higher socioeconomic status. NCD multimorbidity was associated with a higher number of outpatient visits (compared with those without NCD, incidence rate ratio (IRR) 4.25, 95% CI 3.33 to 5.42 for individuals with >3 NCDs) and inpatient visits (IRR 3.68, 95% CI 2.21 to 6.12 for individuals with >3 NCDs). NCD multimorbidity was also associated with a greater likelihood of experiencing catastrophic health expenditure (for >3 NCDs, adjusted OR (aOR) 1.69, 95% CI 1.02 to 2.81) and lower participation in the labour force (aOR 0.23, 95% CI 0.16 to 0.33) compared with no NCD.ConclusionsNCD multimorbidity is associated with substantial direct and indirect costs to individuals, households and the wider society. Our study highlights the importance of preparing health systems for addressing the burden of multimorbidity in low-income and middle-income countries.

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Treatment as insurance: HIV antiretroviral therapy offers financial risk protection in Malawi

Health Policy and Planning ◽

10.1093/heapol/czaa023 ◽

2020 ◽

Vol 35 (6) ◽

pp. 676-683

Author(s):

Sarah Dickerson ◽

Victoria Baranov ◽

Jacob Bor ◽

Jeremy Barofsky

Keyword(s):

Health Expenditure ◽

Financial Risk ◽

Health Expenditures ◽

Catastrophic Health Expenditure ◽

Hiv Treatment ◽

Financial Risk Protection ◽

Urban Households ◽

Medical Spending ◽

Risk Protection ◽

The Impact

Abstract Many countries have expanded insurance programmes in an effort to achieve universal health coverage (UHC). We assess a complementary path toward financial risk protection: increased access to technologies that improve health and reduce the risk of large health expenditures. Malawi has provided free HIV treatment since 2004 with significant US Government support. We investigate the impact of treatment access on medical spending, capacity to pay and catastrophic health expenditures at the population level, exploiting the phased rollout of HIV treatment in a difference-in-differences design. We find that increased access to HIV treatment generated a 10% decline in medical spending for urban households, a 7% increase in capacity to pay for rural households and a 3-percentage point decrease in the likelihood of catastrophic health expenditure among urban households. These risk protection benefits are comparable to that found from broad-based insurance coverage in other contexts. Our findings show that targeted treatment programmes that provide free care for high burden causes of death can provide substantial financial risk protection against catastrophic health expenditure, while moving developing nations toward UHC.

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Decomposition of changes in socioeconomic inequalities in catastrophic health expenditure in Kenya

PLoS ONE ◽

10.1371/journal.pone.0244428 ◽

2020 ◽

Vol 15 (12) ◽

pp. e0244428

Author(s):

Purity Njagi ◽

Jelena Arsenijevic ◽

Wim Groot

Keyword(s):

Health Expenditure ◽

Financial Burden ◽

Household Wealth ◽

Catastrophic Health Expenditure ◽

Socioeconomic Inequalities ◽

Financial Risk Protection ◽

Wealth Status ◽

The Poor ◽

Household Heads ◽

Over Time

Background Catastrophic health expenditure (CHE) is frequently used as an indicator of financial protection. CHE exists when health expenditure exceeds a certain threshold of household consumption. Although CHE is reported to have declined in Kenya, it is still unacceptably high and disproportionately affects the poor. This study examines the socioeconomic factors that contribute to inequalities in CHE as well as the change in these inequalities over time in Kenya. Methods We used data from the Kenya household health expenditure and utilisation (KHHEUS) surveys in 2007 and 2013. The concertation index was used to measure the socioeconomic inequalities in CHE. Using the Wagstaff (2003) approach, we decomposed the concentration index of CHE to assess the relative contribution of its determinants. We applied Oaxaca-type decomposition to assess the change in CHE inequalities over time and the factors that explain it. Results The findings show that while there was a decline in the incidence of CHE, inequalities in CHE increased from -0.271 to -0.376 and was disproportionately concentrated amongst the less well-off. Higher wealth quintiles and employed household heads positively contributed to the inequalities in CHE, suggesting that they disadvantaged the poor. The rise in CHE inequalities overtime was explained mainly by the changes in the elasticities of the household wealth status. Conclusion Inequalities in CHE are persistent in Kenya and are largely driven by the socioeconomic status of the households. This implies that the existing financial risk protection mechanisms have not been sufficient in cushioning the most vulnerable from the financial burden of healthcare payments. Understanding the factors that sustain inequalities in CHE is, therefore, paramount in shaping pro-poor interventions that not only protect the poor from financial hardship but also reduce overall socioeconomic inequalities. This underscores the fundamental need for a multi-sectoral approach to broadly address existing socioeconomic inequalities.

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Catastrophic health expenditure: a community-based study in Sarawak, Malaysia

International Journal of Community Medicine and Public Health ◽

10.18203/2394-6040.ijcmph20213516 ◽

2021 ◽

Vol 8 (9) ◽

pp. 4182

Author(s):

Johnny Pangkas ◽

M. Mizanur Rahman ◽

Raili Bin Suhaili

Keyword(s):

Socioeconomic Status ◽

Family Size ◽

Health Expenditure ◽

Binary Logistic Regression ◽

Catastrophic Health Expenditure ◽

Household Expenditure ◽

Binary Logistic Regression Analysis ◽

Factors Affecting ◽

Face To Face ◽

Regression Methods

Background: Accessing health services can lead to individuals having to pay catastrophic proportions of their available income and push many households into poverty. The aim of the study was to estimate the catastrophic health expenditure in respect of household expenditure and to determine the factors affecting it in Sarawak, Malaysia.Methods: We collected household expenses based on a recall period of one month through a face-to-face interview. We calculated the catastrophic health expenditure in terms of 10% of household expenditure and 40% of the capacity to pay. A binary logistic regression analysis was done to determine the factors associated with catastrophic health expenditure. Data analysis was done by IBM SPSS version 27.0. Results: The analysis revealed that one-quarter (25.7%) of the household expenditure was on food, equivalent to MYR 373.562, and 18.83% of the total household expenditure was on health (MYR 292.83). About two-fifths (37.4%) of the households had incurred catastrophic health expenditure on 10% of household consumption and 15.6% catastrophic health expenditure on 40% of household expenditure. Multivariate analysis with forward and backward linear regression methods revealed that age, gender, family size, socioeconomic status, and chronic illness appeared to be potential predictors of 10% catastrophic health expenditure (p<0.05). In contrast, socioeconomic status and level of education appeared to be potential predictors for 40% catastrophic health expenditure (p<0.05).Conclusions: Subsidised health care may not protect against the occurrence of catastrophic health expenditure among the household in the lower socioeconomic status. Family size and age also could affect household catastrophic health expenditure.

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Free access to antiretroviral treatment and protection against the risk of catastrophic health expenditure in people living with HIV: evidence from Cameroon

BMC Health Services Research ◽

10.1186/s12913-021-06331-5 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Marwân-al-Qays Bousmah ◽

Marie Libérée Nishimwe ◽

Christopher Kuaban ◽

Sylvie Boyer

Keyword(s):

Socioeconomic Status ◽

Health Expenditure ◽

Antiretroviral Treatment ◽

Catastrophic Health Expenditure ◽

Hiv Care ◽

Free Access ◽

People Living With Hiv ◽

Art Policy ◽

Living With Hiv ◽

The Impact

Abstract Background To foster access to care and reduce the burden of health expenditures on people living with HIV (PLHIV), several sub-Saharan African countries, including Cameroon, have adopted a policy of removing HIV-related fees, especially for antiretroviral treatment (ART). We investigate the impact of Cameroon’s free antiretroviral treatment (ART) policy, enacted in May 2007, on catastrophic health expenditure (CHE) risk according to socioeconomic status, in PLHIV enrolled in the country’s treatment access program. Methods Based on primary data from two cross-sectional surveys of PLHIV outpatients in 2006–2007 and 2014 (i.e., before and after the policy’s implementation, respectively), we used inverse propensity score weighting to reduce covariate imbalances between participants in both surveys, combined with probit regressions of CHE incidence. The analysis included participants treated with ART in one of the 11 HIV services common to both surveys (n = 1275). Results The free ART policy was associated with a significantly lower risk of CHE only in the poorest PLHIV while no significant effect was found in lower-middle or upper socioeconomic status PLHIV. Unexpectedly, the risk of CHE was higher in those with middle socioeconomic status after the policy’s implementation. Conclusions Our findings suggest that Cameroon’s free ART policy is pro-poor. As it only benefitted PLHIV with the lowest socioeconomic status, increased comprehensive HIV care coverage is needed to substantially reduce the risk of CHE and the associated risk of impoverishment for all PLHIV.

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

Eastern Mediterranean Health Journal ◽

10.26719/emhj.21.045 ◽

2021 ◽

Vol 27 (10) ◽

pp. 962-973

Author(s):

Ashar Muhammad Malik ◽

Iqbal Azam ◽

Amir Khan ◽

Faisal Rifaq ◽

Kinza Chaudhary

Keyword(s):

Socioeconomic Factors ◽

Rural Areas ◽

Health Expenditure ◽

Financial Risk ◽

National Level ◽

Spatiotemporal Variation ◽

Financial Risk Protection ◽

Middle Income ◽

Services Delivery ◽

Risk Protection

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.

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Microinsurance and Rural Health

Oxford Research Encyclopedia of Economics and Finance ◽

10.1093/acrefore/9780190625979.013.436 ◽

2019 ◽

Author(s):

Syed Abdul Hamid

Keyword(s):

South Asia ◽

Low Income ◽

Informal Economy ◽

Financial Risk ◽

Access To Healthcare ◽

Low Income Countries ◽

Financial Protection ◽

Health Shocks ◽

Financial Risk Protection ◽

Risk Protection

Health microinsurance (HMI) has been used around the globe since the early 1990s for financial risk protection against health shocks in poverty-stricken rural populations in low-income countries. However, there is much debate in the literature on its impact on financial risk protection. There is also no clear answer to the critical policy question about whether HMI is a viable route to provide healthcare to the people of the informal economy, especially in the rural areas. Findings show that HMI schemes are concentrated widely in the low-income countries, especially in South Asia (about 43%) and East Africa (about 25.4%). India accounts for 30% of HMI schemes. Bangladesh and Kenya also possess a good number of schemes. There is some evidence that HMI increases access to healthcare or utilization of healthcare. One set of the literature shows that HMI provides financial protection against the costs of illness to its enrollees by reducing out-of-pocket payments and/or catastrophic spending. On the contrary, a large body of literature with strong methodological rigor shows that HMI fails to provide financial protection against health shocks to its clients. Some of the studies in the latter group rather find that HMI contributes to the decline of financial risk protection. These findings seem to be logical as there is a high copayment and a lack of continuum of care in most cases. The findings also show that scale and dependence on subsidy are the major concerns. Low enrollment and low renewal are common concerns of the voluntary HMI schemes in South Asian countries. In addition, the declining trend of donor subsidies makes the HMI schemes supported by external donors more vulnerable. These challenges and constraints restrict the scale and profitability of HMI initiatives, especially those that are voluntary. Consequently, the existing organizations may cease HMI activities. Overall, although HMI can increase access to healthcare, it fails to provide financial risk protection against health shocks. The existing HMI practices in South Asia, especially in the HMIs owned by nongovernmental organizations and microfinance institutions, are not a viable route to provide healthcare to the rural population of the informal economy. However, HMI schemes may play some supportive role in implementation of a nationalized scheme, if there is one. There is also concern about the institutional viability of the HMI organizations (e.g., ownership and management efficiency). Future research may address this issue.

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Unmet Healthcare Needs, Catastrophic Health Expenditure, and Health in South Korea’s Universal Healthcare System: Progression Towards Improving Equity by NHI Type and Income Level

Healthcare ◽

10.3390/healthcare8040408 ◽

2020 ◽

Vol 8 (4) ◽

pp. 408 ◽

Cited By ~ 1

Author(s):

Minsung Sohn ◽

Xianhua Che ◽

Hee-Jung Park

Keyword(s):

Health Insurance ◽

Health Status ◽

Low Income ◽

Health Expenditure ◽

Income Level ◽

Catastrophic Health Expenditure ◽

Poor Health ◽

Medical Aid ◽

Healthcare Needs ◽

Unmet Healthcare Needs

This study examined the effects of healthcare inequality on personal health. It aimed to determine how health insurance type and income level influence catastrophic health expenditure and unmet healthcare needs among South Koreans. Unbalanced Korean Health Panel data from 2011 to 2015, including 33,374 adults, were used. A time-trend and panel regression analysis were performed. The first to identify changes in the main variables and, the second, mediating effects of unmet healthcare needs and catastrophic health expenditure on the relationship between health insurance type, income level, and health status. The independent variables were: high-, middle-, low-income employee insured, high-, middle-, low-income self-employed insured, and medical aid. The dependent variable was health status, and the mediators were unmet needs and catastrophic health expenditure. The medical aid beneficiaries and low-income self-employed insured groups demonstrated a higher probability of reporting poor health status than the high-income, insured group (15.6%, 2.2%, and 2.3%, respectively). Participants who experienced unmet healthcare needs or catastrophic health expenditure were 10.7% and 5.6% higher probability of reporting poor health, respectively (Sobel test: p < 0.001). National policy reforms could improve healthcare equality by integrating insurance premiums based on income among private-sector employees and self-employed individuals within the health insurance network.

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Are People Enrolled in NCMS and CURBMI Susceptible in Catastrophic Health Expenditure? Evidence From China

INQUIRY The Journal of Health Care Organization Provision and Financing ◽

10.1177/0046958020919282 ◽

2020 ◽

Vol 57 ◽

pp. 004695802091928

Author(s):

Xinpeng Xu ◽

Hai Gu ◽

Hua You ◽

Lan Bai ◽

Decheng Li ◽

...

Keyword(s):

Low Income ◽

Health Expenditure ◽

Medical Insurance ◽

Catastrophic Health Expenditure ◽

New Cooperative Medical Scheme ◽

Basic Medical Insurance ◽

Medical Institutions ◽

Significant Difference ◽

Cooperative Medical Scheme ◽

Basic Medical

This study investigated associations between different types of medical insurance and the incidence of catastrophic health expenditure among middle-aged and the aged in China. The data came from the China Health and Retirement Longitudinal Survey implemented in 2013, with 9782 individuals analyzed. Probit regression models and multiple linear regressions were employed to explore the relationship mentioned above and potential mechanisms behind it. It was found that compared with participants in Urban Resident Basic Medical Insurance, individuals participating in New Cooperative Medical Scheme and Coordinating Urban and Rural Basic Medical Insurance was less likely to undergo catastrophic health expenditure ( P < .001, P = .008), especially for low-income and middle-income group. Participants in New Cooperative Medical Scheme and Coordinating Urban and Rural Basic Medical Insurance were more likely to utilize inpatient medical service ( P < .001, P = .020) and choose low-level medical institutions for treatment ( P = .003, P = .006). And individuals participating in New Cooperative Medical Scheme had lower out-of-pocket expenditure ( P = .034). The study showed the significant difference in the incidence of catastrophic health expenditure among participants in different medical insurances. Efforts should be made to improve the service quality of grassroots medical institutions except for the increase of reimbursement ratio, so that rural residents can enjoy high-quality medical services.

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Catastrophic health expenditure incidence and its equity in China: a study on the initial implementation of the medical insurance integration system

BMC Public Health ◽

10.1186/s12889-019-8121-2 ◽

2019 ◽

Vol 19 (1) ◽

Author(s):

Huan Liu ◽

Hong Zhu ◽

Jiahui Wang ◽

Xinye Qi ◽

Miaomiao Zhao ◽

...

Keyword(s):

Health Insurance ◽

Health Services ◽

Low Income ◽

Health Expenditure ◽

Concentration Index ◽

Medical Insurance ◽

Catastrophic Health Expenditure ◽

Integration System ◽

Integration Policies ◽

The Impact

Abstract Background By 2013, several regions in China had introduced health insurance integration policies. However, few studies addressed the impact of medical insurance integration in China. This study investigates the catastrophic health expenditure and equity in the incidence of catastrophic health expenditure by addressing its potential determinants in both integrated and non-integrated areas in China in 2013. Methods The primary data are drawn from the fifth China National Health Services Survey in 2013. The final sample comprises 19,788 households (38.4%) from integrated areas and 31,797 households (61.6%) from non-integrated areas. A probit model is employed to decompose inequality in the incidence of catastrophic health expenditure in line with the methodology used for decomposing the concentration index. Results The incidence of catastrophic health expenditure in integrated areas is higher than in non-integrated areas (13.87% vs. 13.68%, respectively). The concentration index in integrated areas and non-integrated areas is − 0.071 and − 0.073, respectively. Average household out-of-pocket health expenditure and average capacity to pay in integrated areas are higher than those in non-integrated areas. However, households in integrated areas have lower share of out-of-pocket expenditures in the capacity to pay than households in non-integrated areas. The majority of the observed inequalities in catastrophic health expenditure can be explained by differences in the health insurance and householders’ educational attainment both in integrated areas and non-integrated areas. Conclusions The medical insurance integration system in China is still at the exploratory stage; hence, its effects are of limited significance, even though the positive impact of this system on low-income residents is confirmed. Moreover, catastrophic health expenditure is associated with pro-poor inequality. Medical insurance, urban-rural disparities, the elderly population, and use of health services significantly affect the equity of catastrophic health expenditure incidence and are key issues in the implementation of future insurance integration policies.

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