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Abstract Background One of the key functions and ultimate goals of health systems is to provide financial protection for individuals when using health services. This study sought to evaluate the level of financial protection and its inequality among individuals covered by the Social Security Organization (SSO) health insurance between September and December 2023 in Iran. Methods We collected data on 1691 households in five provinces using multistage sampling to examine the prevalence of catastrophic healthcare expenditure (CHE) at four different thresholds (10%, 20%, 30%, and 40%) of the household’s capacity to pay (CTP). Additionally, we explored the prevalence of impoverishment due to health costs and assessed socioeconomic-related inequality in OOP payments for healthcare using the concentration index and concentration curve. To measure equity in out-of-pocket (OOP) payments for healthcare, we utilized the Kakwani progressivity index (KPI). Furthermore, we employed multiple logistic regression to identify the main factors contributing to households experiencing CHE. Findings : The study revealed that households in our sample allocated approximately 11% of their budgets to healthcare services. The prevalence of CHE at the thresholds of 10%, 20%, 30%, and 40% was found to be 47.1%, 30.1%, 20.1%, and 15.7%, respectively. Additionally, we observed that about 7.9% of the households experienced impoverishment due to health costs. Multiple logistic regression analysis indicated that the age of the head of the household, place of residence, socioeconomic status, utilization of dental services, utilization of medicine, and province of residence were the main factors influencing CHE. Furthermore, the study demonstrated that while wealthy households spend more money on healthcare, poorer households spend a larger proportion of their total income to healthcare costs. The KPI showed that households with lower total expenditures had higher OOP payments relative to their CTP. Conclusion The study findings underscore the need for targeted interventions to improve financial protection in healthcare and mitigate inequalities among individuals covered by SSO. It is recommended that these interventions prioritize the expansion of coverage for dental services and medication expenses, particularly for lower socioeconomic status household.

Background: One of the key functions and ultimate goals of health systems is to provide financial protection for individuals when using health services. This study sought to evaluate the level of financial protection and its inequality among individuals covered by the Social Security Organization (SSO) health insurance between September and December 2023 in Iran. Methods: We collected data on 1691 households in five provinces using multistage sampling to examine the prevalence of catastrophic healthcare expenditure (CHE) at four different thresholds (10%, 20%, 30%, and 40%) of the household's capacity to pay (CTP). Additionally, we explored the prevalence of impoverishment due to health costs and assessed socioeconomic-related inequality in OOP payments for healthcare using the concentration index and concentration curve. To measure equity in out-of-pocket (OOP) payments for healthcare, we utilized the Kakwani progressivity index (KPI). Furthermore, we employed multiple logistic regression to identify the main factors contributing to households experiencing CHE. Findings: : The study revealed that households in our sample allocated approximately 11% of their budgets to healthcare services. The prevalence of CHE at the thresholds of 10%, 20%, 30%, and 40% was found to be 47.1%, 30.1%, 20.1%, and 15.7%, respectively. Additionally, we observed that about 7.9% of the households experienced impoverishment due to health costs. Multiple logistic regression analysis indicated that the age of the head of the household, place of residence, socioeconomic status, utilization of dental services, utilization of medicine, and province of residence were the main factors influencing CHE. Furthermore, the study demonstrated that while wealthy households spend more money on healthcare, poorer households spend a larger proportion of their total income to healthcare costs. The KPI showed that households with lower total expenditures had higher OOP payments relative to their CTP. Conclusion: The study findings underscore the need for targeted interventions to improve financial protection in healthcare and mitigate inequalities among individuals covered by SSO. It is recommended that these interventions prioritize the expansion of coverage for dental services and medication expenses, particularly for lower socioeconomic status household. [ABSTRACT FROM AUTHOR]

Abstract Background To achieve Universal Health Coverage (UHC), China have implemented health system reform to expend health coverage and improve health equity. Scholars have explored the implementing effect of this health reform, but gaps remained in health care received by elderly. This study aims to assess the effect of implementing health insurance payment reform on health care received by elderly, as well as to evaluate its effect on cost sharing to identify whether improve financial protection of elderly under this reform. Methods We identified hospitalization of 46,714 elderly with cerebral infarction from 2013 to 2023. To examine the determinant role played by DRGs payment reform in healthcare for elderly and their financial protection, this study employs the OLS linear regression model for analysis. In the robustness checks, we validated the baseline results through several methods, including excluding the data from the initial implementation of the reform (2021), reducing the impact of the pandemic, and exploring the group effects of different demographic characteristics. Results The findings proposed that implementing DRGs payment reduces drug expenses but increases treatment expense of chronic disease for elderly in China. This exacerbates healthcare costs for elderly patients and seems to be contrary to the original purpose of health care reform. Additionally, the implementation of DRGs payment reduced the spending of medical insurance fund, while increased the out-of-pocket of patients, revealing a shift in health care expenses from health insurance fund to out-of-pocket. Conclusions This study shares the lessons from China’s health reform and provides enlightenment on how to effective implement health reform to improve health equity and achieve UHC in such low- and middle-income countries facing challenges in health financing.

Background: To achieve Universal Health Coverage (UHC), China have implemented health system reform to expend health coverage and improve health equity. Scholars have explored the implementing effect of this health reform, but gaps remained in health care received by elderly. This study aims to assess the effect of implementing health insurance payment reform on health care received by elderly, as well as to evaluate its effect on cost sharing to identify whether improve financial protection of elderly under this reform. Methods: We identified hospitalization of 46,714 elderly with cerebral infarction from 2013 to 2023. To examine the determinant role played by DRGs payment reform in healthcare for elderly and their financial protection, this study employs the OLS linear regression model for analysis. In the robustness checks, we validated the baseline results through several methods, including excluding the data from the initial implementation of the reform (2021), reducing the impact of the pandemic, and exploring the group effects of different demographic characteristics. Results: The findings proposed that implementing DRGs payment reduces drug expenses but increases treatment expense of chronic disease for elderly in China. This exacerbates healthcare costs for elderly patients and seems to be contrary to the original purpose of health care reform. Additionally, the implementation of DRGs payment reduced the spending of medical insurance fund, while increased the out-of-pocket of patients, revealing a shift in health care expenses from health insurance fund to out-of-pocket. Conclusions: This study shares the lessons from China's health reform and provides enlightenment on how to effective implement health reform to improve health equity and achieve UHC in such low- and middle-income countries facing challenges in health financing. [ABSTRACT FROM AUTHOR]

IntroductionTo achieve universal health coverage consistent with World Health Organization recommendations, monitoring financial protection is vital, even in the context of free medical care. Toward this end, this study investigated out-of-pocket (OOP) expenditure on medicines and their determinants among adults in Saudi Arabia.MethodsThis analysis was based on cross-sectional data derived from the Family Health Survey conducted by the General Authority for Statistics in 2018. Data analyses for this study were based on the total sample of 10,785 respondents. Descriptive statistics were used to identify the sample distribution for all variables included in the study. Tobit regression analysis was used to examine the determinants of OOP expenditure on medicines.ResultsThe average OOP expenditure on medicines was estimated to be 279.69 Saudi Riyal in the sampled population. Tobit regression analysis showed that age, average household monthly income, education level, and suffering a chronic condition were the main determinants of OOP expenditure on medicines. Conversely, being married and employed were associated with a lower probability of OOP expenditure on medicines.ConclusionThis study could assist policy makers to provide additional insurance funding and benefits to reduce the possibility of catastrophic OOP expenditure on medicines, especially for the most vulnerable demographic.

Equitable distribution of quality healthcare services among different subpopulations in China and Nigeria is inconsistent. This necessitates an examination of potential avenues for improving healthcare provision in both countries. A comparative analysis of both health systems was carried out to provide insights into the progress each nation has made, the obstacles they face, and areas both countries can learn from each other. We assessed 3 key dimensions of these systems using the Hsiao analytical framework. First, we scrutinized the policy levers of the health systems. Next, we evaluated intermediate outcomes, such as access to healthcare and the quality of care. Lastly, we assessed the extent to which the health systems achieve their ultimate goals, including improving citizen health status and enhancing overall patient satisfaction with the healthcare services. China surpasses Nigeria in terms of better birth outcomes, life expectancy, and management of communicable diseases. Both countries offer minimal protection against out-of-pocket spending on medical bills, which consequently exacerbates the poverty rate. China surpasses Nigeria in every health metrics. However, Nigeria's healthcare system offers services to a larger proportion of its populace because of the involvement of the private sector in healthcare delivery. Both countries continue to experience significant challenges, such as limited access to healthcare services in rural areas and overall patient dissatisfaction with the quality of care provided. • The Chinese healthcare service system has a predominant 3-tiered structure known as the "dual and three grades" system, whereas in the healthcare system of Nigeria, public healthcare system is patterned after the 3 levels of government. • The study unveils the challenges common to both nations, which include a disproportionate concentration of high-quality healthcare facilities in the urban regions, short consultation periods, low doctor-to-patient ratios, and the inability of to deliver basic treatment to vast, primarily impoverished patient groups, especially in the rural areas. • Out-of-pocket healthcare costs are common in both countries. This problem can be solved by providing nationalized or social insurance or by encouraging private insurance. Both countries also have serious difficulties with disadvantaged and neglected populations. China and Nigeria should invest more in primary healthcare institutions, particularly those that provide preventive and basic curative care. [ABSTRACT FROM AUTHOR]

Background: Multidrug resistant tuberculosis (MDR-TB) has attracted increasing attention in achieving the global goal of tuberculosis (TB) control. China has the second largest TB burden worldwide and has been experiencing large-scale domestic migration. This study aims to explore the effect of migrants on non-adherence to MDR-TB treatment. Materials and Methods: A cross-sectional study was carried out in Wuhan, China. The exposure cases were migrants who were not locally registered in the residence registration system. The control cases were local residents. Non-adherence cases were patients who were lost follow-up or refused treatment. Chi-square and t-test were used to compare variables between migrants and local residents. Logistic regression models using enter method were used to determine the relationship between migration and non-adherence to treatment. Moderation and medication effects on the association between migrant status and non-adherence were also explored. Results: We studied 73 migrants and 219 local residents. The migrants, who did not to adhere to treatment (55, 75.3%), was far higher than that of local residents (89, 40.6%). Migrants with MDR-TB had 10.38-times higher difficulty in adhering to treatment (adjusted OR = 10.38, 95% CI 4.62– 25.28) than local residents. This additional likelihood was moderated by age and treatment registration group. Migration had an indirect association with non-adherence to treatment via social medial insurance (adjusted OR = 1.05, 95% CI 1.01– 1.13). Conclusion: There a significant increased likelihood of non-adherence to treatment among migrants with MDR-TB, highlighting the importance of improving treatment adherence in this population. Migration prevented migrants from gaining access to social medical insurance and indirectly reduced their likelihood of adherence to treatment. [ABSTRACT FROM AUTHOR]

Health care expenses in Nigeria are done mainly through Out-of-pocket (OOP) expenses. Women irrespective of their age, status and location have need for medical care and this creates a burden on their expenses due to OOP medical expenses. This study therefore, examines the implications of healthcare payment through OOP medical expenses on the health status of women in Enugu State, South East Nigeria. A cross sectional study was conducted in Nsukka LGA and Enugu urban both in South – East Nigeria. Quantitative data was collected from 522 female respondents through structured questionnaire. The result shows that women irrespective of their place of residence are aware of health insurance scheme (p

Introduction: Despite the presence of multiple Government Health Insurance (GHI) schemes in West Bengal, the National Family Health Survey report (NFHS-5) has indicated that only 29.3% of households are covered by a health scheme. Awareness of health insurance schemes increases their utilisation. The absence of health insurance coverage results in increased out-of-pocket health expenditures, pushing families into debt. Therefore, there is a need to determine whether this lack of awareness among patients contributes to the issue. Aim: To estimate the awareness level, enrollment in GHI schemes, experiences of their utilisation, and to determine the contributory factors of awareness and enrollment among patients attending the Outdoor Patient Departments (OPDs) at a tertiary care hospital in Kolkata. Materials and Methods: An observational cross-sectional study was conducted from April 2023 to June 2023 at Medical College, Kolkata, West Bengal, India. A total of 390 respondents were chosen using a systematic random sampling technique and were interviewed using a predesigned, pretested, and semistructured questionnaire. Data were analysed using R Studio version 4.3.0. A p-value

Penelitian ini bertujuan untuk mengkaji pengaruh program bantuan sosial lansia pemda terhadap belanja kesehatan out-of-pocket (OOP) kelompok lansia miskin di Indonesia. Data yang digunakan adalah data Susenas bulan Maret tahun 2020 dengan menggunakan analisis counterfactual. Karena syarat untuk dapat melakukan analisis counterfactual adalah subjek dari penelitian harus memiliki karakteristik yang sama/seimbang, maka data yang digunakan dibatasi pada lansia kelompok ekonomi 40 persen terbawah. Selain itu, dilakukan teknik randomisasi metode Propensity Score Matching-Nearest-Neighbors (PSM-NN) yaitu mengkonstruksi data yang memiliki karakteristik serupa menjadi dua grup yaitu grup yang mendapatkan perlakuan (treatment) dan grup yang tidak mendapatkan perlakuan (grup kontrol). Hasil dari penelitian ini menunjukkan bahwa kelompok lansia miskin yang mendapatkan bantuan sosial lansia pemda memiliki belanja kesehatan OOP lebih tinggi sebesar 28,3 persen dibanding kelompok lansia miskin yang tidak mendapatkan bantuan. Tingginya belanja OOP ini terutama disebabkan oleh peningkatan belanja untuk pengobatan/kuratif.

Abstract Background A heavy financial burden is imposed on patients suffering from chronic diseases due to medicine out-of-pocket payments. Objectives This study focuses on assessing the affordability of medications used for chronic respiratory diseases (CRDs) such as asthma, chronic obstructive pulmonary disease (COPD), and cystic fibrosis (CF) in Iran, specifically on the category R medicines listed in the 2017 Iran drug list (IDL) that are used for the treatment of these diseases, based on the anatomical therapeutic chemical (ATC) drug code. Methods The affordability of medicines in mono and combination therapy approaches was assessed in CRDs using the World Health Organization/Health Action International (WHO/HAI) methodology. Accordingly, if out-of-pocket payment for 30-days of pharmacotherapy exceeds one day for the lowest-paid unskilled government worker (LPGW), it’s considered non-affordable. Results Based on the monotherapy approach, our finding demonstrates that all generic medicines of category R were affordable. However, branded drugs such as Symbicort®, Pulmicort Respules®, Flusalmex®, Seretide®, Fluticort Plus®, Seroflo®, and Salmeflo® cost between 1.2 and 2.5 days’ wage of LPGW and considered unaffordable despite 70% insurance coverage. Moreover, based on the affordability ratio in the combination therapy approach, all medicines used in asthma, COPD, and CF patients with mild respiratory problems are affordable except omalizumab (inj), which is non-affordable due to its high price and no insurance coverage. Conclusion Results showed that the existing insurance coverage does not protect households from hardship, so more considerations are needed such as different insurance schedules and patient support programs.

Introduction: Despite the presence of multiple Government Health Insurance (GHI) schemes in West Bengal, the National Family Health Survey report (NFHS-5) has indicated that only 29.3% of households are covered by a health scheme. Awareness of health insurance schemes increases their utilisation. The absence of health insurance coverage results in increased out-of-pocket health expenditures, pushing families into debt. Therefore, there is a need to determine whether this lack of awareness among patients contributes to the issue. Aim: To estimate the awareness level, enrollment in GHI schemes, experiences of their utilisation, and to determine the contributory factors of awareness and enrollment among patients attending the Outdoor Patient Departments (OPDs) at a tertiary care hospital in Kolkata. Materials and Methods: An observational cross-sectional study was conducted from April 2023 to June 2023 at Medical College, Kolkata, West Bengal, India. A total of 390 respondents were chosen using a systematic random sampling technique and were interviewed using a predesigned, pretested, and semistructured questionnaire. Data were analysed using R Studio version 4.3.0. A p-value <0.05 was considered statistically sign Results: Awareness about Swasthya Sathi was found to be present in 318 (81.54%) patients, but only 109 (34.28%) of them were enrolled. Awareness of Sishu Saathi and Rashtriya Bal Swasthya Karyakram (RBSK) was 12 (3.08%) and 10 (2.57%), respectively, and none were enrolled. The major source of information (11.03%) regarding health insurance among respondents was informal sources such as friends, relatives, and neighbours. The age of the respondents, type of family, occupation, and economic status were found to have a significant association with the right awareness (p=0.008, 0.012, 0.0005, and 0.029, respectively). The patient satisfaction level after utilising Swasthya Sathi was found to have a significant positive correlation with the right awareness (Spearman's ρ=0.322, p-value <0.01). The determinants of enrollment in Swasthya Sathi were female gender, rural residence, and right awareness (p<0.001). The commonest reason for not enrolling in any GHI among the non subscribers was a lack of awareness (82.56%). Conclusion: Correct awareness was found to be a determinant of enrollment in GHI. In order to bridge the gap between awareness and utilisation of GHI, there is a need to focus on Information, Education, and Communication (IEC) activities involving mass media and frontline health workers. [ABSTRACT FROM AUTHOR]

In order to guarantee equal access to healthcare, it must be funded in an equitable manner to ensure that people are not forced to forgo healthcare and to prevent healthcare from becoming too large a financial burden for patients. This is achieved by ensuring that health‑ care received by the poorest people is subsidised by wealthier people, while also ensuring that patients suffering poor health are not burdened with excessive costs for a given income. In prac‑ tice, patients are required to cover some of their healthcare costs across all European healthcare systems. Since out‑of‑pockets are only paid by healthcare consumers, their existence may com‑ promise equity in healthcare financing. In this article, we evaluate how out‑of‑pockets contribute to vertical and horizontal equity in healthcare financing for people aged 50 and over in Europe. Using concentration indices, we demonstrate that equity in financing is not respected, particu‑ larly in healthcare systems where out-of-pockets are the least regulated. [ABSTRACT FROM AUTHOR]

Abstract Out-of-pocket payments are expenditures borne directly by an individual/household for health services that are not reimbursed by any third-party. Households can experience financial hardship when the burden of such out-of-pocket payments is significant. This financial hardship is commonly measured using the “catastrophic health expenditure” (CHE) metric. CHE has been applied as an indicator in several health sectors and health policies. However, despite its importance, the methods used to measure the incidence of CHE vary across different studies and the terminology used can be inconsistent. In this paper, we introduce and raise awareness of the main approaches used to calculate CHE and discuss critical areas of methodological variation in a global health context. We outline the key features, foundation and differences between the two main methods used for estimating CHE: the budget share and the capacity-to-pay approach. We discuss key sources of variation within CHE calculation and using data from Ethiopia as a case study, illustrate how different approaches can lead to notably different CHE estimates. This variation could lead to challenges when decisionmakers and policymakers need to compare different studies' CHE estimates. This overview is intended to better understand how to interpret and compare CHE estimates and the potential variation across different studies.

Abstract Background Although diagnosis and treatment services for tuberculosis (TB) are provided free of charge in most countries, direct non-medical and indirect costs due to absenteeism, also place a significant burden on patients and their families. Sichuan Province has the second highest incidence of TB in China, with an incidence of approximately 100 cases per 100 000 people. However, there are limited research on out-of-pocket expenditure (OOPE) and its influencing factors in TB patients in Sichuan Province. Methods A retrospective cross-sectional study was conducted on TB patients in designated medical institutions for TB in Sichuan Province from 2017-2021. A face-to-face questionnaire was conducted to obtain the information related to hospitalization of patients, and the multi-level regression model was used to analyse the factors that influence OOPE and total out-of-pocket expenditure (TOOPE) of TB patients. Results A total of 2644 patients were investigated, and 74.24% of TB patients and their families experienced catastrophic total costs due to TB. The median total cost was 9223.37 CNY (1429.98 USD), in which the median direct and indirect costs of TB patients were 10185.00 CNY (1579.07 USD) and 2400.00 CNY (372.09 USD), respectively, and indirect costs contributed to 43% of total costs. The median OOPE and TOOPE costs were 6024.00 CNY (933.95 USD) and 11890.50 CNY (1843.49 USD), respectively. OOPE and TOOPE had common influencing factors including whether the patient's family had four or more members, a history of hospitalization, combination with other types of TB, the number of visits before diagnosis, and co-occurrence with chronic disease. Conclusions The OOPE and TOOPE for TB patients and their families in Sichuan Province are still heavy. In the long run, it is necessary to strengthen education and awareness campaigns on TB related knowledge, disseminate basic medical knowledge to the public, improve healthcare-seeking behavior, and enhance the healthcare infrastructure to improve the accuracy of TB diagnosis and reduce the significant OOPE and TOOPE faced by TB patients and their families in Sichuan Province.

Abstract Background Chronic prurigo or prurigo nodularis is a severe condition with chronic pruritus and skin lesions. Current unnmet medical needs are numerous and generate a significant burden for the patients. Financial consequences are poorly known. Objectives The aim of this study was to evaluate out‐of‐pocket (OOP) expenditures for the patients. Methods A digital detailed questionnaire was submitted to adult patients living in France. The severity of pruritus was assessed with the 5‐D itch scale and the psychological well‐being was assessed with the well‐being questionnaire WBQ‐12. Results A total of 141 patients answered to all questions. The mean global score for the 5‐D itch scale was 16/25. The mean WBQ‐12 score was low: 14.7/36. The amount of OOP expenditures was high in patients with chronic prurigo (€855 ± 769 [median €605]). It was correlated with the severity of itch, higher in women than in men, higher when lesions were visible, and inversely correlated with psychological well‐being. Conclusions Chronic prurigo or prurigo nodularis is insufficiently managed and treated until now. Consequently, itch remains poorly treated, the psychological well‐being is deeply altered, and the personal cost related to the disease remains high for these patients.

Abstract Objectives Most people who develop chronic diseases, including cardiovascular disease (CVD), live in their homes in the community in their last year of life. Since cost-sharing is common in most countries, including those with universal health insurance, these people incur out of pocket expenditure (OOPE). The study aims to identify the prevalence and measure the size of OOPE among CVD decedents at end-of-life (EOL) explore differences among countries in OOPE, and examine whether the decedents’ characteristics or their countries’ health policy affects OOPE more. Methods SHARE data among people aged 50 + from seven European countries (including Israel) who died from CVD are analyzed. Decedents’ family members are interviewed to learn about OOPE on their relatives’ account. Results We identified 1,335 individuals who had died from CVD (average age 80.8 years, 54% men). More than half of CVD-decedent people spend OOPE on community services at EOL and their expenditure varies widely among countries. About one-third of people in France and Spain had OOPE, rising to around two-thirds in Israel and Italy and almost all in Greece. The average OOPE is 391.9 PPT, with wide variance across countries. Significant odds of OOPE exist in the country variable only, and significant differences exist in the amount of OOPE among countries and duration of illness preceding death. Conclusions Since improving CVD care efficiency and effectiveness are key aims, healthcare policymakers should broaden the investigation into expanding public funding for community services in order to mitigate OOPE, alleviate the economic burden on households, mitigate forgoing of community services due to price, and reduce rehospitalization.

Background: In many countries the community pharmacist's role includes collecting prescription medicine co-payments at the point of dispensing. This is a context which can provide unique insights into individuals' access to prescription medicines, as interactions with service users about out-of-pocket (OOP) expenses that may negatively affect a pharmacist's patient counselling role. Prior research has identified that OOP expenses for prescription medicines led to decreased treatment adherence. This study aims to understand the role of community pharmacists in the collection of co-payments for prescription medicines in one region of Aotearoa New Zealand, and the possible implications for equitable access to medicines. Methods: This is a qualitative study using a case study research design. Data were collected through focus groups, individual interviews, and an electronic survey. Using a critical realist approach in thematic analysis, findings were categorised as Causal tendencies (the things that cause the events); Events (the things that community pharmacists experience); and Experiences (the perceptions and feelings of individual participants). Results: Our analysis finds that the current profession of community pharmacy in Aotearoa New Zealand, is under strain. The results suggest that broader government policies, such as the pharmacist's role in delivering essential health services, the fairness of standard prescription co-payments, and the role of community pharmacists as gatekeepers, have a significant influence on the profession. In addition, the study found that individual community pharmacists have a unique position in the co-payment process, face power imbalances within their role, and the study indicates evidence of value judgements towards service users. Conclusions: This study is exploratory; however, its examination of the policy of prescription medicine co-payments from the perspective of community pharmacists, who play a vital role in both dispensing medicines and collecting prescription medicine co-payments, is novel. Despite prescription medicine co-payments being a routine part of pharmacists' role in many countries, it is a topic where there is limited published peer-reviewed literature. The study adds to existing evidence that funding models influence community pharmacists' role. In addition, this study identified value judgements about service users in relation to prescription medicine co-payments which may influence service users' health-seeking behaviour. In this setting, limited representation of at-risk populations in the community pharmacy profession may be a factor that negatively influence interactions between pharmacists and service users. Highlights: This study is novel as examines the policy of prescription medicine co-payments from the perspective of community pharmacists, a critical yet overlooked profession in discussions about out-of-pocket costs and implications for equitable access to medicines. Findings indicate that the implementation of the government financial risk protection for out-of-pocket payments for medicines in Aotearoa New Zealand, the Prescription Subsidy Scheme, may be inadequately implemented and lead to people missing out on further discount to subsidised medicines. The study identified value judgements by community pharmacists which may impact on their counselling role, which may influence service users' health-seeking behaviour. [ABSTRACT FROM AUTHOR]

Background: A heavy financial burden is imposed on patients suffering from chronic diseases due to medicine out-of-pocket payments. Objectives: This study focuses on assessing the affordability of medications used for chronic respiratory diseases (CRDs) such as asthma, chronic obstructive pulmonary disease (COPD), and cystic fibrosis (CF) in Iran, specifically on the category R medicines listed in the 2017 Iran drug list (IDL) that are used for the treatment of these diseases, based on the anatomical therapeutic chemical (ATC) drug code. Methods: The affordability of medicines in mono and combination therapy approaches was assessed in CRDs using the World Health Organization/Health Action International (WHO/HAI) methodology. Accordingly, if out-of-pocket payment for 30-days of pharmacotherapy exceeds one day for the lowest-paid unskilled government worker (LPGW), it's considered non-affordable. Results: Based on the monotherapy approach, our finding demonstrates that all generic medicines of category R were affordable. However, branded drugs such as Symbicort®, Pulmicort Respules®, Flusalmex®, Seretide®, Fluticort Plus®, Seroflo®, and Salmeflo® cost between 1.2 and 2.5 days' wage of LPGW and considered unaffordable despite 70% insurance coverage. Moreover, based on the affordability ratio in the combination therapy approach, all medicines used in asthma, COPD, and CF patients with mild respiratory problems are affordable except omalizumab (inj), which is non-affordable due to its high price and no insurance coverage. Conclusion: Results showed that the existing insurance coverage does not protect households from hardship, so more considerations are needed such as different insurance schedules and patient support programs. [ABSTRACT FROM AUTHOR]

Abstract Background and objectives Lebanon has one of the highest incidence rates of bladder cancer (BC) in the world. In 2019, Lebanon’s economy collapsed which majorly impacted healthcare costs and coverage. This study assesses the overall direct costs of urothelial BC in Lebanon, from the perspective of public and private third-party payers (TPP) and households, and evaluates the impact of the economic collapse on these costs. Methods This was a quantitative, incidence-based cost-of-illness study, conducted using a macro-costing approach. Costs of medical procedures were obtained from the records of various TPPs and the Ministry of Public Health. We modeled the clinical management processes for each stage of BC, and conducted probabilistic sensitivity analyses to estimate and compare the cost of each stage, pre-and post-collapse, and for each payer category. Results Before the collapse, the total annual cost of BC in Lebanon was estimated at LBP 19,676,494,000 (USD 13,117,662). Post-collapse, the total annual cost of BC in Lebanon increased by 768% and was estimated at LBP 170,727,187,000 (USD 7,422,921). TPP payments increased by 61% whereas out-of-pocket (OOP) payments increased by 2,745% resulting in a decrease in TPP coverage to only 17% of total costs. Conclusion Our study shows that BC in Lebanon constitutes a significant economic burden costing 0.32% of total health expenditures. The economic collapse induced an increase of 768% in the total annual cost, and a catastrophic increase in OOP payments.

Background: Catastrophic health expenditure (CHE) has been explained as a growth in spending for health care services that exceeds 40% of total household income. Therefore, devoting a large portion of household resources to health care services can greatly threaten to standards of living in the short and long term. The present study was an attempt to evaluate the financial contribution of Iranian households in health care services system in Hamadan Province in 2017.Methods: This cross-sectional study reflected on spending for health care services. For this purpose, the data were extracted from the household expenditure statistics published in the database of the Statistical Center of Iran. Accordingly, among the common econometric models associated with the subject matter, the logit model was employed, and the data were then analyzed using the Stata 14 software.Results: The study findings revealed that 8.9% of the total household costs had been allocated to health care services. The results also showed that 3.5% of the households faced catastrophic cost among all the studied households. Upon examining the factors, significant relationship was further observed between the probability of exposure to CHE and living in rural areas, income decile group, number of employees, and marital status in the households concerned.Conclusion: It was concluded that poor distribution of health care services, unequal distribution of income and wealth among jobs, as well as socioeconomic conditions could influence CHE. Therefore, there is a need to plan and develop policies for better access to health care services.

Abstract Background Financial burden is a common phenomenon, often noticed in the caregivers of children with Down syndrome. It echoes adverse effects on the caregiver’s mental and physical health. The economic burden covers direct healthcare costs, direct non-health-care costs, and indirect costs and is substantial for the family of a person with Down syndrome, as well as for society. Evidence, in this area, is necessary to reduce mental stress and promote financial well-being among caregivers. Methods In this review, quantitative studies that assess the economic burden on caregivers of children with Down syndrome will be considered. We will perform a systematic literature search conducted from the year 2000 to 2022 on electronic databases CINAHL, EBSCO, EMBASE, PubMed, Scopus, Web of Science, and EconLit. An additional gray literature search will be carried out. Two researchers will independently conduct the screening and data extraction and assess the risk of bias. Discussions The review attempts to methodically analyze the economic burden among caregivers of children with Down syndrome from the societal perspective and individual perspectives. The current study will provide an evidence base to researchers, academicians, and society in identifying need-based learning to caregivers, and the selection of appropriate therapies for children suffering from Down syndrome. Systematic review registration PROSPERO CRD42021265312

The present study intends to examine whether there exists any gender gap in out-of-pocket spending on hospitalization between elderly men and elderly women. Data were drawn from the NSS 75th Round Health Care Survey (2017–2018) consisting of a total number of 45,299 elderly. Bivariate analysis and t-test were used to examine the disease burden and gender gap in health spending. The burden of noncommunicable diseases such as bone disease and anemia is considerably higher among elderly women than elderly men. There is a significant, positive gender gap in inpatient health spending, especially in the rural area across various diseases. Lower level of awareness, male dominance in health-related decision-making, and financial dependence are some possible factors for the gender gap. Generating awareness among households and particularly among women regarding health-care system, chronic diseases, and sources of health financing along with formulating disease-specific policy may reduce the gender gap in health spending.

Abstract Background Many high-income countries have made significant progress towards achieving universal health coverage. Nevertheless, out-of-pocket (OOP) health expenditure continues to undermine the effectiveness of the universal healthcare system. In Saudi Arabia, due to the overburdened free public health services, many people opt for alternative healthcare services, risking high OOP payments. The presence of chronic illness further exacerbates this situation. However, there is limited evidence on the extent of the gap in OOP health expenditure between the chronically and non-chronically ill and the associated drivers contributing to this gap. The aim of this study was to assess inequalities in relative OOP health expenditure, estimated as the percentage of income spent on healthcare, between the chronically and non-chronically ill in Saudi Arabia and their associated drivers. Methods Data from 10,785 respondents were obtained from a national cross-sectional survey conducted in Saudi Arabia as part of the 2018 Family Health Survey. Inequalities in relative OOP health expenditure were measured using concentration indices and curves. A Blinder-Oaxaca decomposition analysis was used to assess the differences in relative OOP health expenditure between the chronically and non-chronically ill. Results The results showed that the chronically ill experience a higher financial burden due to healthcare services in absolute costs and relative to their income compared to the non-chronically ill. In addition, there was higher pro-poor inequality (–0.1985) in relative OOP health expenditure among the chronically ill compared to that (–0.1195) among the non-chronically ill. There was a 2.6% gap in relative OOP health expenditure among the chronically and non-chronically ill, of which 53.8% was attributable to unexplained factors, with explained factors accounting for the 46.2% difference. Factors that significantly contributed to the overall gap (i.e. both explained and non-explained factors) included employment status, insurance status, self-rated health, and periodic check-ups. Conclusion This study underscores the high financial burden due to OOP payments among the chronically ill and the existence of pro-poor inequalities. In addition, there is a significant gap in relative OOP health expenditure between the chronically and non-chronically ill, which is mainly attributable to differences in socio-economic characteristics. This indicates that the existing financial mechanisms have not been sufficient in cushioning the chronically ill and less well off in Saudi Arabia. This situation calls for health policymakers to integrate a social safety net into the health financing system and to prioritize the disadvantaged population, thereby ensuring access to health services without experiencing financial hardship.

Out-of-pocket payments are expenditures borne directly by an individual/household for health services that are not reimbursed by any third-party. Households can experience financial hardship when the burden of such out-of-pocket payments is significant. This financial hardship is commonly measured using the "catastrophic health expenditure" (CHE) metric. CHE has been applied as an indicator in several health sectors and health policies. However, despite its importance, the methods used to measure the incidence of CHE vary across different studies and the terminology used can be inconsistent. In this paper, we introduce and raise awareness of the main approaches used to calculate CHE and discuss critical areas of methodological variation in a global health context. We outline the key features, foundation and differences between the two main methods used for estimating CHE: the budget share and the capacity-to-pay approach. We discuss key sources of variation within CHE calculation and using data from Ethiopia as a case study, illustrate how different approaches can lead to notably different CHE estimates. This variation could lead to challenges when decisionmakers and policymakers need to compare different studies' CHE estimates. This overview is intended to better understand how to interpret and compare CHE estimates and the potential variation across different studies. [ABSTRACT FROM AUTHOR]

Background: Although diagnosis and treatment services for tuberculosis (TB) are provided free of charge in most countries, direct non-medical and indirect costs due to absenteeism, also place a significant burden on patients and their families. Sichuan Province has the second highest incidence of TB in China, with an incidence of approximately 100 cases per 100 000 people. However, there are limited research on out-of-pocket expenditure (OOPE) and its influencing factors in TB patients in Sichuan Province. Methods: A retrospective cross-sectional study was conducted on TB patients in designated medical institutions for TB in Sichuan Province from 2017-2021. A face-to-face questionnaire was conducted to obtain the information related to hospitalization of patients, and the multi-level regression model was used to analyse the factors that influence OOPE and total out-of-pocket expenditure (TOOPE) of TB patients. Results: A total of 2644 patients were investigated, and 74.24% of TB patients and their families experienced catastrophic total costs due to TB. The median total cost was 9223.37 CNY (1429.98 USD), in which the median direct and indirect costs of TB patients were 10185.00 CNY (1579.07 USD) and 2400.00 CNY (372.09 USD), respectively, and indirect costs contributed to 43% of total costs. The median OOPE and TOOPE costs were 6024.00 CNY (933.95 USD) and 11890.50 CNY (1843.49 USD), respectively. OOPE and TOOPE had common influencing factors including whether the patient's family had four or more members, a history of hospitalization, combination with other types of TB, the number of visits before diagnosis, and co-occurrence with chronic disease. Conclusions: The OOPE and TOOPE for TB patients and their families in Sichuan Province are still heavy. In the long run, it is necessary to strengthen education and awareness campaigns on TB related knowledge, disseminate basic medical knowledge to the public, improve healthcare-seeking behavior, and enhance the healthcare infrastructure to improve the accuracy of TB diagnosis and reduce the significant OOPE and TOOPE faced by TB patients and their families in Sichuan Province. [ABSTRACT FROM AUTHOR]

Objectives: Most people who develop chronic diseases, including cardiovascular disease (CVD), live in their homes in the community in their last year of life. Since cost-sharing is common in most countries, including those with universal health insurance, these people incur out of pocket expenditure (OOPE). The study aims to identify the prevalence and measure the size of OOPE among CVD decedents at end-of-life (EOL) explore differences among countries in OOPE, and examine whether the decedents' characteristics or their countries' health policy affects OOPE more. Methods: SHARE data among people aged 50 + from seven European countries (including Israel) who died from CVD are analyzed. Decedents' family members are interviewed to learn about OOPE on their relatives' account. Results: We identified 1,335 individuals who had died from CVD (average age 80.8 years, 54% men). More than half of CVD-decedent people spend OOPE on community services at EOL and their expenditure varies widely among countries. About one-third of people in France and Spain had OOPE, rising to around two-thirds in Israel and Italy and almost all in Greece. The average OOPE is 391.9 PPT, with wide variance across countries. Significant odds of OOPE exist in the country variable only, and significant differences exist in the amount of OOPE among countries and duration of illness preceding death. Conclusions: Since improving CVD care efficiency and effectiveness are key aims, healthcare policymakers should broaden the investigation into expanding public funding for community services in order to mitigate OOPE, alleviate the economic burden on households, mitigate forgoing of community services due to price, and reduce rehospitalization. [ABSTRACT FROM AUTHOR]

Background: People with diabetes need extensive self-management support, medications, regular screening for and treatment of possible complications and comorbidities, all of which can increase out-of-pocket (OOP) costs in patients and their families. There is a very strong correlation between the level of OOPs and an indicator that is used to monitor how well a health system is performing in terms of financial protection namely, incidence of catastrophic health expenditure. Objectives: 1. To assess the catastrophic health expenditure on treatment of diabetes mellitus and its complications in the study population. 2. To find out the association of CHE with sociodemographic profile, diabetic profile, and treatment compliance among the study population. Methodology: After applying the inclusion criteria 360 known diabetics were included from the four randomly selected slum areas of Agra city. A cross- sectional study through face-to-face interview using predesigned, pretested, and semi-structured questionnaire was conducted from September 2020 to March 2022. Data was entered on MS excel and appropriate statistical analysis was done. Results: Males and females were 59% and 41% respectively. Nearly 66% participants were of age group 35-60 years, 28% were illiterates, 54% were unemployed & 44% belong to upper lower socioeconomic class. Almost 96% were having type 2 diabetes, 74% were on oral hypoglycaemic agents and 70% were compliant to treatment. Monthly median direct out-of-pocket expenses were INR 1500 and indirect expenses were INR 505. Type of diabetes, and treatment regimen were the factors found to be associated with Catastrophic health expenditure. Conclusion: A significant proportion of 39.4% of the study participants were found to have catastrophic health expenditure.

Background High out-of-pocket (OOP) health expenditures are a common problem in developing countries. Studies rarely investigate the crowding-out effect of OOP health expenditures on other areas of household consumption. OOP health costs are a colossal burden on families and can lead to adjustments in other areas of consumption to cope with these costs. Methods This cross-sectional study used self-reported household consumption data from the nationally representative Household Socioeconomic Survey (HSES), collected in 2018 by the National Statistical Office of Mongolia. We estimated a quadratic conditional Engel curves system to determine intrahousehold resource allocation among 12 consumption variables. The 3-stage least squared method was used to deal with heteroscedasticity and endogeneity problems to estimate the causal crowding-out effect of OOP. Results The mean monthly OOP health expenditure per household was ₮64 673 (standard deviation [SD] = 259 604), representing approximately 6.9% of total household expenditures. OOP health expenditures were associated with crowding out durables, communication, transportation, and rent, and with crowding in education and heating for all households. The crowding-out effect of ₮10 000 in OOP health expenditures was the largest for food (₮5149, 95% CI = -8582; -1695) and crowding-in effect was largest in heating (₮2691, 95% CI = 737; 4649) in the lowest-income households. The effect of heating was more than 10 times greater than that in highest-income households (₮261, 95% CI = 66; 454); in the highest-income households, food had a crowding-in effect (₮179, 95% CI = -445; 802) in absolute amounts. In terms of absolute amount, the crowding-out effect for food was up to 5 times greater in households without social health insurance (SHI) than in those with SHI. Conclusion Our findings suggest that Mongolia’s OOP health expenses are associated with reduced essential expenditure on items such as durables, communication, transportation, rent, and food. The effect varies by household income level and SHI status, and the lowest- income families were most vulnerable. SHI in Mongolia may not protect households from large OOP health expenditures.

Background and objectives: Lebanon has one of the highest incidence rates of bladder cancer (BC) in the world. In 2019, Lebanon's economy collapsed which majorly impacted healthcare costs and coverage. This study assesses the overall direct costs of urothelial BC in Lebanon, from the perspective of public and private third-party payers (TPP) and households, and evaluates the impact of the economic collapse on these costs. Methods: This was a quantitative, incidence-based cost-of-illness study, conducted using a macro-costing approach. Costs of medical procedures were obtained from the records of various TPPs and the Ministry of Public Health. We modeled the clinical management processes for each stage of BC, and conducted probabilistic sensitivity analyses to estimate and compare the cost of each stage, pre-and post-collapse, and for each payer category. Results: Before the collapse, the total annual cost of BC in Lebanon was estimated at LBP 19,676,494,000 (USD 13,117,662). Post-collapse, the total annual cost of BC in Lebanon increased by 768% and was estimated at LBP 170,727,187,000 (USD 7,422,921). TPP payments increased by 61% whereas out-of-pocket (OOP) payments increased by 2,745% resulting in a decrease in TPP coverage to only 17% of total costs. Conclusion: Our study shows that BC in Lebanon constitutes a significant economic burden costing 0.32% of total health expenditures. The economic collapse induced an increase of 768% in the total annual cost, and a catastrophic increase in OOP payments. Highlights: Lebanon has one the highest Bladder Cancer (BC) incidence rates. One study examined the cost of BC, from 2008 to 2017 using data from one TPP, and estimated the average annual cost of BC at 3538 USD per patient. These estimates might not reflect the current reality since the 2019–2020 Lebanese economic collapse majorly impacted healthcare utilization, management, and costs. Moreover, the cost of BC from Lebanese households' perspective remains unknown. Before the 2019–2020 economic collapse, the total annual cost of BC in Lebanon was estimated at LBP 19,676,494,000 (USD 13,117,662). TPPs covered 89% and 11% was paid OOP. Post-collapse, the total annual cost of BC in LBP increased by 768%. TPP payments increased by 61% whereas OOP payments increased by 2,745%. This paper sheds light on the catastrophic increase in OOP payments in BC patients post-collapse, informing the decision makers of the urgency to tackle this subject and the crucial need to support households. In addition, due to the devaluation of the LBP, the total cost of BC per patient in USD dropped by 43% post-collapse, which implies a readjustment of international aid allocations, as they can be expected to cover a larger number of patients. [ABSTRACT FROM AUTHOR]

Abstract In 2009, the Democratic Republic of Congo (DRC) started its journey towards achieving Universal Health Coverage (UHC). This study examines the evolution of financial risk protection and health outcomes indicators in the context of the commitment of DRC to UHC. To measure the effects of such a commitment on financial risk protection and health outcomes indicators, we analyse whether changes have occurred over the last two decades and, if applicable, when these changes happened. Using five variables as indicators for the measurement of the financial risk protection component, there as well retained three indicators to measure health outcomes. To identify time-related effects, we applied the parametric approach of breakpoint regression to detect whether the UHC journey has brought change and when exactly the change has occurred. Although there is a slight improvement in the financial risk protection indicators, we found that the adopted strategies have fostered access to healthcare for the wealthiest quantile of the population while neglecting the majority of the poorest. The government did not thrive persistently over the past decade to meet its commitment to allocate adequate funds to health expenditures. In addition, the support from donors appears to be unstable, unpredictable and unsustainable. We found a slight improvement in health outcomes attributable to direct investment in building health centres by the private sector and international organizations. Overall, our findings reveal that the prevention of catastrophic health expenditure is still not sufficiently prioritized by the country, and mostly for the majority of the poorest. Therefore, our work suggests that DRC’s UHC journey has slightly contributed to improve the financial risk protection and health outcomes indicators but much effort should be undertaken.

Abstract Background Limited health literacy is a public health challenge contributing to the rising health care costs. We assess the economic costs of limited health literacy in China using data from the National Health Literacy Surveillance survey. Methods Our data includes a sample of 6316 residents aged 15–69 years old living in Ningbo, China, in 2019. We use box plots to examine the distribution of out-of-pocket health expenditure by the level of health literacy. We then use the estimates from a two-part model to assess the contribution of limited health literacy to individual medical spending and the aggregate health expenditure at different levels of health literacy for the adult population in Ningbo. Results Medical costs of limited health literacy are about 10% (177 CNY or about 25 USD) of the annual medical expense of a resident aged 15–69 living in Ningbo. The medical cost of limited health literacy is greater among the rural, female, and older groups than others. If the proportion of people with adequate health literacy increases from 22 to 30% (the target level by 2030), the aggregate out-of-pocket health expenditure in Ningbo will decrease by 100 million CNY (14 million USD), or 0.88% of the 2019 Ningbo government expenditure on health care. Conclusions This paper highlights the direct and indirect economic costs associated with limited health literacy. The results should help policymakers evaluate the cost-effectiveness of relevant programs that aim to improve residents’ health literacy.

IntroductionThis study aims to determine the out-of-pocket health expenditures of households in Turkey where individuals with rare diseases are residing.MethodsThe research population consisted registered members of associations who are members of the Rare Diseases Network. In addition to the general analysis including all participants, expenditures based on characteristics of disease holders were also calculated.ResultsA total of 439 participants were included in the analysis. We determined that special nutrition was the highest expenditure group and emergency departments were the lowest expenditure group. When all the participants were evaluated, the average cost of rare diseases was found to be Ł22,743 (€2,877). A significant relationship was found between income status and out-of-pocket health expenditures (p = 0.012).DiscussionPolicy makers should consider inclusion of special nutritional products and medical/non-medical devices used in treatment of rare diseases within the scope of reimbursement and the development of orphan drug legislation as the first actions to be taken.

Background: Financial burden is a common phenomenon, often noticed in the caregivers of children with Down syndrome. It echoes adverse effects on the caregiver's mental and physical health. The economic burden covers direct healthcare costs, direct non-health-care costs, and indirect costs and is substantial for the family of a person with Down syndrome, as well as for society. Evidence, in this area, is necessary to reduce mental stress and promote financial well-being among caregivers. Methods: In this review, quantitative studies that assess the economic burden on caregivers of children with Down syndrome will be considered. We will perform a systematic literature search conducted from the year 2000 to 2022 on electronic databases CINAHL, EBSCO, EMBASE, PubMed, Scopus, Web of Science, and EconLit. An additional gray literature search will be carried out. Two researchers will independently conduct the screening and data extraction and assess the risk of bias. Discussions: The review attempts to methodically analyze the economic burden among caregivers of children with Down syndrome from the societal perspective and individual perspectives. The current study will provide an evidence base to researchers, academicians, and society in identifying need-based learning to caregivers, and the selection of appropriate therapies for children suffering from Down syndrome. Systematic review registration: PROSPERO CRD42021265312 [ABSTRACT FROM AUTHOR]

Out-of-pocket (OOP) costs may constitute a substantial financial burden to patients diagnosed with cancer. Earlier stage diagnosis and treatment of cancers may promote decreased morbidity and mortality, subsequently also lowering costs. To better understand costs experienced by patients with cancer, OOP costs by stage post-diagnosis were estimated. A retrospective analysis was conducted using Optum's de-identified Integrated Claims-Clinical dataset with Enriched Oncology, which includes data from commercially insured members (June 1, 2015–July 31, 2020). Mean annual and cumulative OOP costs (co-pay + co-insurance + deductible) (2020 USD) were reported through a 3-year period post-cancer diagnosis among adult commercially insured members (not including Medicare Advantage members) diagnosed with staged breast, cervical, colorectal, lung, ovarian, or prostate cancer between January 1, 2016 and June 30, 2020 with continuous enrollment for ≥1-month post-diagnosis. A total of 7,494 eligible members were identified who were diagnosed with breast, cervical, colorectal, lung, ovarian, or prostate cancer. A greater proportion of OOP costs were incurred in year 1 post-diagnosis but remained relatively high through year 3 post-diagnosis. Cumulative mean OOP costs were as high as $35,243 (lung stage IV) per commercially insured patient by year 3 post-diagnosis and were generally higher among those diagnosed at later stages (III/IV) than those diagnosed at earlier stages (I/II) across all cancers. Generalizability of these results is limited to those with commercial health insurance coverage. Additionally, cancer staging was dependent on accuracy of staging as recorded in the electronic medical record and as determined by Optum's proprietary algorithm using natural language processing. Cumulative mean OOP costs among commercially insured patients during the 3-year period post-cancer diagnosis were substantial and generally higher among those with later stage cancer diagnoses. Diagnosis of cancer at earlier stages may allow for more timely treatment and lessen patient OOP costs. Patients diagnosed with cancer may face significant out-of-pocket costs (expenses that are not reimbursed by insurance) for care. However, lower costs may be achieved if the cancer is identified, diagnosed, and treated at earlier stages before the cancer tumor can grow or spread to other parts of the body. In this study, we examined patient out-of-pocket costs on an annual basis and over a 3-year period by cancer stage (I–IV) at diagnosis. Data were obtained from a large healthcare database (Optum's Claims-Clinical dataset with Enriched Oncology) that has administrative claims with out-of-pocket cost records as well as health records to determine cancer type and stage at diagnosis. Out-of-pocket costs recorded in the database included the co-pay, co-insurance, and deductible. Data from 7,494 adult patients with commercial insurance (not including Medicare Advantage) who were newly diagnosed with breast, cervical, colorectal, lung, ovarian, or prostate cancer between January 1, 2016 and June 30, 2020 were identified and analyzed. Patients incurred most of their out-of-pocket costs during the first year after a cancer diagnosis and these costs remained high for an additional 2 years. In general, patients diagnosed with cancer at later stages (III/IV) had a higher 3-year total out-of-pocket cost compared to those diagnosed at earlier stages (I/II) and this reached as high as $35,243 among patients diagnosed with stage IV lung cancer. Diagnosis of cancer at an earlier stage may reduce out-of-pocket costs for patients. [ABSTRACT FROM AUTHOR]

Background: Many high-income countries have made significant progress towards achieving universal health coverage. Nevertheless, out-of-pocket (OOP) health expenditure continues to undermine the effectiveness of the universal healthcare system. In Saudi Arabia, due to the overburdened free public health services, many people opt for alternative healthcare services, risking high OOP payments. The presence of chronic illness further exacerbates this situation. However, there is limited evidence on the extent of the gap in OOP health expenditure between the chronically and non-chronically ill and the associated drivers contributing to this gap. The aim of this study was to assess inequalities in relative OOP health expenditure, estimated as the percentage of income spent on healthcare, between the chronically and non-chronically ill in Saudi Arabia and their associated drivers. Methods: Data from 10,785 respondents were obtained from a national cross-sectional survey conducted in Saudi Arabia as part of the 2018 Family Health Survey. Inequalities in relative OOP health expenditure were measured using concentration indices and curves. A Blinder-Oaxaca decomposition analysis was used to assess the differences in relative OOP health expenditure between the chronically and non-chronically ill. Results: The results showed that the chronically ill experience a higher financial burden due to healthcare services in absolute costs and relative to their income compared to the non-chronically ill. In addition, there was higher pro-poor inequality (–0.1985) in relative OOP health expenditure among the chronically ill compared to that (–0.1195) among the non-chronically ill. There was a 2.6% gap in relative OOP health expenditure among the chronically and non-chronically ill, of which 53.8% was attributable to unexplained factors, with explained factors accounting for the 46.2% difference. Factors that significantly contributed to the overall gap (i.e. both explained and non-explained factors) included employment status, insurance status, self-rated health, and periodic check-ups. Conclusion: This study underscores the high financial burden due to OOP payments among the chronically ill and the existence of pro-poor inequalities. In addition, there is a significant gap in relative OOP health expenditure between the chronically and non-chronically ill, which is mainly attributable to differences in socio-economic characteristics. This indicates that the existing financial mechanisms have not been sufficient in cushioning the chronically ill and less well off in Saudi Arabia. This situation calls for health policymakers to integrate a social safety net into the health financing system and to prioritize the disadvantaged population, thereby ensuring access to health services without experiencing financial hardship. [ABSTRACT FROM AUTHOR]

Nelson J Alvis-Zakzuk,1,2 Diana Díaz-Jiménez,1 Pablo Chaparro-Narváez,1 Juan C Gutiérrez-Clavijo,1 Liliana Castillo-Rodríguez,1 Francisco Edna-Estrada,3 Carlos Castañeda-Orjuela,1 Fernando De La Hoz-Restrepo4 1Observatorio Nacional de Salud, Instituto Nacional de Salud, Bogotá, D.C., Colombia; 2Departamento de Ciencias de la Salud, Universidad de la Costa-CUC, Barranquilla, Colombia; 3Federación Colombiana de Obstetricia y Ginecología, Cartagena, Bolívar, Colombia; 4Grupo de Evaluación en Epidemiología y Salud Pública, Universidad Nacional de Colombia, Bogotá, D.C., ColombiaCorrespondence: Nelson J Alvis-ZakzukDepartamento de Ciencias de la Salud, Universidad de la Costa-CUC, Cl. 58 #55 - 66, Barranquilla, ColombiaEmail nalvis1@cuc.edu.coObjective: We aimed to estimate out-of-pocket (OOP) health expenditures and the indirect costs related to prenatal check-ups in pregnant women seen in a maternity hospital in the Colombian Caribbean region.Methods: We described the economic costs of pregnant women, with no age limits, who attended prenatal check-ups in a maternity hospital. To estimate OOP and indirect costs owing to prenatal check-ups in pregnant women, a survey was constructed, where the woman was asked about some sociodemographic variables, to characterize those attending the prenatal check-ups. Absolute and relative frequencies, averages and confidence intervals were used to characterize the population and estimate OOP and indirect costs in pregnant women. The latter were estimated from the percentile method. A bootstrapping was performed to reduce the bias within the analysis.Results: In total, 56 pregnant women were surveyed, with an average age of 25.9 years (± 6.2). All women surveyed had OOP associated to the prenatal check-up in at least one cost-item, and the OOP ranged between

Background: Across the globe, morbidity and mortality due to non-communicable diseases (NCDs) are major public health issues. The resulting concern is not just epidemiological but also about the economic consequences at the household level. Objective: To assess the various facets of out-of-pocket spending (OOPs) incurring on NCDs, namely hypertension and diabetes on patients attending a healthcare teaching institute in Rajasthan. Methodology: This cross-sectional study involves patients older than 18 years attending either out-patient clinics or who were admitted in the wards in a healthcare teaching institute for seeking care for diabetes or hypertension. Four hundred patients were chosen purposively and a pretested questionnaire was used to elicit information on incurring OOPs for NCDs. Descriptive statistics (like percentage, mean, median, and standard deviation) were calculated. Results: The study shows a significant expenditure other than out-patient, in-patient admissions, in the form of personal expenditure and loss of employment, amounting to 31.86 and 34.07%, respectively, of the mean total expenditure. In a quarter (3 months), the mean total expenditure is ₹9014.37 ± 6452.37. On average, the OOP expenditure per visit for an out-patient visit was ₹370.54 ± 237, while for the patients admitted to the hospital, the average OOPs was ₹1564.72 ± 1310.5. Conclusions: Health expenditures can contribute toward the impoverishment of many segments of the community. Undoubtedly, numerous people may tend to neglect the needed care for NCDs due to financial hurdles. Thus, there is a need to develop NCD care management centers with health insurance packages and make them accessible for all.

Aim/purpose – The aim of this study was to estimate the effect of health insurance on Out-of-Pocket (OOP) health care expenditure in Kenya. It is informed by persistence in the challenges of access and utilization of quality and affordable health care services. Previously, researchers have estimated the effects of different forms of health care financing on its demand and shown that affordability not only enhances access and use of health services but also cushions people against adverse financial risks associated with catastrophic health care spending.

BackgroundMany European Health Systems are implementing or increasing levels of cost-sharing for medicine in response to the growing constrains on public spending on health despite their negative impact on population health due to delay in seeking care.ObjectiveThis study aims to examine the relationships between multimorbidity (two or more coexisting chronic diseases, CDs), complex multimorbidity (three or more CDs impacting at least three different body systems), and out-of-pocket expenditure (OOPE) for medicine across European nations.MethodsThis study utilized data on participants aged 50 years and above from two recent waves of the Survey of Health, Aging, and Retirement in Europe conducted in 2013 (n = 55,806) and 2015 (n = 51,237). Pooled cross-sectional and longitudinal study designs were used, as well as a two-part model, to analyse the association between multimorbidity and OOPE for medicine.ResultsThe prevalence of multimorbidity was 50.4% in 2013 and 48.2% in 2015. Nearly half of those with multimorbidity had complex multimorbidity. Each additional CD was associated with a 34% greater likelihood of incurring any OOPE for medicine (Odds ratio = 1.34, 95% CI = 1.31–1.36). The average incremental OOPE for medicine was 26.4 euros for each additional CD (95% CI = 25.1–27·7), and 32.1 euros for each additional body system affected (95% CI 30.6–33.7). In stratified analyses for country-specific quartiles of household income the average incremental OOPE for medicine was not significantly different across groups.ConclusionBetween 2013 and 2015 in 13 European Health Systems increased prevalence of CDs was associated with greater likelihood of having OOPE on medication and an increase in the average amount spent when one occurred. Monitoring this indicator is important considering the negative association with treatment adherence and subsequent effects on health.

Background: High out-of-pocket (OOP) health expenditures are a common problem in developing countries. Studies rarely investigate the crowding-out effect of OOP health expenditures on other areas of household consumption. OOP health costs are a colossal burden on families and can lead to adjustments in other areas of consumption to cope with these costs. Methods: This cross-sectional study used self-reported household consumption data from the nationally representative Household Socioeconomic Survey (HSES), collected in 2018 by the National Statistical Office of Mongolia. We estimated a quadratic conditional Engel curves system to determine intrahousehold resource allocation among 12 consumption variables. The 3-stage least squared method was used to deal with heteroscedasticity and endogeneity problems to estimate the causal crowding-out effect of OOP. Results: The mean monthly OOP health expenditure per household was ₮64 673 (standard deviation [SD] = 259 604), representing approximately 6.9% of total household expenditures. OOP health expenditures were associated with crowding out durables, communication, transportation, and rent, and with crowding in education and heating for all households. The crowding-out effect of ₮10 000 in OOP health expenditures was the largest for food (₮5149, 95% CI = -8582; -1695) and crowding-in effect was largest in heating (₮2691, 95% CI = 737; 4649) in the lowest-income households. The effect of heating was more than 10 times greater than that in highest-income households (₮261, 95% CI = 66; 454); in the highest-income households, food had a crowding-in effect (₮179, 95% CI = -445; 802) in absolute amounts. In terms of absolute amount, the crowding-out effect for food was up to 5 times greater in households without social health insurance (SHI) than in those with SHI. Conclusion: Our findings suggest that Mongolia's OOP health expenses are associated with reduced essential expenditure on items such as durables, communication, transportation, rent, and food. The effect varies by household income level and SHI status, and the lowest-income families were most vulnerable. SHI in Mongolia may not protect households from large OOP health expenditures. [ABSTRACT FROM AUTHOR]

Background: Out-of-Pocket (OOP) payment is categorized among the critical indicators of health system financing. Given the high hospitalization costs of the hospitals, the ministry of health has attempted to implement Health Transformation Plan (HTP) in Iran to reduce OOP. The purpose of this paper is to show the effects of HTP on OOP payments of the hospitalized patients in Hamedan, Iran. Methods: This descriptive-analytical study was carried out on 587 patients in the educational hospitals of Hamedan. The data obtained before and after implementing the HTP was from 2013 to 2015. Data analysis was performed using SPSS16. Results: In this study, each patient's expenditures increased by 32.2 % in 2015, compared to before the implementation of the HTP. Therefore, the health insurance organization's coverage of OOP payments decreased to 8.3 % of the total costs by a 20.2 % reduction in 2015, compared to before the implementation of the plan. Conclusion: According to the study, HTP and government health subsidies were adequate, but the total hospitalization costs had an upward trend in all funds.

In 2009, the Democratic Republic of Congo (DRC) started its journey towards achieving Universal Health Coverage (UHC). This study examines the evolution of financial risk protection and health outcomes indicators in the context of the commitment of DRC to UHC. To measure the effects of such a commitment on financial risk protection and health outcomes indicators, we analyse whether changes have occurred over the last two decades and, if applicable, when these changes happened. Using five variables as indicators for the measurement of the financial risk protection component, there as well retained three indicators to measure health outcomes. To identify time-related effects, we applied the parametric approach of breakpoint regression to detect whether the UHC journey has brought change and when exactly the change has occurred.Although there is a slight improvement in the financial risk protection indicators, we found that the adopted strategies have fostered access to healthcare for the wealthiest quantile of the population while neglecting the majority of the poorest. The government did not thrive persistently over the past decade to meet its commitment to allocate adequate funds to health expenditures. In addition, the support from donors appears to be unstable, unpredictable and unsustainable. We found a slight improvement in health outcomes attributable to direct investment in building health centres by the private sector and international organizations. Overall, our findings reveal that the prevention of catastrophic health expenditure is still not sufficiently prioritized by the country, and mostly for the majority of the poorest. Therefore, our work suggests that DRC's UHC journey has slightly contributed to improve the financial risk protection and health outcomes indicators but much effort should be undertaken. [ABSTRACT FROM AUTHOR]

Objectives: Nigeria is one of the 30 high‐burden countries for TB and currently, recurrent costs of TB treatment services are largely dependent on donor‐funding, with government providing the health facilities. This study aims to assess the benefit incidence of TB treatment services so as to determine if the poor and rural dwellers preferentially benefit from such services that were subsidized by government and donors. Methods: A survey of patients (n = 202) accessing TB treatment services was conducted between 2019 and 2020 in five purposively selected rural and urban health facilities in Enugu state. Socio‐economic status (SES) was estimated using household assets ownership. Benefits of TB services were measured by multiplying the unit cost of utilization of different services while the net benefit was calculated by subtracting out‐of‐pocket (OOP) payments incurred from the benefits. We estimated the benefit for 1 month and the benefit for the whole TB treatment course (6 months). Concentration index was used to determine the level of equity in spending across the socio‐economic quintiles. Results: 56.4% of the respondents were from urban facilities. 100% had used TB drugs in the past months, 73% had undergone a Gene‐Xpert test, and 67% had had a consultation. All patients received TB drugs without OOP payment, but 90% paid for X‐ray. Urban respondents captured a disproportionally higher share of benefit from TB services. The concentration index was −0.025 for net benefit from TB services across different quintiles, indicating the pro‐poor distribution of TB services in Nigeria. Conclusions: The benefit from TB services had a pro‐poor distribution, but urban respondents obtained a disproportionally higher share of gross and net benefit from TB services. Funding for TB services needs to be secured to promote the equitable access to TB services. [ABSTRACT FROM AUTHOR]

Abstract Background In 2003, Ghana implemented a National Health Insurance Scheme (NHIS) designed to promote universal health coverage and equitable access to health care. The scheme has largely been successful, yet it is confronted with many challenges threatening its sustainability. Out-of-pocket payments (OOP) by insured clients is one of such challenges of the scheme. This study sought to examine the types of services OOP charges are made for by insured clients and how much insured clients pay out-of-pocket. Methods This was a descriptive cross-sectional health facility survey. A total of 2066 respondents were interviewed using structured questionnaires at the point of health care exit in the Ashanti, Northern and Central regions of Ghana. Health facilities of different levels were selected from 3 districts in each of the three regions. Data were collected between April and June 2018. Using Epidata and STATA Version 13.1 data analyses were done using multiple logistic regression and simple descriptive statistics and the results presented as proportions and means. Results Of all the survey respondents 49.7% reported paying out-of-pocket for out-patient care while 46.9% of the insured clients paid out-of-pocket. Forty-two percent of the insured poorest quintile also paid out-of-pocket. Insured clients paid for consultation (75%) and drugs (63.2%) while 34.9% purchased drugs outside the health facility they visited. The unavailability of drugs (67.9%) and drugs not covered by the NHIS (20.8%) at the health facility led to out-of-pocket payments. On average, patients paid GHS33.00 (USD6.6) out-of-pocket. Compared to the Ashanti region, patients living in the Northern region were 74% less at odds to pay out-of-pocket for health care. Conclusion and recommendation Insured clients of Ghana’s NHIS seeking health care in accredited health facilities make out-of-pocket payments for consultation and drugs that are covered by the scheme. The out-of-pocket payments are largely attributed to unavailability of drugs at the facilities while the consultation fees are charged to meet the administrative costs of services. These charges occur in disadvantaged regions and in all health facilities. The high reliance on out-of-pocket payments can impede Ghana’s progress towards achieving Universal Health Coverage and the Sustainable Development Goal 3, seeking to end poverty and reduce inequalities. In order to build trust and confidence in the NHIS there is the need to eliminate out-of-pocket payments for consultation and medicines by insured clients.

Abstract Background Breast cancer disease is the most common cancer among Iranian women and imposing a significant financial burden on the households. This study calculated out-of-pocket (OOP), catastrophic health expenditure (CHE), and impoverishing health spending attributed to breast cancer in Iran. Methods In this cross-sectional household study, clinical and financial information on breast cancer and also household information (expenditures and income) were obtained through face-to-face interviews and completing a questionnaire by 138 women with this disease in 2019. We applied three non-food expenditure thresholds of 40, 20, and 10% to defining the CHE. Disease costs included periodical visits, diagnostic services, hospitalization care, treatment and rehabilitation services, home, and informal care. Households were disaggregated into socioeconomic status quintiles based on their Adult Equivalent values standardized monthly consumption expenditures. To identify the factors affecting these indicators, we performed the two different multivariate logistic regression models. Results This study finds that each patient had a monthly average OOP payment of $US 97.87 for the requested services, leading to impoverished of 5.07% and exposed 13.77% of their households to CHE. These indicators have been mainly concentrated among the poor, as they have spent a large part of their meager income on buying the needed services, and for this purpose, most of them forced to sell their assets, borrow, or take a bank loan. Conclusions The patients in lower SES quintiles can be protected from impoverishing and catastrophic health spending by expanding insurance coverage, providing financial risk protection programs, and increasing access to quality and effective public sector services. Alongside, expanding inpatient coverage and adding drug benefits for the poor can significantly decrease their OOP payments.

Yohannes Shumet,1 Solomon Ahmed Mohammed,2 Mesfin Haile Kahissay,2 Birhanu Demeke2 1Department of Pharmacy, College of Medicine and Health Science, Debre Tabor University, Debre Tabor, Ethiopia; 2Department of Pharmacy, College of Medicine and Health Science, Wollo University, Dessie, EthiopiaCorrespondence: Solomon Ahmed Mohammed Tel +251-91-050-4378Email ahmedsolomon21@gmail.comBackground: Catastrophic health expenditure is health spending that is not covered by a health-care plan. These costs tend to escalate over time, due to chronic illnesses. Catastrophic health expenditure leads to decreased use of health services and poorer treatment outcomes. This study measured the extent of and factors associated with catastrophic health expenditure among chronically ill patients attending Dessie Referral Hospital in northeast Ethiopia.Methods: An institution-based cross-sectional study design was used to quantify catastrophic health expenditure among 302 chronically ill patients from May 25, 2018 to June 30, 2018. A stratified sampling technique was used to select the study participants. Descriptive and inferential statistics were computed using SPSS 20.Results: Catastrophic health expenditure was found in 194 (64.2%, 95% CI 58.8%– 70.5%) of chronic patients. Costly service (151, 50%), transport (104, 34.4%), and pharmaceuticals (189, 62.6%) were the reasons for catastrophic health expenditure among chronic patients. Factors associated with catastrophic health expenditure were age < 30 years (AOR 7.74, CI 0.94– 63.62; P=0.01), patient monthly income