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Colombia is among the countries with the most robust financial protection against personal health spending in the world, with out-of-pocket spending ranking lowest across OECD countries. We investigate the evolution, distribution, and persistence of health spending by age group, sex, health care setting, health condition and geographic region for over 19 million users of Colombia's health system between 2013 and 2021 (contributory scheme). We use average patient-level expenditure data from the Health-Promoting Entities of the Ministry of Health and Social Protection. We applied multivariate statistical techniques such as multiple correspondence analysis, factor maps and correlations. For both sexes, average health expenditure increases gradually with age until 60 years, accelerating thereafter abruptly. Health conditions with the highest percentage of expenditure were those related to neoplasms, blood diseases, circulatory system, pregnancy, puerperium and perinatal period. We found that home-based care in Amazonía-Orinoquía is almost non-existent, and that outpatient care represents a high proportion in all age groups (over 65%) compared to the other regions. There is a strong persistence of expenditure from one year to the next (i.e. they can provide relevant information for prediction), especially in areas with a larger supply of health services such as Bogotá-Cundinamarca. To the authors' knowledge, this is the most comprehensive and detailed micro-analysis of health spending that has been developed for a Latin American country to date. Key messages: • Health conditions with the highest percent of expenditure were those related to neoplasms and blood diseases. • A significant proportion of health spending for the different life cycles is in the hospital setting. • Medical expenditure is concentrated in people over 60 years of age. [ABSTRACT FROM AUTHOR]

We study credit contracts under a life‐cycle setting where time‐inconsistent agents lack the internal commitment to stick to consumption plans and external commitment to repaying loans. With unrestricted credit, agents with only internal commitment problems may overborrow. If, additionally, they face external commitment problems, lenders endogenously impose borrowing limits similar to the ability‐to‐repay rules consumer financial protection agencies impose. Even with restricted credit access, except in exceptional cases, agents suffering from the twin commitment problems can achieve, at most, fully sophisticated allocations. The government can achieve the first‐best allocations if and only if it is assisted with endogenously imposed borrowing limits. [ABSTRACT FROM AUTHOR]

Background: Out-of-pocket healthcare expenditure (OOPHE) without adequate social protection often translates to inequitable financial burden and utilization of services. Recent publications highlighted Cambodia's progress towards Universal Health Coverage (UHC) with reduced incidence of catastrophic health expenditure (CHE) and improvements in its distribution. However, departing from standard CHE measurement methods suggests a different storyline on trends and inequality in the country. Objective: This study revisits the distribution and impact of OOPHE and its financial burden from 2009–19, employing alternative socio-economic and economic shock metrics. It also identifies determinants of the financial burden and evaluates inequality-contributing and -mitigating factors from 2014–19, including coping mechanisms, free healthcare, and OOPHE financing sources. Methods: Data from the Cambodian Socio-Economic Surveys of 2009, 2014, and 2019 were utilized. An alternative measure to CHE is proposed: Excessive financial burden (EFB). A household was considered under EFB when its OOPHE surpassed 10% or 25% of total consumption, excluding healthcare costs. A polychoric wealth index was used to rank households and measure EFB inequality using the Erreygers Concentration Index. Inequality shifts from 2014–19 were decomposed using the Recentered Influence Function regression followed by the Oaxaca-Blinder method. Determinants of financial burden levels were assessed through zero-inflated ordered logit regression. Results: Between 2009–19, EFB incidence increased from 10.95% to 17.92% at the 10% threshold, and from 4.41% to 7.29% at the 25% threshold. EFB was systematically concentrated among the poorest households, with inequality sharply rising over time, and nearly a quarter of the poorest households facing EFB at the 10% threshold. The main determinants of financial burden were geographic location, household size, age and education of household head, social health protection coverage, disease prevalence, hospitalization, and coping strategies. Urbanization, biased disease burdens, and preventive care were key in explaining the evolution of inequality. Conclusion: More efforts are needed to expand social protection, but monitoring those through standard measures such as CHE has masked inequality and the burden of the poor. The financial burden across the population has risen and become more unequal over the past decade despite expansion and improvements in social health protection schemes. Health Equity funds have, to some extent, mitigated inequality over time. However, their slow expansion and the reduced reliance on coping strategies to finance OOPHE could not outbalance inequality. Key messages: • The healthcare financial burden and its inequality have sharply increased between 2009–19; disproportionally impacting socio-economically disadvantaged households even with Health Equity Funds offering some mitigation since their national expansion. Urbanization, demographic shifts, and changing disease patterns are key factors in understanding these trends. • Standard methods for measuring catastrophic healthcare expenditure underestimate the financing burden on less-wealthy households by inflating their consumption and shifting their socio-economic rank. • The mitigating effect of out-of-pocket spending exemptions and preventive healthcare on both inequality and the overall financial burden of the population suggests a way forward towards UHC for the Cambodian healthcare system. [ABSTRACT FROM AUTHOR]

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]

Purpose: Uncorrected refractive error is the leading cause of vision impairment globally; however, little attention has been given to equity and access to services. This study aimed to identify and prioritise: (1) strategies to address inequity of access to refractive error services and (2) population groups to target with these strategies in five sub‐regions within the Western Pacific. Methods: We invited eye care professionals to complete a two‐round online prioritisation process. In round 1, panellists nominated population groups least able to access refractive error services, and strategies to improve access. Responses were summarised and presented in round 2, where panellists ranked the groups (by extent of difficulty and size) and strategies (in terms of reach, acceptability, sustainability, feasibility and equity). Groups and strategies were scored according to their rank within each sub‐region. Results: Seventy five people from 17 countries completed both rounds (55% women). Regional differences were evident. Indigenous peoples were a priority group for improving access in Australasia and Southeast Asia, while East Asia identified refugees and Oceania identified rural/remote people. Across the five sub‐regions, reducing out‐of‐pocket costs was a commonly prioritised strategy for refraction and spectacles. Australasia prioritised improving cultural safety, East Asia prioritised strengthening school eye health programmes and Oceania and Southeast Asia prioritised outreach to rural areas. Conclusion: These results provide policy‐makers, researchers and funders with a starting point for context‐specific actions to improve access to refractive error services, particularly among underserved population groups who may be left behind in existing private sector‐dominated models of care. [ABSTRACT FROM AUTHOR]

Despite the remarkable health achievements of Japan's universal health coverage since 1961, along with numerous social programs to ensure financial protection, a growing proportion of the older population reportedly experiences financial hardship for essential health care. The socio-behavioral and economic situation of the households in need and the effective policy interventions remain unknown. To identify the reasons behind older persons' financial hardship and the effective policy interventions, we performed a questionnaire survey of social workers in all hospitals, local government offices and social service agencies across six prefectures in Kansai region. Data from 553 respondents revealed that the financial difficulties related to health care are often closely intertwined with social and mental health hardships experienced by older people and their families. Notably, potentially helpful programs including 'free/low-cost medical treatment program' and the adult guardianship system for dementia were infrequently used. Moreover, male, social workers at local offices/agencies, and less than 10 years' professional experience associated with infrequent use of key protective programs. To close the gap between policy and practice, policies should focus on clients' daily living needs, and new frontline social workers should receive lifelong training that incorporates their own backgrounds, experiences, and values, including the use of anti-oppressive gerontological approaches. [ABSTRACT FROM AUTHOR]

Abstract Colombia is among the countries with the most robust financial protection against personal health spending in the world, with out-of-pocket spending ranking lowest across OECD countries. We investigate the evolution, distribution, and persistence of health spending by age group, sex, health care setting, health condition and geographic region for over 19 million users of Colombia’s health system between 2013 and 2021 (contributory scheme). We use average patient-level expenditure data from the Health-Promoting Entities of the Ministry of Health and Social Protection. We applied multivariate statistical techniques such as multiple correspondence analysis, factor maps and correlations. For both sexes, average health expenditure increases gradually with age until 60 years, accelerating thereafter abruptly. Health conditions with the highest percentage of expenditure were those related to neoplasms, blood diseases, circulatory system, pregnancy, puerperium and perinatal period. We found that home-based care in Amazonía-Orinoquía is almost non-existent, and that outpatient care represents a high proportion in all age groups (over 65%) compared to the other regions. There is a strong persistence of expenditure from one year to the next (i.e. they can provide relevant information for prediction), especially in areas with a larger supply of health services such as Bogotá-Cundinamarca. To the authors’ knowledge, this is the most comprehensive and detailed micro-analysis of health spending that has been developed for a Latin American country to date.

Abstract Background Out-of-pocket healthcare expenditure (OOPHE) without adequate social protection often translates to inequitable financial burden and utilization of services. Recent publications highlighted Cambodia’s progress towards Universal Health Coverage (UHC) with reduced incidence of catastrophic health expenditure (CHE) and improvements in its distribution. However, departing from standard CHE measurement methods suggests a different storyline on trends and inequality in the country. Objective This study revisits the distribution and impact of OOPHE and its financial burden from 2009–19, employing alternative socio-economic and economic shock metrics. It also identifies determinants of the financial burden and evaluates inequality-contributing and -mitigating factors from 2014–19, including coping mechanisms, free healthcare, and OOPHE financing sources. Methods Data from the Cambodian Socio-Economic Surveys of 2009, 2014, and 2019 were utilized. An alternative measure to CHE is proposed: Excessive financial burden (EFB). A household was considered under EFB when its OOPHE surpassed 10% or 25% of total consumption, excluding healthcare costs. A polychoric wealth index was used to rank households and measure EFB inequality using the Erreygers Concentration Index. Inequality shifts from 2014–19 were decomposed using the Recentered Influence Function regression followed by the Oaxaca-Blinder method. Determinants of financial burden levels were assessed through zero-inflated ordered logit regression. Results Between 2009–19, EFB incidence increased from 10.95% to 17.92% at the 10% threshold, and from 4.41% to 7.29% at the 25% threshold. EFB was systematically concentrated among the poorest households, with inequality sharply rising over time, and nearly a quarter of the poorest households facing EFB at the 10% threshold. The main determinants of financial burden were geographic location, household size, age and education of household head, social health protection coverage, disease prevalence, hospitalization, and coping strategies. Urbanization, biased disease burdens, and preventive care were key in explaining the evolution of inequality. Conclusion More efforts are needed to expand social protection, but monitoring those through standard measures such as CHE has masked inequality and the burden of the poor. The financial burden across the population has risen and become more unequal over the past decade despite expansion and improvements in social health protection schemes. Health Equity funds have, to some extent, mitigated inequality over time. However, their slow expansion and the reduced reliance on coping strategies to finance OOPHE could not outbalance inequality.

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.

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: India launched a national health insurance scheme named Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) in 2018 as a key policy for universal health coverage. The ambitious scheme covers 100 million poor households. None of the studies have examined its impact on the quality of care. The existing studies on the impact of AB-PMJAY on financial protection have been limited to early experiences of its implementation. Since then, the government has improved the scheme's design. The current study was aimed at evaluating the impact of AB-PMJAY on improving utilisation, quality, and financial protection for inpatient care after four years of its implementation. Methods: Two annual waves of household surveys were conducted for years 2021 and 2022 in Chhattisgarh state. The surveys had a sample representative of the state's population, covering around 15,000 individuals. Quality was measured in terms of patient satisfaction and length of stay. Financial protection was measured through indicators of catastrophic health expenditure at different thresholds. Multivariate adjusted models and propensity score matching were applied to examine the impacts of AB-PMJAY. In addition, the instrumental variable method was used to address the selection problem. Results: Enrollment under AB-PMJAY was not associated with increased utilisation of inpatient care. Among individuals enrolled under AB-PMJAY who utilised private hospitals, the proportion incurring catastrophic health expenditure at the threshold of 10% of annual consumption expenditure was 78.1% and 70.9% in 2021 and 2022, respectively. The utilisation of private hospitals was associated with greater catastrophic expenditure irrespective of AB-PMJAY coverage. Enrollment under AB-PMJAY was not associated with reduced out-of-pocket expenditure or catastrophic health expenditure. Conclusions: AB-PMJAY has achieved a large coverage of the population but after four years of implementation and an evidence-based increase in reimbursement prices for hospitals, it has not made an impact on improving utilisation, quality, or financial protection. The private hospitals contracted under the scheme continued to overcharge patients, and purchasing was ineffective in regulating provider behaviour. Further research is recommended to assess the impact of publicly funded health insurance schemes on financial protection in other low- and middle-income countries. [ABSTRACT FROM AUTHOR]

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]

The Fourth Industrial Revolution (4IR) is a modern and evolving technological environment whereby advancements such as artificial intelligence (AI) affect people's livelihoods and jobs. The 4IR is anticipated to have an impact on numerous employment relationships in the South African retail industry by substituting workers with new technologies and systems, forcing retail companies to retrench retail sector workers. In light of this concern, methodologically, this article used a literature review research approach to critically examine the protection offered by the Labour Relations Act (LRA), Unemployment Insurance Act (UIA), Unemployment Insurance Contributions Act (UICA), and Basic Conditions of Employment Act (BCEA), to determine what protective mechanisms these legislation offer to safeguard the rights of South African retail sector workers who will lose their jobs due to the introduction of new technologies in the workplace. The findings were that the LRA and the BCEA offer severance pay as the sole financial protection designed exclusively to mitigate the effect that lawful retrenchments have on affected employees, whereas the UIA provides a UIF benefit only to retrenched workers who were registered by their employers to the UIF and who had contributed appropriately to the UIF, to the exclusion of employees whose employers did not register them to the UIF. This means that the UIF and severance package provide compensatory benefits to only a certain portion of employees. Consequently, these benefits are insufficient to safeguard the rights of retrenched South African retail sector workers who may become permanently unemployed in the era of 4IR. As a result, it was proposed to implement measures such as reskilling the workforce before retrenchment considerations to increase their chances of obtaining employment in the 4IR era. [ABSTRACT FROM AUTHOR]

Economists originally developed methods to assess financial catastrophe using total or aggregate out-of-pocket health spending. Aggregate out-of-pocket health spending is financially catastrophic when it exceeds a fixed proportion (i.e., threshold) of a household's total income or expenditure in a given period. However, these methods are now applied to assess financial catastrophe in disease- or service-specific rather than aggregate out-of-pocket health spending without using disease- or service-specific thresholds. This paper argues that not using disease- or service-specific thresholds for such assessments is misleading and underestimates the burden of financial catastrophe, especially among households from poorer backgrounds. It then proposed disease- or service-specific catastrophic payment thresholds, applied them to Nigeria and found that financial catastrophe was underestimated for the five service groups considered. The paper stresses the importance of using disease- or service-specific thresholds and avoiding unadjusted thresholds, which may leave poorer households behind as financially protected. [ABSTRACT FROM AUTHOR]

Abstract Background Low- and middle-income countries have committed to achieving universal health coverage (UHC) as a means to enhance access to services and improve financial protection. One of the key health financing reforms to achieve UHC is the introduction or expansion of health insurance to enhance access to basic health services, including maternal and reproductive health care. However, there is a paucity of evidence of the extent to which these reforms have had impact on the main policy objectives of enhancing service utilization and financial protection. The aim of this systematic review is to assess the existing evidence on the causal impact of health insurance on maternal and reproductive health service utilization and financial protection in low- and lower middle-income countries. Methods The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search included six databases: Medline, Embase, Web of Science, Cochrane, CINAHL, and Scopus as of 23rd May 2023. The keywords included health insurance, impact, utilisation, financial protection, and maternal and reproductive health. The search was followed by independent title and abstract screening and full text review by two reviewers using the Covidence software. Studies published in English since 2010, which reported on the impact of health insurance on maternal and reproductive health utilisation and or financial protection were included in the review. The ROBINS-I tool was used to assess the quality of the included studies. Results A total of 17 studies fulfilled the inclusion criteria. The majority of the studies (82.4%, n = 14) were nationally representative. Most studies found that health insurance had a significant positive impact on having at least four antenatal care (ANC) visits, delivery at a health facility and having a delivery assisted by a skilled attendant with average treatment effects ranging from 0.02 to 0.11, 0.03 to 0.34 and 0.03 to 0.23 respectively. There was no evidence that health insurance had increased postnatal care, access to contraception and financial protection for maternal and reproductive health services. Various maternal and reproductive health indicators were reported in studies. ANC had the greatest number of reported indicators (n = 10), followed by financial protection (n = 6), postnatal care (n = 5), and delivery care (n = 4). The overall quality of the evidence was moderate based on the risk of bias assessment. Conclusion The introduction or expansion of various types of health insurance can be a useful intervention to improve ANC (receiving at least four ANC visits) and delivery care (delivery at health facility and delivery assisted by skilled birth attendant) service utilization in low- and lower-middle-income countries. Implementation of health insurance could enable countries’ progress towards UHC and reduce maternal mortality. However, more research using rigorous impact evaluation methods is needed to investigate the causal impact of health insurance coverage on postnatal care utilization, contraceptive use and financial protection both in the general population and by socioeconomic status. Trial registration This study was registered with Prospero (CRD42021285776).

Abstract Background Vietnam’s primary mechanism of achieving sustainable funding for universal health coverage (UHC) and financial protection has been through its social health insurance (SHI) scheme. Steady progress towards access has been made and by 2020, over 90% of the population were enrolled in SHI. In 2022, as part of a larger transition towards the increased domestic financing of healthcare, tuberculosis (TB) services were integrated into SHI. This change required people with TB to use SHI for treatment at district-level facilities or to pay out of pocket for services. This study was conducted in preparation for this transition. It aimed to understand more about uninsured people with TB, assess the feasibility of enrolling them into SHI, and identify the barriers they faced in this process. Methods A mixed-method case study was conducted using a convergent parallel design between November 2018 and January 2022 in ten districts of Hanoi and Ho Chi Minh City, Vietnam. Quantitative data were collected through a pilot intervention that aimed to facilitate SHI enrollment for uninsured individuals with TB. Descriptive statistics were calculated. Qualitative interviews were conducted with 34 participants, who were purposively sampled for maximum variation. Qualitative data were analyzed through an inductive approach and themes were identified through framework analysis. Quantitative and qualitative data sources were triangulated. Results We attempted to enroll 115 uninsured people with TB into SHI; 76.5% were able to enroll. On average, it took 34.5 days to obtain a SHI card and it cost USD 66 per household. The themes indicated that a lack of knowledge, high costs for annual premiums, and the household-based registration requirement were barriers to SHI enrollment. Participants indicated that alternative enrolment mechanisms and greater procedural flexibility, particularly for undocumented people, is required to achieve full population coverage with SHI in urban centers. Conclusions Significant addressable barriers to SHI enrolment for people affected by TB were identified. A quarter of individuals remained unable to enroll after receiving enhanced support due to lack of required documentation. The experience gained during this health financing transition is relevant for other middle-income countries as they address the provision of financial protection for the treatment of infectious diseases.

Purpose: Monitoring progress towards universal health coverage (UHC) has become increasingly important, especially given the centrality of UHC in achieving the sustainable development goals. We sought to estimate the progress towards UHC in the 22 Middle East and North Africa (MENA) countries. Methods: Employing the Joint World Bank and World Health Organization Framework for Monitoring UHC, we estimated the UHC index for MENA countries using both service coverage and financial protection indicators. We also explored the correlation between the UHC index with government expenditure/investment in health. Results: The 2021 UHC index ranged from 48.2 (Somalia) to 90.3 (United Arab Emirates) with a mean, median, and standard deviation of 74.9, 77.4, and 11.1, respectively, with significant differences between low-income and high-income countries. Service coverage lags behind financial protection in most MENA countries. There is a significant positive relationship between UHC and government health spending/investments. Conclusion: The majority of MENA countries are yet to achieve UHC. There is a need to expand healthcare services, especially PHC services, and adopt strategies that address concerns related to financial protection.

Sharia insurance is essential in providing sustainable financial protection for individuals and communities. By adhering to the principles of Islamic Sharia, Islamic insurance offers financial protection in accordance with religious values while promoting shared prosperity and sustainable risk management. This research uses a library research method with data collection carried out in several stages, from collecting references to analyzing references relevant to this research. In contrast, data sources are obtained from literature reviews from books, journals, the internet, and other media. This article outlines the general background of Islamic insurance and the importance of financial protection and explains the fundamental differences between conventional insurance and other insurance. In addition, the article discusses the long-term benefits to society at large. A better understanding of the role of Islamic insurance in providing sustainable financial protection is expected to strengthen the overall Islamic financial system and offer significant benefits to individuals and society. Shariah insurance focuses on meeting financial needs and adherence to moral and ethical principles in Islam. This insurance firmly holds principles: ta'awunu 'ala al birr wa al-taqwa (help you all in goodness and piety) and al-ta'min (security). [ABSTRACT FROM AUTHOR]

Background: Vietnam's primary mechanism of achieving sustainable funding for universal health coverage (UHC) and financial protection has been through its social health insurance (SHI) scheme. Steady progress towards access has been made and by 2020, over 90% of the population were enrolled in SHI. In 2022, as part of a larger transition towards the increased domestic financing of healthcare, tuberculosis (TB) services were integrated into SHI. This change required people with TB to use SHI for treatment at district-level facilities or to pay out of pocket for services. This study was conducted in preparation for this transition. It aimed to understand more about uninsured people with TB, assess the feasibility of enrolling them into SHI, and identify the barriers they faced in this process. Methods: A mixed-method case study was conducted using a convergent parallel design between November 2018 and January 2022 in ten districts of Hanoi and Ho Chi Minh City, Vietnam. Quantitative data were collected through a pilot intervention that aimed to facilitate SHI enrollment for uninsured individuals with TB. Descriptive statistics were calculated. Qualitative interviews were conducted with 34 participants, who were purposively sampled for maximum variation. Qualitative data were analyzed through an inductive approach and themes were identified through framework analysis. Quantitative and qualitative data sources were triangulated. Results: We attempted to enroll 115 uninsured people with TB into SHI; 76.5% were able to enroll. On average, it took 34.5 days to obtain a SHI card and it cost USD 66 per household. The themes indicated that a lack of knowledge, high costs for annual premiums, and the household-based registration requirement were barriers to SHI enrollment. Participants indicated that alternative enrolment mechanisms and greater procedural flexibility, particularly for undocumented people, is required to achieve full population coverage with SHI in urban centers. Conclusions: Significant addressable barriers to SHI enrolment for people affected by TB were identified. A quarter of individuals remained unable to enroll after receiving enhanced support due to lack of required documentation. The experience gained during this health financing transition is relevant for other middle-income countries as they address the provision of financial protection for the treatment of infectious diseases. [ABSTRACT FROM AUTHOR]

Background and Aims: Noncommunicable diseases are one of the main difficulties faced by older adults in many countries. The study aimed to investigate the households' catastrophic health expenditure (CHE) among older people with noncommunicable diseases. Methods: This cross‐sectional study was conducted between October and December 2022 in Semnan, Iran, with the participation of 400 older individuals suffering from diabetes and hypertension. The Content Validity Ratio (which is calculated based on necessity criterion) and Content Validity Index (which calculated based on relevance, transparency, and simplicity criteria) values of 0.94 and 0.89, respectively, confirmed the content validity of the researcher‐made questionnaire. The occurrence of CHE was estimated using the World Health Organization's rule of "allocating at least 40% of non‐food household costs to healthcare." Due to the qualitative nature of the data, the χ2 test was utilized to assess the statistical association between demographic and background variables and occurrence of CHE. Results: Older people with diabetes and hypertension had an annual direct medical costs of $821 averagely, which includes 9.7% for diagnosis, 23.9% for doctor visits, and 66.4% for treatment. Direct medical costs account for around 0.26 of nonfood costs, with 12.5% of seniors facing high medical charges. Age, marital status, type of basic health insurance, diabetes, the time elapsed since initial diabetes diagnosis, the severity of diabetes complications, and the development of diabetes‐related visual impairments, are associated with CHE (p < 0.05). Conclusion: While the prevalence of CHE among elderly individuals with diabetes and hypertension is reasonably manageable, targeted promotional efforts are still necessary to protect those at high risk. [ABSTRACT FROM AUTHOR]

Abstract Background Universal health coverage means that all people can access essential health services without incurring financial hardship. Even in countries with good service coverage and financial protection, the progress towards universal health coverage may decelerate or be limited with respect to the growing older population. This study investigates the incidence/prevalence, determinants, and consequences of catastrophic health expenditure (CHE) and unmet need for healthcare and assesses the potential heterogeneity between younger (≤ 64 years) and older people (65 years≤). Methods Utilising an annual nationally representative survey of Japanese aged 20 years and over, we estimated the incidence of CHE and unmet need for healthcare using disaggregated estimates by household members’ age (i.e. ≤64 years vs. 65 years≤) between 2004 and 2020. Using a fixed-effects model, we assessed the determinants of CHE and unmet need along with the consequences of CHE. We also assessed the heterogeneity by age. Results Households with older members were more likely to have their healthcare needs met but experienced CHE more so than households without older members. The financial consequences of CHE were heterogeneous by age, suggesting that households with older members responded to CHE by reducing food and social expenditures more so than households without older members reducing expenditure on education. Households without older members experienced an income decline in the year following the occurrence of CHE, while this was not found among households with older members. A U-shaped relationship was observed between age and the probability of experiencing unmet healthcare need. Conclusions Households with older members are more likely to experience CHE with different financial consequences compared to those with younger members. Unmet need for healthcare is more common among younger and older members than among their middle-aged counterparts. Different types and levels of health and financial support need to be incorporated into national health systems and social protection policies to meet the unique needs of individuals and households.

Abstract Background Major depressive disorder (MDD) is one of the world’s leading causes of disability. Our purpose was to characterize the total costs of MDD and evaluate the degree to which the British Columbia provincial health system meets its objective to protect people from the financial impact of illness. Methods We performed a population-based cohort study of adults newly diagnosed with MDD between 2015 and 2020 and followed their health system costs over two years. The expenditure proportion of MDD-related, patient paid costs relative to non-subsistence income was estimated, incidences of financial hardship were identified and the slope index of inequality (SII) between the highest and lowest income groups compared across regions. Results There were 250,855 individuals diagnosed with MDD in British Columbia over the observation period. Costs to the health system totalled >$1.5 billion (2020 CDN), averaging $138/week for the first 12 weeks following a new diagnosis and $65/week to week 52 and $55/week for weeks 53–104 unless MDD was refractory to treatment ($125/week between week 12–52 and $101/week over weeks 53–104). The proportion of MDD-attributable costs not covered by the health system was 2-15x greater than costs covered by the health system, exceeding $700/week for patients with severe MDD or MDD that was refractory to treatment. Population members in lower-income groups and urban homeowners had disadvantages in the distribution of financial protection received by the health system (SII reached − 8.47 and 15.25, respectively); however, financial hardship and inequities were mitigated province-wide if MDD went into remission (SII − 0.07 to 0.6). Conclusions MDD-attributable costs to health systems and patients are highest in the first 12 weeks after a new diagnosis. During this time, lower income groups and homeowners in urban areas run the risk of financial hardship.

Background: Universal health coverage means that all people can access essential health services without incurring financial hardship. Even in countries with good service coverage and financial protection, the progress towards universal health coverage may decelerate or be limited with respect to the growing older population. This study investigates the incidence/prevalence, determinants, and consequences of catastrophic health expenditure (CHE) and unmet need for healthcare and assesses the potential heterogeneity between younger (≤ 64 years) and older people (65 years≤). Methods: Utilising an annual nationally representative survey of Japanese aged 20 years and over, we estimated the incidence of CHE and unmet need for healthcare using disaggregated estimates by household members' age (i.e. ≤64 years vs. 65 years≤) between 2004 and 2020. Using a fixed-effects model, we assessed the determinants of CHE and unmet need along with the consequences of CHE. We also assessed the heterogeneity by age. Results: Households with older members were more likely to have their healthcare needs met but experienced CHE more so than households without older members. The financial consequences of CHE were heterogeneous by age, suggesting that households with older members responded to CHE by reducing food and social expenditures more so than households without older members reducing expenditure on education. Households without older members experienced an income decline in the year following the occurrence of CHE, while this was not found among households with older members. A U-shaped relationship was observed between age and the probability of experiencing unmet healthcare need. Conclusions: Households with older members are more likely to experience CHE with different financial consequences compared to those with younger members. Unmet need for healthcare is more common among younger and older members than among their middle-aged counterparts. Different types and levels of health and financial support need to be incorporated into national health systems and social protection policies to meet the unique needs of individuals and households. [ABSTRACT FROM AUTHOR]

Background: Major depressive disorder (MDD) is one of the world's leading causes of disability. Our purpose was to characterize the total costs of MDD and evaluate the degree to which the British Columbia provincial health system meets its objective to protect people from the financial impact of illness. Methods: We performed a population-based cohort study of adults newly diagnosed with MDD between 2015 and 2020 and followed their health system costs over two years. The expenditure proportion of MDD-related, patient paid costs relative to non-subsistence income was estimated, incidences of financial hardship were identified and the slope index of inequality (SII) between the highest and lowest income groups compared across regions. Results: There were 250,855 individuals diagnosed with MDD in British Columbia over the observation period. Costs to the health system totalled >$1.5 billion (2020 CDN), averaging $138/week for the first 12 weeks following a new diagnosis and $65/week to week 52 and $55/week for weeks 53–104 unless MDD was refractory to treatment ($125/week between week 12–52 and $101/week over weeks 53–104). The proportion of MDD-attributable costs not covered by the health system was 2-15x greater than costs covered by the health system, exceeding $700/week for patients with severe MDD or MDD that was refractory to treatment. Population members in lower-income groups and urban homeowners had disadvantages in the distribution of financial protection received by the health system (SII reached − 8.47 and 15.25, respectively); however, financial hardship and inequities were mitigated province-wide if MDD went into remission (SII − 0.07 to 0.6). Conclusions: MDD-attributable costs to health systems and patients are highest in the first 12 weeks after a new diagnosis. During this time, lower income groups and homeowners in urban areas run the risk of financial hardship. [ABSTRACT FROM AUTHOR]

Abstract Background and Aims Noncommunicable diseases are one of the main difficulties faced by older adults in many countries. The study aimed to investigate the households' catastrophic health expenditure (CHE) among older people with noncommunicable diseases. Methods This cross‐sectional study was conducted between October and December 2022 in Semnan, Iran, with the participation of 400 older individuals suffering from diabetes and hypertension. The Content Validity Ratio (which is calculated based on necessity criterion) and Content Validity Index (which calculated based on relevance, transparency, and simplicity criteria) values of 0.94 and 0.89, respectively, confirmed the content validity of the researcher‐made questionnaire. The occurrence of CHE was estimated using the World Health Organization's rule of “allocating at least 40% of non‐food household costs to healthcare.” Due to the qualitative nature of the data, the χ2 test was utilized to assess the statistical association between demographic and background variables and occurrence of CHE. Results Older people with diabetes and hypertension had an annual direct medical costs of $821 averagely, which includes 9.7% for diagnosis, 23.9% for doctor visits, and 66.4% for treatment. Direct medical costs account for around 0.26 of nonfood costs, with 12.5% of seniors facing high medical charges. Age, marital status, type of basic health insurance, diabetes, the time elapsed since initial diabetes diagnosis, the severity of diabetes complications, and the development of diabetes‐related visual impairments, are associated with CHE (p

Achieving the targets of eliminating tuberculosis (TB) requires a combination of biomedical, epidemiological, and social approaches. Having hitted by the coronavirus disease 2019 (COVID-19) pandemic which diminishes the financial capacity of TB-affected households, the importance of delivering socioeconomic support to TB-affected household emerges. However, the evidence of TB-related socioeconomic support is still scarce, and some questions are left unanswered. A sequential explanatory mixed-methods study by Dave and Rupani shows that the direct benefit transfer (DBT), a form of cash transfer, to TB-affected households improves TB treatment outcomes in India despite the challenges. Some critical issues remain to be discussed: trading-off between the amount of cash and its sustainability, choosing the most appropriate support packages, detecting, and reaching the target population, and arranging the most effective delivery strategy. Knowledge gap remains to be answered, and a global research agenda and political commitment are critical to encourage more evidence in delivering socioeconomic support for TB control.

Background. Health systems are responsible for providing healthcare services for all people in a community with reasonable costs. The primary objective was to evaluate and minimize the various expenses the patients incur consistently. The current study aimed to examine the direct non-medical and indirect expenses incurred to hospitalized patients infected with the Omicron variant of COVID-19. Methods. This cross-sectional study was conducted in February 2022 at Kosar Hospital in Semnan, Iran to investigate 400 hospitalized patients infected with the COVID-19 Omicron variant. The data were collected using a standardized instrument and conducting interviews with the patient. The descriptive findings were presented as frequencies (percentages) for qualitative variables and as means (standard deviations) for quantitative variables. The statistical relationship between demographic and background variables and the types of costs imposed on patients was examined performing T-test, ANOVA, and Tukey's post hoc test. Results. The study findings revealed that the patients and their families spent 20,260,000 IRR on direct non-medical treatment and 28,300,000 IRR on indirect treatment. A comprehensive statistical analysis was conducted to examine the correlation between demographic and background variables and the types of the costs incurred by patients and their families. The results indicated that a previous lung disease, asthma, diabetes, an admission to the intensive care unit (ICU), a coma in the patient, and COVID-19-induced heart complications were statistically and significantly associated with the direct non-medical costs. Furthermore, it was found that variables such as age, gender, educational status, employment status, engagement in occupational and physical activities, as well as the occurrence of a coma imposed additional indirect costs on the patients and their families. Conclusion. In sum, an infection with the Omicron variant of COVID-19 placed a substantial financial burden on the individuals and their households. Various factors may have influenced the magnitude of these expenses; therefore, it was recommended that these factors should be considered when implementing the promotional initiatives.

OBJECTIVES: To determine the incidence and major drivers of catastrophic costs among TB-affected households in Zimbabwe. METHODS: We conducted a nationally representative health facility-based survey with random cluster sampling among consecutively enrolled drug-susceptible (DS-TB) and drug-resistant TB (DR-TB) patients. Costs incurred and income lost due to TB illness were captured using an interviewer-administered standardised questionnaire. We used multivariable logistic regression to determine the risk factors for experiencing catastrophic costs. RESULTS: A total of 841 patients were enrolled and were weighted to 900 during data analysis. There were 500 (56%) males and 46 (6%) DR-TB patients. Thirty-five (72%) DR-TB patients were HIV co-infected. Overall, 80% (95% CI: 77-82) of TB patients and their households experienced catastrophic costs. The major cost driver pre-TB diagnosis was direct medical costs. Nutritional supplements were the major cost driver post-TB diagnosis, with a median cost of US$360 (IQR: 240-600). Post-TB median diagnosis costs were three times higher among DR-TB (US$1,659 [653-2,787]) than drug DS-TB-affected households (US$537 [204-1,134]). Income loss was five times higher among DR-TB than DS-TB patients. In multivariable analysis, household wealth was the only covariate that remained significantly associated with catastrophic costs: The poorest households had 16 times the odds of incurring catastrophic costs versus the wealthiest households (adjusted odds ratio [aOR: 15.7 95% CI: 7.5-33.1]). CONCLUSION: The majority of TB-affected households, especially those affected by DR-TB, experienced catastrophic costs. Since the major cost drivers fall outside the healthcare system, multi-sectoral approaches to TB control and linking TB patients to social protection may reduce catastrophic costs.

The article examines the issues of financial and legal protection of servicemen as a direction of the State's financial activity under martial law. It has been determined that the financial and legal protection of servicemen is aimed at material support of the entire range of measures on social policy of the State at the expense of budgetary funds. It has been proved that the allocation and use of budget expenditures in 2023 are conditioned by the martial law in which the country is, and have a temporary content, but cover a significant amount of funds, which affected the State's ability to perform its social function. The problem of financial and legal protection is related to the problem of financing special social rights of servicemen, and its implementation depends, firstly, on the distribution and volume of State budget expenditures, secondly, on the improvement of the social protection system, which is inherent in ensuring the implementation of the social function of the State, and thirdly, on the distribution of budget funds, the administrator of which is the Ministry of Defence of Ukraine, the available amount of which is a result of the distribution of State expenditures. At the second and third stages of the budget process, the legal basis for the allocation and use of budget funds is established, in particular for the financing of social rights, the realisation of which depends on the amount of expenditures and the impact of various political, economic and other factors. To conclude, we note that budget expenditures for the social sphere in general and for the financing of special social rights of military personnel in particular, as well as for other categories of citizens, need to be regulated at the stages of drafting, reviewing and adopting the budget law. The implementation of measures on financial and legal protection of servicemen depends on the fulfilment of the state's tasks on the distribution and use of budget expenditures for financing benefits, guarantees and compensations for servicemen and is ensured, firstly, by financing social standards and state social guarantees, and secondly, by financing special social rights of servicemen.

ABSTRACTLatin America has experienced a rise in noncommunicable diseases (NCDs) which is having repercussions on the structuring of healthcare delivery and social protection for vulnerable populations. We examined catastrophic (CHE) and excessive (EHE, impoverishing and/or catastrophic) health care expenditures in Mexican households with and without elderly members (≥65 years), by gender of head of the households, during 2000–2020. We analyzed pooled cross-sectional data for 380,509 households from eleven rounds of the National Household Income and Expenditure Survey. Male- and female-headed households (MHHs and FHHs) were matched using propensity scores to control for gender bias in systematic differences regarding care-seeking (demand for healthcare) preferences. Adjusted probabilities of positive health expenditures, CHE and EHE were estimated using probit and two-stage probit models, respectively. Quintiles of EHE by state among FHHs with elderly members were also mapped. CHE and EHE were greater among FHHs than among MHHs (4.7% vs 3.9% and 5.5% vs 4.6%), and greater in FHHs with elderly members (5.8% vs 4.9% and 6.9% vs 5.8%). EHE in FHHs with elderly members varied geographically from 3.9% to 9.1%, being greater in less developed eastern, north-central and southeastern states. Compared with MHHs, FHHs face greater risks of CHE and EHE. This vulnerability is exacerbated in FHHs with elderly members, because of gender intersectional vulnerability. The present context, marked by a growing burden of NCDs and inequities amplified by COVID-19, makes key interlinkages across multiple Sustainable Development Goals (SDGs) apparent, and calls for urgent measures that strengthen social protection in health.

The healthcare system relies on critical components such as medical insurance, nutrition plans, and the management of drug side effects to ensure individuals' well-being and access to quality healthcare. Medical insurance protects people financially from medical costs by enabling them to afford the essential treatments, diagnostic procedures, and preventive care. By putting an emphasis on balanced diets and important nutrients while minimizing dangerous substances, nutrition plans play a crucial part in preventive healthcare. A large number of people suffer from noncommunicable diseases such as diabetes, heart disease, high blood pressure and so on. Individuals can improve their general health, prevent chronic diseases, and strengthen their immune systems by following welldesigned nutrition plans that help them manage their daily caloric needs and BMI. It is common practice to utilize pharmaceuticals in healthcare procedures, but it is crucial to be aware of any possible negative effects. The well-being of patients and the success of their treatments may be impacted by these side effects, which can vary from minor discomfort to serious adverse reactions. To ensure patient safety and treatment effectiveness, healthcare professionals are essential in controlling drug side effects. Using datasets of medical side and several machine learning algorithms, we can provide comprehensive healthcare system incorporates medical insurance, nutrition plans, and the management of drug side effects. By promoting healthy lifestyles through appropriate eating and reducing the risks connected with medical procedures, this integration guarantees cheap healthcare access. The healthcare system can successfully promote individual well-being and enhance outcomes for public health by taking into account these factors. [ABSTRACT FROM AUTHOR]

Background. Health systems are responsible for providing healthcare services for all people in a community with reasonable costs. The primary objective was to evaluate and minimize the various expenses the patients incur consistently. The current study aimed to examine the direct non-medical and indirect expenses incurred to hospitalized patients infected with the Omicron variant of COVID-19. Methods. This cross-sectional study was conducted in February 2022 at Kosar Hospital in Semnan, Iran to investigate 400 hospitalized patients infected with the COVID-19 Omicron variant. The data were collected using a standardized instrument and conducting interviews with the patient. The descriptive findings were presented as frequencies (percentages) for qualitative variables and as means (standard deviations) for quantitative variables. The statistical relationship between demographic and background variables and the types of costs imposed on patients was examined performing T-test, ANOVA, and Tukey's post hoc test. Results. The study findings revealed that the patients and their families spent 20,260,000 IRR on direct non-medical treatment and 28,300,000 IRR on indirect treatment. A comprehensive statistical analysis was conducted to examine the correlation between demographic and background variables and the types of the costs incurred by patients and their families. The results indicated that a previous lung disease, asthma, diabetes, an admission to the intensive care unit (ICU), a coma in the patient, and COVID-19-induced heart complications were statistically and significantly associated with the direct non-medical costs. Furthermore, it was found that variables such as age, gender, educational status, employment status, engagement in occupational and physical activities, as well as the occurrence of a coma imposed additional indirect costs on the patients and their families (P<0.05). Conclusion. In sum, an infection with the Omicron variant of COVID-19 placed a substantial financial burden on the individuals and their households. Various factors may have influenced the magnitude of these expenses; therefore, it was recommended that these factors should be considered when implementing the promotional initiatives. [ABSTRACT FROM AUTHOR]

Considering that ensuring the stability, reliability and efficiency of the financial system is a prerequisite for the country's defence capability, it has been noted that these positions are the basis for the interdependence of military and financial security. The essence, place and importance of financial security as a condition for ensuring military security have been investigated. The components of the military security system and the impact of the financial system on their functioning have been analysed. The author's own definition of the “financial security” concept and elements of the State’s financial security system have been proposed. The challenges and threats to the financial system of the State under martial law and the tasks of ensuring its stability, invincibility and effective functioning are considered. Based on the analysis of the Economic Security Strategy of Ukraine, it has been found that the state of the country’s financial security is assessed as unsatisfactory. It has been noted that the constant deficit of the state budget and the associated significant debt burden, insufficient development of long-term investment lending to the economy and the stock market, the growth of economic crime, and low financial culture in society are negative factors affecting the state of the financial system. It has been noted that different academic opinions on the constituent elements of financial security depend on the object of consideration. It has been noted that scientific analysis of financial security as a categorical institution has a significant impact not only on ensuring the country’s defence capability, but also on substantiating the current tasks of its organisational and legal support at the State level. General scientific theoretical methods have been used: system analysis aimed at identifying the object and subject of research, in particular, public finance; abstract and logical method – to provide scientifically sound generalisations and conclusions on the problems of legal regulation of financial security as a factor influencing military security and to define financial security measures as means of protecting the interests of a person and the State. The institutional, instrumental and functional components of financial security have been clarified. Attention has been drawn to the need to reform the system of state financial control bodies and improve the legal framework for monitoring public financial resources. It has been proved that there is a need for legislative regulation of relations on the circulation of public financial resources, and the directions of their orientation towards the actual tasks of ensuring military security have been substantiated.

Universal health coverage is essential for the progress to end threats of the acquired immunodeficiency syndrome epidemic. The current review assesses the publication rate, strategies and barriers for antiretroviral therapy (ART) coverage, equity, quality of care, and financial protection. We searched Web of Science, PubMed, and Google Scholar. Of the available articles, 43.13% were on ART coverage, 40.28% were on financial protection, 10.43% were on quality of care, and 6.16% were on equity. A lack of ART, fear of unwanted disclosure, lack of transportation, unaffordable health care costs, long waiting time to receive care, and poverty were barriers to ART coverage. Catastrophic health care costs were higher among individuals who were living in rural settings, walked greater distances to reach health care institutions, had a lower socioeconomic status, and were immunocompromised. There were challenges to the provision of quality of care, including health care providers’ inadequate salary, high workload and inadequate health workforce, inappropriate infrastructure, lack of training opportunities, unclear division of responsibility, and the presence of strict auditing. In conclusion, ART coverage was below the global average, and key populations were disproportionally less covered with ART in most countries. Huge catastrophic health expenditures were observed. UHC contexts of ART will be improved by reaching people with poor socioeconomic status, delivering appropriate services, establishing a proper health workforce and service stewardship.

Abstract Background Diagnostic testing for SARS-CoV-2 is critical to manage the pandemic and its different waves. The requirement to pay out-of-pocket (OOP) for testing potentially represents both a financial barrier to access and, for those who manage to make the payment, a source of financial hardship, as they may be forced to reduce spending on other necessities. This study aims to assess age-related inequality in affordability of COVID-19 tests. Methods Daily data from the Global COVID-19 Trends and Impact Survey among adult respondents across 83 countries from July 2020 to April 2021 was used to monitor age-related inequalities across three indicators: the experiences of, first, reducing spending on necessities because of paying OOP for testing, second, facing financial barriers to get tested (from January to April 2021), and third, having anxiety related to household finance in the future. Logistic regressions were used to assess the association of age with each of these. Results Among the population ever tested, the adjusted odds of reducing spending on necessities due to the cost of the test decreased non-linearly with age from 2.3 [CI95%: 2.1–2.5] among ages 18–24 to 1.6 [CI95%: 1.5–1.8] among ages 45–54. Among the population never tested, odds of facing any type of barrier to testing were highest among the youngest age group 2.5 [CI95%:2.4–2.5] and decreased with age. Finally, among those reporting reducing spending on necessities, the odds of reporting anxiety about their future finances decreased non-linearly with age, with the two younger groups being 2.4–2.5 times more anxious than the oldest age group. Among those reporting financial barriers due to COVID-19 test cost, there was an inverse U-shape relationship. Conclusions COVID-19 testing was associated with a reduction in spending on necessities at varying levels by age. Younger people were more likely to face financial barrier to get tested. Both negative outcomes generated anxiety across all age-groups but more frequently among the younger ones. To reduce age-related inequalities in the affordability of COVID-19 test, these findings support calls for exempting everyone from paying OOP for testing and, removing other type of barriers than financial ones.

Background A direct benefit transfer (DBT) program was launched to address the dual epidemic of under-nutrition and tuberculosis (TB) in India. We conducted this study to determine whether non-receipt of DBT was associated with unfavorable treatment outcomes among patients with TB and to explore the perspectives of patients and program functionaries regarding the program.Methods We conducted a retrospective cohort study among 426 patients with drug-sensitive pulmonary TB on treatment during January-September 2019 to determine the association between non-receipt of DBT and unfavorable treatment outcomes, which was followed by in-depth interviews of 9 patients and 8 program functionaries to explore their perspectives on challenges and suggestions regarding the DBT program. Multivariate logistic regression was applied to determine whether non-receipt of DBT was independently associated with unfavorable treatment outcomes, while the in-depth interviews were transcribed to describe them as codes and categories.Results Among the 426 patients, 9% of the patients did not receive DBT and 91% completed their treatment. Non-receipt of DBT was associated with a 5 (95% CI: 2-12) times higher odds of unfavorable treatment outcomes on multivariable analysis. Patients not owning a bank account was the primary challenge perceived by the program staff. The patients perceived the assistance under DBT to be insufficient to buy nutritious food throughout the course of treatment. The program functionaries as well as the patients suggested increasing the existing assistance under DBT along with the provision of a monthly nutritious food-kit.Conclusion DBT improved the treatment completion rates among patients with TB in our setting. Provision of a monthly nutritious food-kit with an increase in the existing assistance under DBT might further improve the treatment outcomes. Future research should determine the long-term financial sustainability for ‘DBT plus food-kit’ vs. universal cash transfers in India.

Background As countries health financing policies supporting progress towards Universal Health Coverage (UHC), an analysis of these policies is particularly relevant in Low and Middle-Income Countries (LMICs). In 2001, the government of Uganda abolished user-fees to improve accessibility to health services for the population. However, after almost 20 years, the incidence of catastrophic health expenditures is still very high, and the health financing system does not provide a pooled prepayment scheme at national level such as an integrated health insurance scheme. Objective This article aims at analysing the Ugandan experience of health financing reforms with a specific focus on financial protection. Financial protection represents a key pillar of UHC and has been central to health systems reforms even before the launch of the UHC definition. Methods The qualitative study adopts a political economy perspective and it is based on a desk review of relevant documents and a multi-level stakeholder analysis based on 60 Key Informant Interviews in the health sector. Results We find that the current political situation is not yet conducive for implementing a universal health coverage system with widespread financial protection: dominant interests and ideologies do not create a net incentive to implement a comprehensive scheme for this purpose. The health financing landscape remains extremely fragmented, and community-based initiatives to improve health coverage are not supported by a clear government stewardship. Conclusion By examining the negotiation process for health financing reforms through a political economy perspective, this article intends to advance the debate about politically-tenable strategies for achieving UHC and widespread financial protection for the population in LMICs.

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.

Objective: Institutional deliveries have been promoted in India to reduce maternal and neonatal mortality. While the institutional deliveries have increased, they tend to involve large out of pocket expenditure (OOPE) and distress financing for households. In order to protect the families from financial hardship, publicly funded health insurance (PFHI) schemes have been implemented in India. An expanded national health insurance scheme called the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY) was launched in 2018. The current study was aimed at evaluating the performance of PFHI in reducing the OOPE and distress financing for the caesarean and non-caesarean institutional deliveries after the launch of PMJAY. This study analysed the nationally representative dataset of the National Family Health Survey (NFHS-5) conducted in 2019-21. Results: Enrollment under PMJAY or other PFHI was not associated with any reduction in out of pocket expenditure or distress financing for caesarean or non-caesarean institutional deliveries across India. Irrespective of the PFHI coverage, the average OOPE in private hospitals was five times larger than public hospitals. Private hospitals showed an excessive rate of using caesarean-section. Utilization of private hospitals was significantly associated with incurring larger OOPE and occurrence of distress financing. [ABSTRACT FROM AUTHOR]

Background and Aims: One of the goals of the Islamic Republic of Iran is to reduce the prevalence of catastrophic health expenditures among Iranian households to 1% by the end of the sixth 5‐year development plan (2016−2021). This study was conducted to evaluate the level of access to this goal in the final year of this program. Methods: A national cross‐sectional study was conducted on 2000 Iranian households in five provinces of Iran in 2021. Data were collected through interviews using the World Health Survey questionnaire. Data from households whose health care costs were more than 40% of their capacity to pay were included in the group of households with catastrophic health expanditure (CHE). Determinants of CHE were identified using univariate and multivariate regression analysis. Results: 8.3% of households had experienced CHE. The variables of being a female head of household (odd ratio [OR] = 2.7), use of inpatient (OR = 1.82), dental (OR = 3.09), and rehabilitation services (OR = 6.12), families with disabled members (OR = 2.03) and low economic status of the households (OR = 10.73) were significantly associated with increased odds of facing CHE (p < 0.05). Conclusion: In the final year of the sixth 5‐year development plan, Iran has not yet achieved its goal of "reducing the percentage of households exposed to CHE to 1%." Policymakers should pay attention to factors increasing the odds of facing CHE in designing interventions. [ABSTRACT FROM AUTHOR]

Monitoring financial hardship due to out-of-pocket spending on health care is a critical determinant of progress towards universal health coverage. This study investigates the occurrence, intensity and determinants of catastrophic health expenditure and impoverishment in Bhutan using three rounds of the cross-sectional Bhutan Living Standard Surveys carried out in 2007, 2012 and 2017. We use a composite financial hardship measure defined as households experiencing either catastrophic health expenditure or impoverished/further impoverished due to health spending or both. We calculated concentration indices to examine socio-economic inequalities. We used logistic regression to examine the factors associated with financial hardship. We find that, in the context of a significant increase in living standards, there is a sharp increase in the incidence of catastrophic health expenditure (using 40% of capacity to pay) and impoverishment (based on equivalized average food-share-based poverty line) between 2007 and 2017. In 2017, catastrophic health expenditure was estimated at 0.51%, impoverishment at 0.32% and further impoverishment at 1.93% of the population, cumulating to financial hardship affecting 2.55% of the population. Financial hardship particularly burdened rural dwellers and poorer households. Transportation costs almost doubled the risk of facing financial hardship. Households that were poor, had an unemployed head, were larger and had more elderly members had higher odds of financial hardship. This evidence should prompt policy and programmatic interventions to support Bhutan's progress towards universal health coverage. [ABSTRACT FROM AUTHOR]

This article proposes and validates a financial protection perception scale (FPPS) from the perspective of the financial services consumer. The scale was applied to a sample of 1137 individuals residing in Brazil and validated using exploratory and confirmatory factor analysis and standard multivariate validation methods. The FPPS, composed of 14 items, allows the development of an indicator that defines the level of protection perceived by the consumer of financial services, evaluated along the dimensions of transparency, suitability, security, and complaints. The tests and fit indices indicated the reliability and validity of the FPPS. With this scale, researchers, managers, and policymakers can assess the extent to which consumers feel protected when using financial services. [ABSTRACT FROM AUTHOR]

Financial barriers cause many women in low- and middle-income countries to deliver outside of a health facility, contributing to maternal and neonatal mortality. Savings accrued during pregnancy can increase access to safe delivery services. We investigated the relationship between household saving during pregnancy and facility delivery. A cross-section of 2381 women who delivered a child in the previous 12 months was sampled from 40 health facility catchment areas across eight districts in three provinces in Zambia in April and May of 2016. During a household survey, women reported on their perceptions of the adequacy of their household savings during their recent pregnancy. Households were categorized based on women's responses as: did not save; saved but not enough; and saved enough. We estimated crude and adjusted associations between perceived adequacy of savings and facility delivery. We also explored associations between savings and expenditures on delivery. Overall, 51% of women surveyed reported that their household saved enough for delivery; 32% reported saving but not enough; and 17% did not save. Household wealth was positively associated with both categories of saving, while earlier attendance at antenatal care was positively associated with saving enough. Compared with women in households that did not save, those in households that saved but not enough (aOR 1.63; 95% CI: 1.17, 2.25) and saved enough (aOR 2.86; 95% CI: 2.05, 3.99) had significantly higher odds of facility delivery. Both categories of saving were significantly associated with higher overall expenditure on delivery, driven in large part by higher expenditures on baby clothes and transportation. Our findings suggest that interventions that encourage saving early in pregnancy may improve access to facility delivery services.

Abstract Objective China has made remarkable achievements in poverty alleviation. However, with the change in economic development and age structure, the population stricken by poverty due to medical expenses and disability accounted for 42.3 and 14.4% of the total poverty-stricken population, respectively. Accordingly, it is crucial to accurately pinpoint the characteristics of people who are about to become poor due to illness. In this study, we analyzed the incidence of impoverishment by medical expense at the provincial, family, and different medical insurance scheme levels to identify the precise groups that are vulnerable to medical-related poverty. Method Data were extracted from the Fifth National Health Service Survey in China in 2013 through a multi-stage, stratified, and random sampling method, leaving 93,570 households (273,626 people) for the final sample. The method recommended by World Health Organization (WHO) was adopted to calculate impoverishment by medical expense, and logistic regression was adopted to evaluate its determinants. Results The poverty and impoverishment rate in China were 16.2 and 6.3% respectively. The poverty rate in western region was much higher than that of central and eastern regions. The rate of impoverishment by medical expense (IME) was higher in the western region (7.2%) than that in the central (6.5%) and eastern (5.1%) regions. The New Cooperative Medical Scheme (NCMS) was associated with the highest rate (9.1%) of IME cases. The top three diseases associated with IME were malignant tumor, congenital heart disease, and mental disease. Households with non-communicable disease members or hospitalized members had a higher risk on IME. NCMS-enrolled, poorer households were more likely to suffer from IME. Conclusion The joint roles of economic development, health service utilization, and welfare policies result in medical impoverishment for different regions. Poverty and health service utilization are indicative of households with high incidence of medical impoverishment. Chronic diseases lead to medical impoverishment. The inequity existing in different medical insurance schemes leads to different degrees of risk of IME. A combined strategy to precise target multiple vulnerabilities of poor population would be more effective.

Abstract Background The elderly face a greater burden of illnesses than other age groups and have a more frequent need of healthcare, including in-patient hospitalisations. Catastrophic expenditure on hospitalisation of the elderly poses a significant challenge to India’s aim of achieving Universal Health Coverage (UHC). India has implemented a policy of Publicly Funded Health Insurance (PFHI) to provide free inpatient care by empanelling private and public hospitals. The existing studies have examined the performance of PFHI in financial protection of the elderly. Methods This study utilised the Longitudinal Ageing Study in India (LASI) Wave 1, conducted in 2017–18. LASI is a large-scale nationally representative survey collecting data on elderly health including illness burden, healthcare use and out of pocket expenditure (OOPE). It covered a sample 72,250 individuals aged 45 or above. Financial Protection was measured in terms of Catastrophic Health Expenditure (CHE). Multivariate analysis was conducted to find effect of PFHI on OOPE—quantile and logistic models were applied for OOPE and CHE respectively. For robustness, Propensity Score Matching (PSM) model was applied. Results Of the hospitalisations, 35% had taken place in public hospitals. The mean OOPE for a hospitalisation in public sector was Indian Rupees (INR) 8276, whereas it was INR 49,700 in private facilities. Incidence of CHE was several times greater for using private hospitals as compared to public hospitals. Multi-variate analyses showed that enrolment under PFHI was not associated with lower OOPE or CHE. PSM model also confirmed that PFHI-enrolment had no effect on OOPE or CHE. Use of private facilities was a key determinant of OOPE, irrespective of enrolment under PFHI. Conclusions This was the first study in India to examine the performance of PFHI in the context of catastrophic hospitalisation expenditure faced by the elderly. It found that PFHI was not effective in financial protection of the elderly. The ongoing reliance on a poorly regulated private sector seems to be a key limitation of PFHI policy. Governments need to find more effective ways of protecting the elderly from catastrophic health expenditure if the goal of UHC has to be realized.

Abstract Background and Aims One of the goals of the Islamic Republic of Iran is to reduce the prevalence of catastrophic health expenditures among Iranian households to 1% by the end of the sixth 5‐year development plan (2016−2021). This study was conducted to evaluate the level of access to this goal in the final year of this program. Methods A national cross‐sectional study was conducted on 2000 Iranian households in five provinces of Iran in 2021. Data were collected through interviews using the World Health Survey questionnaire. Data from households whose health care costs were more than 40% of their capacity to pay were included in the group of households with catastrophic health expanditure (CHE). Determinants of CHE were identified using univariate and multivariate regression analysis. Results 8.3% of households had experienced CHE. The variables of being a female head of household (odd ratio [OR] = 2.7), use of inpatient (OR = 1.82), dental (OR = 3.09), and rehabilitation services (OR = 6.12), families with disabled members (OR = 2.03) and low economic status of the households (OR = 10.73) were significantly associated with increased odds of facing CHE (p

Universal health coverage is essential for the progress to end threats of the acquired immunodeficiency syndrome epidemic. The current review assesses the publication rate, strategies and barriers for antiretroviral therapy (ART) coverage, equity, quality of care, and financial protection. We searched Web of Science, PubMed, and Google Scholar. Of the available articles, 43.13% were on ART coverage, 40.28% were on financial protection, 10.43% were on quality of care, and 6.16% were on equity. A lack of ART, fear of unwanted disclosure, lack of transportation, unaffordable health care costs, long waiting time to receive care, and poverty were barriers to ART coverage. Catastrophic health care costs were higher among individuals who were living in rural settings, walked greater distances to reach health care institutions, had a lower socioeconomic status, and were immunocompromised. There were challenges to the provision of quality of care, including health care providers' inadequate salary, high workload and inadequate health workforce, inappropriate infrastructure, lack of training opportunities, unclear division of responsibility, and the presence of strict auditing. In conclusion, ART coverage was below the global average, and key populations were disproportionally less covered with ART in most countries. Huge catastrophic health expenditures were observed. UHC contexts of ART will be improved by reaching people with poor socioeconomic status, delivering appropriate services, establishing a proper health workforce and service stewardship. [ABSTRACT FROM AUTHOR]

Background: Diagnostic testing for SARS-CoV-2 is critical to manage the pandemic and its different waves. The requirement to pay out-of-pocket (OOP) for testing potentially represents both a financial barrier to access and, for those who manage to make the payment, a source of financial hardship, as they may be forced to reduce spending on other necessities. This study aims to assess age-related inequality in affordability of COVID-19 tests. Methods: Daily data from the Global COVID-19 Trends and Impact Survey among adult respondents across 83 countries from July 2020 to April 2021 was used to monitor age-related inequalities across three indicators: the experiences of, first, reducing spending on necessities because of paying OOP for testing, second, facing financial barriers to get tested (from January to April 2021), and third, having anxiety related to household finance in the future. Logistic regressions were used to assess the association of age with each of these. Results: Among the population ever tested, the adjusted odds of reducing spending on necessities due to the cost of the test decreased non-linearly with age from 2.3 [CI95%: 2.1–2.5] among ages 18–24 to 1.6 [CI95%: 1.5–1.8] among ages 45–54. Among the population never tested, odds of facing any type of barrier to testing were highest among the youngest age group 2.5 [CI95%:2.4–2.5] and decreased with age. Finally, among those reporting reducing spending on necessities, the odds of reporting anxiety about their future finances decreased non-linearly with age, with the two younger groups being 2.4–2.5 times more anxious than the oldest age group. Among those reporting financial barriers due to COVID-19 test cost, there was an inverse U-shape relationship. Conclusions: COVID-19 testing was associated with a reduction in spending on necessities at varying levels by age. Younger people were more likely to face financial barrier to get tested. Both negative outcomes generated anxiety across all age-groups but more frequently among the younger ones. To reduce age-related inequalities in the affordability of COVID-19 test, these findings support calls for exempting everyone from paying OOP for testing and, removing other type of barriers than financial ones. [ABSTRACT FROM AUTHOR]

COVID-19 imposed unprecedented financing requirements on countries to rapidly implement effective prevention and control measures while dealing with severe economic contraction. The challenges were particularly acute for the 11 countries in the WHO South-East Asia Region (SEAR), home to the lowest average level of public expenditure on health of all WHO regions. We conducted a narrative review of peer-reviewed, grey literature and publicly available sources to analyse the immediate health financing policies adopted by countries in the WHO SEAR in response to COVID-19 in the first 12 months of the pandemic, i.e. from 1 March 2020 to 1 March 2021. Our review focused on the readiness of health systems to address the financial challenges of COVID-19 in terms of revenue generation, financial protection and strategic purchasing including public financial management issues. Twenty peer-reviewed articles were included, and web searches identified media articles (n = 21), policy reports (n = 18) and blog entries (n = 5) from reputable sources. We found that countries in the SEAR demonstrated great flexibility in responding to the COVID-19 pandemic, including exploring various options for revenue raising, removing financial barriers to care and rapidly adapting purchasing arrangements. At the same time, the pandemic exposed pre-existing health financing policy weaknesses such as underinvestment, inadequate regulatory capacity of the private health sector and passive purchasing, which should give countries an impetus for reform towards more resilient health systems. Further monitoring and evaluation are needed to assess the long-term implications of policy responses on issues such as government capacity for debt servicing and fiscal space for health and how they protect progress towards the objectives of universal health coverage. [ABSTRACT FROM AUTHOR]