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The vital role of healthcare financing in achieving universal health coverage is indisputable. However, most countries, including Malaysia, face challenges in establishing an equitable and sustainable healthcare financing system due to escalating healthcare costs, an ageing population and a growing disease burden. With desirable pre-payment and risk pooling features, private health insurance (PHI) is considered an alternative financing option to reduce out-of-pocket (OOP) medical expenditure. However, ongoing theoretical and empirical debates persist regarding the adequacy of financial risk protection provided by PHI largely because it depends on its role, the benefit design and the regulations in place. Our study aimed to investigate the effect of supplementary PHI on OOP inpatient medical expenditure in Malaysia. Secondary data analysis was conducted using the Malaysian National Health and Morbidity Survey 2019 dataset. A total of 983 respondents with a history of inpatient hospitalization in the past 12 months were included in the study. Instrumental variable analysis using a two-stage residual inclusion was performed to address endogeneity bias, with wealth status and education level as the instrumental variables. Tobit regression model was used in the second stage considering the censored distribution of the outcome variable. Missing data were handled using multiple imputation. About one-fifth of the respondents had PHI. In this study, we found that having PHI significantly increased OOP inpatient medical expenditure in all three marginal effects. Additionally, age, residential location, ethnicity (citizenship), being covered by government guarantee letter, government funding and employer-sponsored health insurance were other significant factors associated with OOP inpatient medical expenditure. Our findings undermine a key justification to advocate PHI uptake among the population, with a need for the Malaysian government to reassess the role of PHI in healthcare financing and reconsider PHI subsidization policy. Regulations should also be strengthened to enhance the financial risk protection provided by PHI. [ABSTRACT FROM AUTHOR]

Abstract Background In Malaysia, asthma is a common chronic respiratory illness. Poor asthma control may increase out-of-pocket payment for asthma care, leading to financial hardships Malaysia provides Universal Health Coverage for the population with low user fees in the public health system to reduce financial hardship. We aimed to determine out-of-pocket expenditure on outpatient care for adult patients with asthma visiting government-funded public health clinics. We examined the catastrophic impact and medical impoverishment of these expenses on patients and households in Klang District, Malaysia. Methods This is a cross-sectional face-to-face questionnaire survey carried out in six government-funded public health clinics in Klang District, Malaysia. We collected demographic, socio-economic profile, and outpatient asthma-related out-of-pocket payments from 1003 adult patients between July 2019 and January 2020. Incidence of catastrophic health expenditure was estimated as the proportion of patients whose monthly out-of-pocket payments exceeded 10% of their monthly household income. Incidence of poverty was calculated as the proportion of patients whose monthly household income fell below the poverty line stratified for the population of the Klang District. The incidence of medical impoverishment was estimated by the change in the incidence of poverty after out-of-pocket payments were deducted from household income. Predictors of catastrophic health expenditure were determined using multivariate regression analysis. Results We found the majority (80%) of the public health clinic attendees were from low-income groups, with 41.6% of households living below the poverty line. About two-thirds of the attendees reported personal savings as the main source of health payment. The cost of transportation and complementary-alternative medicine for asthma were the main costs incurred. The incidences of catastrophic expenditure and impoverishment were 1.69% and 0.34% respectively. The only significant predictor of catastrophic health expenditure was household income. Patients in the higher income quintiles (Q2, Q3, Q4) had lower odds of catastrophic risk than the lowest quintile (Q1). Age, gender, ethnicity, and poor asthma control were not significant predictors. Conclusion The public health system in Malaysia provides financial risk protection for adult patients with asthma. Although patients benefited from the heavily subsidised public health services, this study highlighted those in the lowest income quintile still experienced financial catastrophe and impoverishment, and the risk of financial catastrophe was significantly greater in this group. It is crucial to ensure health equity and protect patients of low socio-economic groups from financial hardship.

Background: Ayushman Bharat-Pradhan Mantri Jan Aarogya Yojna (AB-PMJAY) as a financial risk protection scheme intends to reduce catastrophic health expenditure (CHE), especially among poor. The current study was carried out to assess the utility of AB-PMJAY in terms of reduction in CHE from before and after admission in a tertiary hospital in the northern state of India. Methodology: It was a hospital-based cross-sectional study carried out from August 2020 to October 2021 at a public tertiary hospital of Himachal Pradesh, India. Data were collected from surgery- and medicine-allied (SA and MA) specialties. Along with socio-demographic details, information for total monthly family expenditure (TMFE), out-of-pocket expenditure (OOPE), and indirect illness-related expenditure (IIE) was recorded before and after hospital admission. CHE was considered as more than 10.0% OOPE of THFE and more than 40.0% of capacity to pay (CTP). Results: A total of 336 participants with a mean age of 46 years were recruited (MA: 54.6%). The majority (-93.0%) of participants had illness of fewer than 6 months. The mean TMFE was observed to be INR 4213.1 (standard deviation: 2483.7) and found to be similar across specialties. The OOPE share of TMFE declined from 76.1% (before admission) to 30.0% (after admission). Before admission, CHE was found among 65.5% (10.0% of THFE) and 54.2% (40.0% of CTP) participants. It reduced to about 29.0% (based on both THE and CTP) after admission to hospital. Conclusion: AB-PMJAY scheme found to be useful in reducing CHE in a tertiary hospital. [ABSTRACT FROM AUTHOR]

Abstract Background Financial risk protection is a core dimension of universal health coverage. Hardship financing, defined as borrowing and selling land or assets to pay for healthcare, is a measure of last recourse. Increasing indebtedness and high interest rates, particularly among unregulated money lenders, can lead to a vicious cycle of poverty and exacerbate inequity. Methods To inform efforts to improve Cambodia’s social health protection system we analyze 2019–2020 Cambodia Socio-economic Survey data to assess hardship financing, illness and injury related productivity loss, and estimate related economic impacts. We apply two-stage Instrumental Variable multiple regression to address endogeneity relating to net income. In addition, we calculate a direct economic measure to facilitate the regular monitoring and reporting on the devastating burden of excessive out-of-pocket expenditure for policy makers. Results More than 98,500 households or 2.7% of the total population resorted to hardship financing over the past year. Factors significantly increasing risk are higher out-of-pocket healthcare expenditures, illness or injury related productivity loss, and spending of savings. The economic burden from annual lost productivity from illness or injury amounts to US$ 459.9 million or 1.7% of GDP. The estimated household economic cost related to hardship financing is US$ 250.8 million or 0.9% of GDP. Conclusions Such losses can be mitigated with policy measures such as linking a catastrophic health coverage mechanism to the Health Equity Funds, capping interest rates on health-related loans, and using loan guarantees to incentivize microfinance institutions and banks to refinance health-related, high-interest loans from money lenders. These measures could strengthen social health protection by enhancing financial risk protection, mitigating vulnerability to the devastating economic effects of health shocks, and reducing inequities.

Abstract Background Providing financial risk protection is one of the fundamental goals of health systems. Catastrophic health expenditure (CHE) and medical impoverishment (MI) are two common indicators in evaluating financial risk protection in health. As China continues its health system reform to provide accessible and affordable health care, it is important to have a clear understanding of China’s progress in financial risk protection. However, past research showed discrepancies in the incidence of CHE and MI. In this article, using data from four national household surveys, we analyzed levels and characteristics of CHE and MI in China under different definitions. Methods We used multiple conventional thresholds for CHE and MI to comprehensively describe the levels of financial risk protection in China. We used data from four national household surveys to measure the incidence of CHE and MI, and their inequalities by urban/rural status and by income quartiles. The Probit regression model was used to explore influencing factors of CHE and MI. Results We found that the incidences of CHE and MI were largely consistent across four national household surveys, despite different sampling methods and questionnaire designs. At the 40% nonfood expenditure threshold, the incidence of CHE in China was 14.95%-17.73% across four surveys during the period of 2016–2017. Meanwhile, at the 1.9 US dollars poverty line, the incidence of MI was 2.01%-5.63%. Moreover, rural residents, lower-income subgroups, and smaller households were faced with higher financial risks from healthcare expenditures. Although positive progress in financial risk protection has been achieved in recent years, China has disproportionately high incidences of CHE and MI, compared to other countries. Conclusion China has large margins for improvements in risk financial protection, with large inequalities across subgroups. Providing better financial protection for low-income groups in rural areas is the key to improve financial protection in China.

Abstract Background Financial risk protection (FRP) is a key component of universal health coverage (UHC): all individuals must be able to obtain the health services they need without experiencing financial hardship. In many low-income and lower-middle-income countries, however, the health system fails to provide sufficient protection against high out-of-pocket (OOP) spending on health services. In 2018, OOP health spending comprised approximately 40% of current health expenditures in low-income and lower-middle-income countries. Methods We model the household risk of catastrophic health expenditures (CHE), conditional on having a given disease or condition—defined as OOP health spending that exceeds a threshold percentage (10, 25, or 40%) of annual income—for 29 health services across 13 disease categories (e.g., diarrheal diseases, cardiovascular diseases) in 34 low-income and lower-middle-income countries. Health services were included in the analysis if delivered at the primary care level and part of the Disease Control Priorities, 3rd edition “highest priority package.” Data were compiled from several publicly available sources, including national health accounts, household surveys, and the published literature. A risk of CHE, conditional on having disease, was modeled as depending on usage, captured through utilization indicators; affordability, captured via the level of public financing and OOP health service unit costs; and income. Results Across all countries, diseases, and health services, the risk of CHE (conditional on having a disease) would be concentrated among poorer quintiles (6.8% risk in quintile 1 vs. 1.3% in quintile 5 using a 10% CHE threshold). The risk of CHE would be higher for a few disease areas, including cardiovascular disease and mental/behavioral disorders (7.8% and 9.8% using a 10% CHE threshold), while lower risks of CHE were observed for lower cost services. Conclusions Insufficient FRP stands as a major barrier to achieving UHC, and risk of CHE is a major problem for health systems in low-income and lower-middle-income countries. Beyond its threat to the financial stability of households, CHE may also lead to worse health outcomes, especially among the poorest for whom both ill health and financial risk are most severe. Modeling the risk of CHE associated with specific disease areas and services can help policymakers set progressive health sector priorities. Decision-makers could explicitly include FRP as a criterion for consideration when assessing the health interventions for inclusion in national essential benefit packages.

Background: Financial risk protection is a core dimension of universal health coverage. Hardship financing, defined as borrowing and selling land or assets to pay for healthcare, is a measure of last recourse. Increasing indebtedness and high interest rates, particularly among unregulated money lenders, can lead to a vicious cycle of poverty and exacerbate inequity. Methods: To inform efforts to improve Cambodia's social health protection system we analyze 2019–2020 Cambodia Socio-economic Survey data to assess hardship financing, illness and injury related productivity loss, and estimate related economic impacts. We apply two-stage Instrumental Variable multiple regression to address endogeneity relating to net income. In addition, we calculate a direct economic measure to facilitate the regular monitoring and reporting on the devastating burden of excessive out-of-pocket expenditure for policy makers. Results: More than 98,500 households or 2.7% of the total population resorted to hardship financing over the past year. Factors significantly increasing risk are higher out-of-pocket healthcare expenditures, illness or injury related productivity loss, and spending of savings. The economic burden from annual lost productivity from illness or injury amounts to US$ 459.9 million or 1.7% of GDP. The estimated household economic cost related to hardship financing is US$ 250.8 million or 0.9% of GDP. Conclusions: Such losses can be mitigated with policy measures such as linking a catastrophic health coverage mechanism to the Health Equity Funds, capping interest rates on health-related loans, and using loan guarantees to incentivize microfinance institutions and banks to refinance health-related, high-interest loans from money lenders. These measures could strengthen social health protection by enhancing financial risk protection, mitigating vulnerability to the devastating economic effects of health shocks, and reducing inequities. [ABSTRACT FROM AUTHOR]

Abstract Background Non-communicable diseases (NCDs) can impose a substantial financial burden to households in the absence of an effective financial risk protection mechanism. The national health insurance fund (NHIF) has included NCD services in its national scheme. We evaluated the effectiveness of NHIF in providing financial risk protection to households with persons living with hypertension and/or diabetes in Kenya. Methods We carried out a prospective cohort study, following 888 households with at least one individual living with hypertension and/or diabetes for 12 months. The exposure arm comprised households that are enrolled in the NHIF national scheme, while the control arm comprised households that were not enrolled in the NHIF. Study participants were drawn from two counties in Kenya. We used the incidence of catastrophic health expenditure (CHE) as the outcome of interest. We used coarsened exact matching and a conditional logistic regression model to analyse the odds of CHE among households enrolled in the NHIF compared with unenrolled households. Socioeconomic inequality in CHE was examined using concentration curves and indices. Results We found strong evidence that NHIF-enrolled households spent a lower share (12.4%) of their household budget on healthcare compared with unenrolled households (23.2%) (p = 0.004). While households that were enrolled in NHIF were less likely to incur CHE, we did not find strong evidence that they are better protected from CHE compared with households without NHIF (OR = 0.67; p = 0.47). The concentration index (CI) for CHE showed a pro-poor distribution (CI: -0.190, p

Abstract Objective Universal health coverage (UHC) is a major pathway to save many people from catastrophic and impoverishing healthcare spending and address the inequality in health and healthcare. The objective of this paper is to assess the efficiency with which health systems in sub-Saharan Africa (SSA) are utilizing healthcare resources to progress towards achieving the UHC goal by 2030. Methods The study followed the guidelines proposed by the World Health Organization (WHO) and World Bank joint UHC monitoring framework and the computational operationalization approach proposed by Wagstaff et al. (2015) to estimate the UHC index for each of the 30 selected SSA countries. The bootstrapping output-oriented data envelopment analysis (DEA) was used to estimate the bias-corrected technical efficiency scores and examine the environmental factors that influence health system efficiency. Results The estimated UHC levels ranged from a minimum of 52% to a maximum of 81% $$(SD=8.6\%)$$ ( S D = 8.6 % ) with a median coverage of 66%. The average bias-corrected efficiency score was 0.81 $$\left(95\% CI:0.77-0.85\right)$$ 95 % C I : 0.77 - 0.85 . The study found that education, governance quality, public health spending, external health funding, and prepayment arrangements that pool funds for health had a positive significant effect on health system efficiency in improving UHC, while out-of-pocket payment had a negative impact. Conclusion The results show that health systems in SSA can potentially enhance UHC levels by at least 19% with existing healthcare resources if best practices are adopted. Policymakers should aim at improving education, good governance, and healthcare financing architecture to reduce out-of-pocket payments and over-reliance on donor funding for healthcare to achieve UHC.

Abstract Background In Ethiopia, out-of-pocket (OOP) payment is the key means of healthcare financing, and expenses on medicines are a crucial component of such payment. This study aims to investigate the financial implications of OOP payments on medicines for Ethiopian households. Methods The study involved a secondary data analysis of the national household consumption and expenditure surveys of 2010/11 and 2015/16. The "capacity-to-pay" method was used to calculate catastrophic OOP medicine expenditures. The extent of economic status related to catastrophic medicine payment inequity was calculated using concentration index estimation. The impoverishment consequences of OOP payment on medicine were estimated using poverty headcount and poverty gap analysis methods. Logistic regression models were used to identify the variables that predict catastrophic medicine payments. Results Medicines accounted for the majority of healthcare spending (> 65%) across the surveys. From 2010 to 2016, the total percentage of households facing catastrophic medicine payments decreased from 1% to 0.73%. However, the actual number of people expected to have experienced catastrophic medicine payments increased from 399,174 to 401,519 people. Payment for medicines pushed 11,132 households into poverty in 2015/16. The majority of disparities were explained by economic status, place of residence, and type of health services. Conclusion OOP payment on medicine accounted for the majority of total health expenses in Ethiopia. A high medicine OOP payment continued to push households into catastrophic payments and impoverishment. Household seeking inpatient care, those with lower economic status and urban residents were among the most affected. Hence, innovative approaches to improve the supply of medicines in public facilities especially those in urban settings and risk protection mechanisms for medicine expenditures particularly for inpatient care are recommended.

Background Ideally health insurance aims to provide financial security, promote social inclusion, and ensure equitable access to quality healthcare services for all households. Community-based health insurance has been operating in Ethiopia since 2011. However, its nationwide impact on universal health coverage has not yet been evaluated despite several studies being conducted. Objective We evaluated the impact of Ethiopia’s community-based health insurance (2012–2021) on universal health coverage. Methods On 27 August 2022, searches were conducted in Scopus, Hinari, PubMed, Google Scholar, and Semantic Scholar. Twenty-three studies were included. We used the Joana Briggs Institute checklists to assess the risk of bias. We included cross-sectional and mixed studies with low and medium risk. The data were processed in Microsoft Excel and analyzed using RevMan-5. The impact was measured first on insured households and then on insured versus uninsured households. We used a random model to measure the effect estimates (odds ratios) with a p value < 0.05 and a 95% CI. Results The universal health coverage provided by the scheme was 45.6% (OR = 1.92, 95% CI: 1.44–2.58). Being a member of the scheme increased universal health coverage by 24.8%. The healthcare service utilization of the beneficiaries was 64.5% (OR = 1.95, 95% CI: 1.29–2.93). The scheme reduced catastrophic health expenditure by 79.4% (OR = 4.99, 95% CI: 1.27–19.67). It yielded a 92% (OR = 11.58, 95% CI: 8.12–16.51) perception of health service quality. The health-related quality of life provided by it was 63% (OR = 1.71, 95% CI: 1.50–1.94). Its population coverage was 40.1% (OR = 0.64, 95% CI: 0.41–1.02). Conclusion Although the scheme had positive impacts on health service issues by reducing catastrophic costs, the low universal health coverage on a limited population indicates that Ethiopia should move to a broader national scheme that covers the entire population.

Background: Financial risk protection (FRP) is a key component of universal health coverage (UHC): all individuals must be able to obtain the health services they need without experiencing financial hardship. In many low-income and lower-middle-income countries, however, the health system fails to provide sufficient protection against high out-of-pocket (OOP) spending on health services. In 2018, OOP health spending comprised approximately 40% of current health expenditures in low-income and lower-middle-income countries. Methods: We model the household risk of catastrophic health expenditures (CHE), conditional on having a given disease or condition—defined as OOP health spending that exceeds a threshold percentage (10, 25, or 40%) of annual income—for 29 health services across 13 disease categories (e.g., diarrheal diseases, cardiovascular diseases) in 34 low-income and lower-middle-income countries. Health services were included in the analysis if delivered at the primary care level and part of the Disease Control Priorities, 3rd edition "highest priority package." Data were compiled from several publicly available sources, including national health accounts, household surveys, and the published literature. A risk of CHE, conditional on having disease, was modeled as depending on usage, captured through utilization indicators; affordability, captured via the level of public financing and OOP health service unit costs; and income. Results: Across all countries, diseases, and health services, the risk of CHE (conditional on having a disease) would be concentrated among poorer quintiles (6.8% risk in quintile 1 vs. 1.3% in quintile 5 using a 10% CHE threshold). The risk of CHE would be higher for a few disease areas, including cardiovascular disease and mental/behavioral disorders (7.8% and 9.8% using a 10% CHE threshold), while lower risks of CHE were observed for lower cost services. Conclusions: Insufficient FRP stands as a major barrier to achieving UHC, and risk of CHE is a major problem for health systems in low-income and lower-middle-income countries. Beyond its threat to the financial stability of households, CHE may also lead to worse health outcomes, especially among the poorest for whom both ill health and financial risk are most severe. Modeling the risk of CHE associated with specific disease areas and services can help policymakers set progressive health sector priorities. Decision-makers could explicitly include FRP as a criterion for consideration when assessing the health interventions for inclusion in national essential benefit packages. [ABSTRACT FROM AUTHOR]

Abstract Background Evidence on the effectiveness of community-based health insurance (CBHI) in low-income countries is inconclusive. This study assessed the impact of CBHI on health service utilization and financial risk protection in Ethiopia. Methods We conducted a comparative cross-sectional study nested within a larger national household survey in 2020. Data was collected from three groups of households—CBHI member households (n = 1586), non-member households from CBHI implementing woredas (n = 1863), and non-member households from non-CBHI implementing woredas (n = 789). Indicators of health service utilization, out-of-pocket health spending, catastrophic health expenditure, and impoverishment due to health spending among CBHI members were compared with non-members from CBHI implementing woredas and households from non-CBHI implementing woredas. Propensity score matching (PSM) was used to account for possible selection bias. Results The annual number of OPD visits per capita among CBHI member households was 2.09, compared to 1.53 among non-member households from CBHI woredas and 1.75 among households from non-CBHI woredas. PSM estimates indicated that CBHI members had 0.36 (95% CI: 0.25, 0.44) and 0.17 (95% CI: -0.04, 0.19) more outpatient department (OPD) visits per capita per year than their matched non-member households from CBHI-implementing and non-CBHI implementing woredas, respectively. CBHI membership resulted in a 28–43% reduction in annual OOP payments as compared to non-member households. CBHI member households were significantly less likely to incur catastrophic health expenditures (measured as annual OOP payments of more than 10% of the household’s total expenditure) compared to non-members (p

Background: Additional billing is commonly and legally practiced in some countries for patients covered by health insurance. However, knowledge and understanding of the additional billings are limited. This study reviews evidence on additional billing practices including definition, scope of practice, regulations and their effects on insured patients. Methods: A systematic search of the full-text papers that provided the details of balance billing for health services, written in English, and published between 2000 and 2021 was carried out in Scopus, MEDLINE, EMBASE and Web of Science. Articles were screened independently by at least 2 reviewers for eligibility. Thematic analysis was applied. Results: In total, 94 studies were selected for the final analysis. Most of the included articles (83%) reported findings from the United States (US). Numerous terms of additional billings were used across countries such as balance billing, surprise billing, extra billing, supplements and out-of-pocket (OOP) spending. The range of services incurred these additional bills also varied across countries, insurance plans, and healthcare facilities; the frequently reported were emergency services, surgeries, and specialist consultation. There were a few positive though more studies reported negative effects of the substantial additional bills which undermined universal health coverage (UHC) goals by causing financial hardship and reducing access to care. A range of government measures had been applied to mitigate these adverse effects, but some difficulties still exist. Conclusion: Additional billings varied in terms of terminology, definitions, practices, profiles, regulations, and outcomes. There were a set of policy tools aimed to control substantial billing to insured patients despite some limitations and challenges. Governments should apply multiple policy measures to improve financial risk protection to the insured population. [ABSTRACT FROM AUTHOR]

Background: Non-communicable diseases (NCDs) can impose a substantial financial burden to households in the absence of an effective financial risk protection mechanism. The national health insurance fund (NHIF) has included NCD services in its national scheme. We evaluated the effectiveness of NHIF in providing financial risk protection to households with persons living with hypertension and/or diabetes in Kenya. Methods: We carried out a prospective cohort study, following 888 households with at least one individual living with hypertension and/or diabetes for 12 months. The exposure arm comprised households that are enrolled in the NHIF national scheme, while the control arm comprised households that were not enrolled in the NHIF. Study participants were drawn from two counties in Kenya. We used the incidence of catastrophic health expenditure (CHE) as the outcome of interest. We used coarsened exact matching and a conditional logistic regression model to analyse the odds of CHE among households enrolled in the NHIF compared with unenrolled households. Socioeconomic inequality in CHE was examined using concentration curves and indices. Results: We found strong evidence that NHIF-enrolled households spent a lower share (12.4%) of their household budget on healthcare compared with unenrolled households (23.2%) (p = 0.004). While households that were enrolled in NHIF were less likely to incur CHE, we did not find strong evidence that they are better protected from CHE compared with households without NHIF (OR = 0.67; p = 0.47). The concentration index (CI) for CHE showed a pro-poor distribution (CI: -0.190, p < 0.001). Almost half (46.9%) of households reported active NHIF enrolment at baseline but this reduced to 10.9% after one year, indicating an NHIF attrition rate of 76.7%. The depth of NHIF cover (i.e., the share of out-of-pocket healthcare costs paid by NHIF) among households with active NHIF was 29.6%. Conclusion: We did not find strong evidence that the NHIF national scheme is effective in providing financial risk protection to households with individuals living with hypertension and/diabetes in Kenya. This could partly be explained by the low depth of cover of the NHIF national scheme, and the high attrition rate. To enhance NHIF effectiveness, there is a need to revise the NHIF benefit package to include essential hypertension and/diabetes services, review existing provider payment mechanisms to explicitly reimburse these services, and extend the existing insurance subsidy programme to include individuals in the informal labour market. [ABSTRACT FROM AUTHOR]

Background: In Ethiopia, out-of-pocket (OOP) payment is the key means of healthcare financing, and expenses on medicines are a crucial component of such payment. This study aims to investigate the financial implications of OOP payments on medicines for Ethiopian households. Methods: The study involved a secondary data analysis of the national household consumption and expenditure surveys of 2010/11 and 2015/16. The "capacity-to-pay" method was used to calculate catastrophic OOP medicine expenditures. The extent of economic status related to catastrophic medicine payment inequity was calculated using concentration index estimation. The impoverishment consequences of OOP payment on medicine were estimated using poverty headcount and poverty gap analysis methods. Logistic regression models were used to identify the variables that predict catastrophic medicine payments. Results: Medicines accounted for the majority of healthcare spending (> 65%) across the surveys. From 2010 to 2016, the total percentage of households facing catastrophic medicine payments decreased from 1% to 0.73%. However, the actual number of people expected to have experienced catastrophic medicine payments increased from 399,174 to 401,519 people. Payment for medicines pushed 11,132 households into poverty in 2015/16. The majority of disparities were explained by economic status, place of residence, and type of health services. Conclusion: OOP payment on medicine accounted for the majority of total health expenses in Ethiopia. A high medicine OOP payment continued to push households into catastrophic payments and impoverishment. Household seeking inpatient care, those with lower economic status and urban residents were among the most affected. Hence, innovative approaches to improve the supply of medicines in public facilities especially those in urban settings and risk protection mechanisms for medicine expenditures particularly for inpatient care are recommended. [ABSTRACT FROM AUTHOR]

Objective: Universal health coverage (UHC) is a major pathway to save many people from catastrophic and impoverishing healthcare spending and address the inequality in health and healthcare. The objective of this paper is to assess the efficiency with which health systems in sub-Saharan Africa (SSA) are utilizing healthcare resources to progress towards achieving the UHC goal by 2030. Methods: The study followed the guidelines proposed by the World Health Organization (WHO) and World Bank joint UHC monitoring framework and the computational operationalization approach proposed by Wagstaff et al. (2015) to estimate the UHC index for each of the 30 selected SSA countries. The bootstrapping output-oriented data envelopment analysis (DEA) was used to estimate the bias-corrected technical efficiency scores and examine the environmental factors that influence health system efficiency. Results: The estimated UHC levels ranged from a minimum of 52% to a maximum of 81% (S D = 8.6 %) with a median coverage of 66%. The average bias-corrected efficiency score was 0.81 95 % C I : 0.77 - 0.85 . The study found that education, governance quality, public health spending, external health funding, and prepayment arrangements that pool funds for health had a positive significant effect on health system efficiency in improving UHC, while out-of-pocket payment had a negative impact. Conclusion: The results show that health systems in SSA can potentially enhance UHC levels by at least 19% with existing healthcare resources if best practices are adopted. Policymakers should aim at improving education, good governance, and healthcare financing architecture to reduce out-of-pocket payments and over-reliance on donor funding for healthcare to achieve UHC. [ABSTRACT FROM AUTHOR]

Abstract Background Demographic and epidemiological transitions are changing the disease burden from infectious to noncommunicable diseases (NCDs) in low- and middle-income countries, including Bangladesh. Given the rising NCD-related health burdens and growing share of household out-of-pocket (OOP) spending in total health expenditure in Bangladesh, we compared the country’s trends and socioeconomic disparities in financial risk protection (FRP) among households with and without NCDs. Methods We used data from three recent waves of the Bangladesh Household Income and Expenditure Survey (2005, 2010, and 2016) and employed the normative food, housing (rent), and utilities method to measure the levels and distributions of catastrophic health expenditure (CHE) and impoverishing effects of OOP health expenditure among households without NCDs (i.e. non-NCDs only) and with NCDs (i.e. NCDs only, and both NCDs and non-NCDs). Additionally, we examined the incidence of forgone care for financial reasons at the household and individual levels. Results Between 2005 and 2016, OOP expenses increased by more than 50% across all households (NCD-only: USD 95.6 to 149.3; NCD-and-non-NCD: USD 89.5 to 167.7; non-NCD-only: USD 45.3 to 73.0), with NCD-affected families consistently spending over double that of non-affected households. Concurrently, CHE incidence grew among NCD-only families (13.5% to 14.4%) while declining (with fluctuations) among non-NCD-only (14.4% to 11.6%) and NCD-and-non-NCD households (12.9% to 12.2%). Additionally, OOP-induced impoverishment increased among NCD-only and non-NCD-only households from 1.4 to 2.0% and 1.1 to 1.5%, respectively, affecting the former more. Also, despite falling over time, NCD-affected individuals more frequently mentioned prohibiting treatment costs as the reason for forgoing care than the non-affected (37.9% vs. 13.0% in 2016). The lowest quintile households, particularly those with NCDs, consistently experienced many-fold higher CHE and impoverishment than the highest quintile. Notably, CHE and impoverishment effects were more pronounced among NCD-affected families if NCD-afflicted household members were female rather than male, older people, or children instead of working-age adults. Conclusions The lack of FRP is more pronounced among households with NCDs than those without NCDs. Concerted efforts are required to ensure FRP for all families, particularly those with NCDs.

Abstract Background Financial risk protection (FRP), defined as households’ access to needed healthcare services without experiencing undue financial hardship, is a critical health systems target, particularly in low- and middle-income countries (LMICs). Given the remarkable growth in FRP literature in recent times, we conducted a scoping review of the literature on FRP from out-of-pocket (OOP) health spending in LMICs. The objective was to review current knowledge, identify evidence gaps and propose future research directions. Methods We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines to conduct this scoping review. We systematically searched PubMed, Scopus, ProQuest and Web of Science in July 2021 for literature published since 1 January 2015. We included empirical studies that used nationally representative data from household surveys to measure the incidence of at least one of the following indicators: catastrophic health expenditure (CHE), impoverishment, adoption of strategies to cope with OOP expenses, and forgone care for financial reasons. Our review covered 155 studies and analysed the geographical focus, data sources, methods and analytical rigour of the studies. We also examined the level of FRP by disease categories (all diseases, chronic illnesses, communicable diseases) and the effect of health insurance on FRP. Results The extant literature primarily focused on India and China as research settings. Notably, no FRP study was available on chronic illness in any low-income country (LIC) or on communicable diseases in an upper-middle-income country (UMIC). Only one study comprehensively measured FRP by examining all four indicators. Most studies assessed (lack of) FRP as CHE incidence alone (37.4%) or as CHE and impoverishment incidence (39.4%). However, the LMIC literature did not incorporate the recent methodological advances to measure CHE and impoverishment that address the limitations of conventional methods. There were also gaps in utilizing available panel data to determine the length of the lack of FRP (e.g. duration of poverty caused by OOP expenses). The current estimates of FRP varied substantially among the LMICs, with some of the poorest countries in the world experiencing similar or even lower rates of CHE and impoverishment compared with the UMICs. Also, health insurance in LMICs did not consistently offer a higher degree of FRP. Conclusion The literature to date is unable to provide a reliable representation of the actual level of protection enjoyed by the LMIC population because of the lack of comprehensive measurement of FRP indicators coupled with the use of dated methodologies. Future research in LMICs should address the shortcomings identified in this review.

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

Abstract Background Although Ghana is lauded for its National Health Insurance Scheme (NHIS), concerns exist about the scheme’s functioning and sustainability. An often-cited issue—contributing to the scheme’s decreasing membership, long-standing financial deficit, and frequent out-of-pocket payments among members—is the large benefits package (BP). While, on paper, the BP covers over 95% of the conditions occurring in Ghana, its design was not informed by any budget analysis, nor any systematic prioritization of interventions. This paper aims to provide evidence-based input into ongoing discussions regarding a review of the NHIS benefits package. Methods An existing analytic framework is used to calculate net health benefit (NHB) for a range of interventions in order to assess their cost-effectiveness and enable the prioritization of ‘best buys’. The framework is expanded upon by incorporating concerns for financial protection, and practical feasibility, as well as the political economy challenges of disinvesting in currently funded activities. Five different options for the benefits package, each based on policy discourse in Ghana’s health sector, are presented and evaluated. Results Implementing all interventions for which data was available to 100% of the population in need was estimated to cost GH₵4323 million (US$994 million), while the available NHIS budget was only GH₵970 million (US$223 million). Options for the benefits package that focussed on cost-effectiveness and primary care provision achieved the best health outcomes, while options reflecting the status quo and allowing for co-payments included a higher number of healthcare interventions. Apart from the package option focussing on primary care, all packages were faced with physician shortages. Conclusions Current funding to the NHIS is insufficient to provide the historical benefits package, which promises to cover over 95% of disease conditions occurring in Ghana, to the total population. Shifting the NHIS focus from intervention coverage to population coverage is likely to lead to better health outcomes. A primary care package may be most feasible in the short-term, though additional physicians should be trained to provide higher-level care that is highly cost-effective, such as emergency neonatal care.

Financial risk protection (FRP), or the prevention of medical impoverishment, is a major objective of health systems, particularly in low- and middle-income countries where the extent of out-of-pocket (OOP) health expenditures can be substantial. We sought to develop a method that allows decision makers to explicitly integrate FRP outcomes into their priority-setting activities. We used literature review to identify 31 interventions in low- and middle-income countries, each of which provided measures of health outcomes, costs, OOP health expenditures averted, and FRP (proxied by OOP health expenditures averted as a percentage of income), all disaggregated by income quintile. We developed weights drawn from the Z-score of each quintile-intervention pair based on the distribution of FRP of all quintile-intervention pairs. We next ranked the interventions by unweighted and weighted health outcomes for each income quintile. We also evaluated how pro-poor they were by, first, ordering the interventions by cost-effectiveness for each quintile and, next, calculating the proportion of interventions each income quintile would be targeted for a given random budget. A ranking was said to be pro-poor if each quintile received the same or higher proportion of interventions than richer quintiles. Using FRP weights produced a more pro-poor priority setting than unweighted outcomes. Most of the reordering produced by the inclusion of FRP weights occurred in interventions of moderate cost-effectiveness, suggesting that these weights would be most useful as a way of distinguishing moderately cost-effective interventions with relatively high potential FRP. This preliminary method of integrating FRP into priority-setting would likely be most suitable to deciding between health interventions with intermediate cost-effectiveness. [ABSTRACT FROM AUTHOR]

Background: Evidence on the effectiveness of community-based health insurance (CBHI) in low-income countries is inconclusive. This study assessed the impact of CBHI on health service utilization and financial risk protection in Ethiopia. Methods: We conducted a comparative cross-sectional study nested within a larger national household survey in 2020. Data was collected from three groups of households—CBHI member households (n = 1586), non-member households from CBHI implementing woredas (n = 1863), and non-member households from non-CBHI implementing woredas (n = 789). Indicators of health service utilization, out-of-pocket health spending, catastrophic health expenditure, and impoverishment due to health spending among CBHI members were compared with non-members from CBHI implementing woredas and households from non-CBHI implementing woredas. Propensity score matching (PSM) was used to account for possible selection bias. Results: The annual number of OPD visits per capita among CBHI member households was 2.09, compared to 1.53 among non-member households from CBHI woredas and 1.75 among households from non-CBHI woredas. PSM estimates indicated that CBHI members had 0.36 (95% CI: 0.25, 0.44) and 0.17 (95% CI: -0.04, 0.19) more outpatient department (OPD) visits per capita per year than their matched non-member households from CBHI-implementing and non-CBHI implementing woredas, respectively. CBHI membership resulted in a 28–43% reduction in annual OOP payments as compared to non-member households. CBHI member households were significantly less likely to incur catastrophic health expenditures (measured as annual OOP payments of more than 10% of the household's total expenditure) compared to non-members (p < 0.01). Conclusion: CBHI membership increases health service utilization and financial protection. CBHI proves to be an important strategy for promoting universal health coverage. Implementing CBHI in all woredas and increasing membership among households in woredas that are already implementing CBHI will further expand its benefits. [ABSTRACT FROM AUTHOR]

Ideally health insurance aims to provide financial security, promote social inclusion, and ensure equitable access to quality healthcare services for all households. Community-based health insurance has been operating in Ethiopia since 2011. However, its nationwide impact on universal health coverage has not yet been evaluated despite several studies being conducted. We evaluated the impact of Ethiopia's community-based health insurance (2012–2021) on universal health coverage. On 27 August 2022, searches were conducted in Scopus, Hinari, PubMed, Google Scholar, and Semantic Scholar. Twenty-three studies were included. We used the Joana Briggs Institute checklists to assess the risk of bias. We included cross-sectional and mixed studies with low and medium risk. The data were processed in Microsoft Excel and analyzed using RevMan-5. The impact was measured first on insured households and then on insured versus uninsured households. We used a random model to measure the effect estimates (odds ratios) with a p value < 0.05 and a 95% CI. The universal health coverage provided by the scheme was 45.6% (OR = 1.92, 95% CI: 1.44–2.58). Being a member of the scheme increased universal health coverage by 24.8%. The healthcare service utilization of the beneficiaries was 64.5% (OR = 1.95, 95% CI: 1.29–2.93). The scheme reduced catastrophic health expenditure by 79.4% (OR = 4.99, 95% CI: 1.27–19.67). It yielded a 92% (OR = 11.58, 95% CI: 8.12–16.51) perception of health service quality. The health-related quality of life provided by it was 63% (OR = 1.71, 95% CI: 1.50–1.94). Its population coverage was 40.1% (OR = 0.64, 95% CI: 0.41–1.02). Although the scheme had positive impacts on health service issues by reducing catastrophic costs, the low universal health coverage on a limited population indicates that Ethiopia should move to a broader national scheme that covers the entire population. [ABSTRACT FROM AUTHOR]

While Australia’s health system has reached universal health coverage (UHC), recent scholarship points to its strengths and identifies ways it could be more effective and equitable, especially for tackling non-communicable diseases (NCDs). Building on the Australian experience, we add to these perspectives and present pertinent lessons for the quest towards UHC, and for policy-makers globally with regard to NCDs. Potential lessons include: the need for (i) vigilance – UHC requires ongoing monitoring and evaluation of not only financial risk protection but non-financial barriers and impacts such as forgone care; (ii) investment and action now on structural determinants of NCDs and related inequalities to avoid potentially higher (fiscal, social and health) costs in the longer term; and (iii) the opportunity for policy-makers globally and nationally to revisit their ambitions for UHC to include population health policies/programs beyond essential health services that are required for healthier, more equitable and thriving societies.

Abstract Background Sarcopenia was thought to be associated with adverse outcomes and will cause lots of health expenditure. But the relationship between sarcopenia and catastrophic health expenditure (CHE) had been little explored. Here, we examined the distribution of sarcopenia in relation to medical and payment burdens. Methods We used data from three waves of China Health and Retirement Longitudinal Study including 14 130 participants from 9077 households aged over 50 years old. Sarcopenia was operationalized according to the Asian Working Group for Sarcopenia 2019. Medical expenditure was obtained by self‐reported data, and CHE was identified by WHO definitions. We used the negative binomial regression model and logistic mixed‐effects models to examine the associations between sarcopenia and medical and CHE. Results A total of 14 130 participants [52.2% female, aged 60.8 (SD 9.3)] from 9077 households were included in this study. The prevalence of sarcopenia was 19.8%, 11.9% for moderate sarcopenia, and 7.9% for severe sarcopenia, respectively. We identified 1416 household CHE events in all three waves. Severe sarcopenia was associated with an increase in the number of inpatient visits [incidence rate ratio 1.31, 95% confidence interval (CI): 1.03–1.66, P = 0.03] and the risk of CHE (odds ratio: 1.04, 95% CI: 1.01–1.07, P

Abstract Background Under-five malaria in Nigeria is a leading cause of global child mortality, accounting for 95,000 annual child deaths. High out-of-pocket medical expenditure contributes to under-five malaria mortality by discouraging care-seeking and use of effective anti-malarials in the poorest households. The significant inequity in child health outcomes in Nigeria stresses the need to evaluate the outcomes of potential interventions across socioeconomic lines. Methods Using a decision tree model, an extended cost-effectiveness analysis was done to determine the effects of subsidies covering the direct and indirect costs of case management of under-five malaria in Nigeria. This analysis estimates the number of child deaths averted, out-of-pocket (OOP) expenditure averted, cases of catastrophic health expenditure (CHE) averted, and cost of implementation. An optimization analysis was also done to determine how to optimally allocate money across wealth groups using different combinations of interventions. Results Fully subsidizing direct medical, non-medical, and indirect costs could annually avert over 19,000 under-five deaths, 8600 cases of CHE, and US$187 million in OOP spending. Per US$1 million invested, this corresponds to an annual reduction of 76 under-five deaths, 34 cases of CHE, and over US$730,000 in OOP expenditure. Due to low initial treatment coverage in poorer socioeconomic groups, health and financial-risk protection benefits would be pro-poor, with the poorest 40% of Nigerians accounting for 72% of all deaths averted, 55% of all OOP expenditure averted, and 74% of all cases of CHE averted. Subsidies targeted to the poor would see greater benefits per dollar spent than broad, non-targeted subsidies. In an optimization scenario, the strategy of fully subsidizing direct medical costs would be dominated by a partial subsidy of direct medical costs as well as a full subsidy of direct medical, nonmedical, and indirect costs. Conclusion Subsidizing case management of under-five malaria for the poorest and most vulnerable would reduce illness-related impoverishment and child mortality in Nigeria while preserving limited financial resources. This study is an example of how focusing a targeted policy-intervention on a single, high-burden disease can yield large health and financial-risk protection benefits in a low and middle-income country context and address equity consideration in evidence-informed policymaking.

The growing burden of non-communicable diseases (NCDs) in low- and middle-income countries may have implications for health system performance in the area of financial risk protection, as measured by catastrophic health expenditure (CHE). We compare NCD CHE to the CHE cases caused by communicable diseases (CDs) across health systems to examine whether: (1) disease burden and CHE are linked, (2) NCD CHE disproportionately affects wealthier households and (3) whether the drivers of NCD CHE differ from the drivers of CD CHE. We used the Study on Global Aging and Adult Health survey, which captured nationally representative samples of 44 089 adults in China, Ghana, India, Mexico, Russia and South Africa. Using two-part regression and random forests, we estimated out-of-pocket spending and CHE by disease area. We compare the NCD share of CHE to the NCD share of disability-adjusted life years (DALYs) or years of life lost to disability and death. We tested for differences between NCDs and CDs in the out-of-pocket costs per visit and the number of visits occurring before spending crosses the CHE threshold. NCD CHE increased with the NCD share of DALYs except in South Africa, where NCDs caused more than 50% of CHE cases but only 30% of DALYs. A larger share of households incurred CHE due to NCDs in the lowest than the highest wealth quintile. NCD CHE cases were more likely to be caused by five or more health care visits relative to communicable disease CHE cases in Ghana (P = 0.003), India (P = 0.004) and China (P = 0.093). Health system attributes play a key mediating factor in how disease burden translates into CHE by disease. Health systems must target the specific characteristics of CHE by disease area to bolster financial risk protection as the epidemiological transition proceeds. [ABSTRACT FROM AUTHOR]

Background: Demographic and epidemiological transitions are changing the disease burden from infectious to noncommunicable diseases (NCDs) in low- and middle-income countries, including Bangladesh. Given the rising NCD-related health burdens and growing share of household out-of-pocket (OOP) spending in total health expenditure in Bangladesh, we compared the country's trends and socioeconomic disparities in financial risk protection (FRP) among households with and without NCDs. Methods: We used data from three recent waves of the Bangladesh Household Income and Expenditure Survey (2005, 2010, and 2016) and employed the normative food, housing (rent), and utilities method to measure the levels and distributions of catastrophic health expenditure (CHE) and impoverishing effects of OOP health expenditure among households without NCDs (i.e. non-NCDs only) and with NCDs (i.e. NCDs only, and both NCDs and non-NCDs). Additionally, we examined the incidence of forgone care for financial reasons at the household and individual levels. Results: Between 2005 and 2016, OOP expenses increased by more than 50% across all households (NCD-only: USD 95.6 to 149.3; NCD-and-non-NCD: USD 89.5 to 167.7; non-NCD-only: USD 45.3 to 73.0), with NCD-affected families consistently spending over double that of non-affected households. Concurrently, CHE incidence grew among NCD-only families (13.5% to 14.4%) while declining (with fluctuations) among non-NCD-only (14.4% to 11.6%) and NCD-and-non-NCD households (12.9% to 12.2%). Additionally, OOP-induced impoverishment increased among NCD-only and non-NCD-only households from 1.4 to 2.0% and 1.1 to 1.5%, respectively, affecting the former more. Also, despite falling over time, NCD-affected individuals more frequently mentioned prohibiting treatment costs as the reason for forgoing care than the non-affected (37.9% vs. 13.0% in 2016). The lowest quintile households, particularly those with NCDs, consistently experienced many-fold higher CHE and impoverishment than the highest quintile. Notably, CHE and impoverishment effects were more pronounced among NCD-affected families if NCD-afflicted household members were female rather than male, older people, or children instead of working-age adults. Conclusions: The lack of FRP is more pronounced among households with NCDs than those without NCDs. Concerted efforts are required to ensure FRP for all families, particularly those with NCDs. [ABSTRACT FROM AUTHOR]

Background: A limited benefit package for outpatient care in Chinese universal health coverage led to high out-of-pocket outpatient payments, and even medical impoverishment. The outpatient pooling fund model was introduced in China's Urban Employee Basic Medical Insurance to reduce cost-sharing for outpatient care. This study attempts to examine the dynamic effects of the outpatient pooling scheme on financial risk protection for its enrollees., Methods: A total of 18,097 individual-level observations covering 52 prefectures were extracted from six waves of China Health and Nutrition Survey (2000-2015). The difference-in-differences model with multiple periods and event study were employed to investigate the dynamic effects of reform on catastrophic health expenditure (CHE) and impoverishing health expenditure (IHE) and potential mechanisms., Results: Our results showed outpatient pooling scheme generated a significant effect on reducing the probability of incurring CHE (β = -0.004, 95% CI = -0.009 to -0.006) and IHE (β = -0.007, 95% CI = -0.012 to -0.001), especially for elderly people over 60 years old. The realization of this effect may depend on the reduction of outpatient cost-sharing, increased outpatient care utilization, as well as decreased inpatient care utilization after reform. However, event study found the effectiveness of outpatient pooling reducing CHE and IHE occurrences appeared to be weak even insignificant in more recent years relative to the initial years of policy implementation., Conclusions: Establishing an outpatient pooling system is effective to alleviate the financial risk caused by health expenditures in China. Optimising health service delivery aimed at enhancing health insurance purchasing efficiency are deemed imperative for sustaining the policy effectiveness., (© 2024 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

India has high rates of catastrophic health expenditure (CHE): 16% of Indian households incur CHE. To understand why CHE is so high, we conducted an in-depth analysis in the state of Odisha-a state with high rates of public sector facility use, reported eligibility for public insurance of 80%, and the provision of drugs for free in government-run facilities-yet with the second-highest rates of CHE across India (24%). We collected household data in 2019 representative of the state of Odisha and captured extensive information about healthcare seeking, including the facility type, its sector (private or public), how much was spent out-of-pocket, and where drugs were obtained. We employ Shapley decomposition to attribute variation in CHE and other financial hardship metrics to characteristics of healthcare, controlling for health and social determinants. We find that 36.3% (95% uncertainty interval: 32.7-40.1) of explained variation in CHE is attributed to whether a private sector pharmacy was used and the number of drugs obtained. Of all outpatient visits, 13% are with a private sector chemist, a similar rate as public primary providers (15%). Insurance was used in just 6% of hospitalizations and its use explained just 0.2% (0.1-0.4) of CHE overall. Eighty-six percent of users of outpatient care obtained drugs from the private sector. We estimate that eliminating spending on private drugs would reduce CHE by 56% in Odisha. The private sector for pharmaceuticals fulfills an essential health system function in Odisha-supplying drugs to the vast majority of patients. To improve financial risk protection in Odisha, the role currently fulfilled by private sector pharmacies must be considered alongside existing shortcomings in the public sector provision of drugs and the lack of outpatient care and drug coverage in public insurance programs. [ABSTRACT FROM AUTHOR]

Background: Financial risk protection (FRP), defined as households' access to needed healthcare services without experiencing undue financial hardship, is a critical health systems target, particularly in low- and middle-income countries (LMICs). Given the remarkable growth in FRP literature in recent times, we conducted a scoping review of the literature on FRP from out-of-pocket (OOP) health spending in LMICs. The objective was to review current knowledge, identify evidence gaps and propose future research directions.Methods: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines to conduct this scoping review. We systematically searched PubMed, Scopus, ProQuest and Web of Science in July 2021 for literature published since 1 January 2015. We included empirical studies that used nationally representative data from household surveys to measure the incidence of at least one of the following indicators: catastrophic health expenditure (CHE), impoverishment, adoption of strategies to cope with OOP expenses, and forgone care for financial reasons. Our review covered 155 studies and analysed the geographical focus, data sources, methods and analytical rigour of the studies. We also examined the level of FRP by disease categories (all diseases, chronic illnesses, communicable diseases) and the effect of health insurance on FRP.Results: The extant literature primarily focused on India and China as research settings. Notably, no FRP study was available on chronic illness in any low-income country (LIC) or on communicable diseases in an upper-middle-income country (UMIC). Only one study comprehensively measured FRP by examining all four indicators. Most studies assessed (lack of) FRP as CHE incidence alone (37.4%) or as CHE and impoverishment incidence (39.4%). However, the LMIC literature did not incorporate the recent methodological advances to measure CHE and impoverishment that address the limitations of conventional methods. There were also gaps in utilizing available panel data to determine the length of the lack of FRP (e.g. duration of poverty caused by OOP expenses). The current estimates of FRP varied substantially among the LMICs, with some of the poorest countries in the world experiencing similar or even lower rates of CHE and impoverishment compared with the UMICs. Also, health insurance in LMICs did not consistently offer a higher degree of FRP.Conclusion: The literature to date is unable to provide a reliable representation of the actual level of protection enjoyed by the LMIC population because of the lack of comprehensive measurement of FRP indicators coupled with the use of dated methodologies. Future research in LMICs should address the shortcomings identified in this review. [ABSTRACT FROM AUTHOR]

Background: Although Ghana is lauded for its National Health Insurance Scheme (NHIS), concerns exist about the scheme's functioning and sustainability. An often-cited issue—contributing to the scheme's decreasing membership, long-standing financial deficit, and frequent out-of-pocket payments among members—is the large benefits package (BP). While, on paper, the BP covers over 95% of the conditions occurring in Ghana, its design was not informed by any budget analysis, nor any systematic prioritization of interventions. This paper aims to provide evidence-based input into ongoing discussions regarding a review of the NHIS benefits package. Methods: An existing analytic framework is used to calculate net health benefit (NHB) for a range of interventions in order to assess their cost-effectiveness and enable the prioritization of 'best buys'. The framework is expanded upon by incorporating concerns for financial protection, and practical feasibility, as well as the political economy challenges of disinvesting in currently funded activities. Five different options for the benefits package, each based on policy discourse in Ghana's health sector, are presented and evaluated. Results: Implementing all interventions for which data was available to 100% of the population in need was estimated to cost GH₵4323 million (US$994 million), while the available NHIS budget was only GH₵970 million (US$223 million). Options for the benefits package that focussed on cost-effectiveness and primary care provision achieved the best health outcomes, while options reflecting the status quo and allowing for co-payments included a higher number of healthcare interventions. Apart from the package option focussing on primary care, all packages were faced with physician shortages. Conclusions: Current funding to the NHIS is insufficient to provide the historical benefits package, which promises to cover over 95% of disease conditions occurring in Ghana, to the total population. Shifting the NHIS focus from intervention coverage to population coverage is likely to lead to better health outcomes. A primary care package may be most feasible in the short-term, though additional physicians should be trained to provide higher-level care that is highly cost-effective, such as emergency neonatal care. [ABSTRACT FROM AUTHOR]

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

Universal health coverage (UHC) aims to provide access to health services for all without financial hardship. Moving toward UHC while ensuring financial risk protection (FRP) from out-of-pocket (OOP) health expenditures is a critical objective of the Sustainable Development Goal for Health. In tracking country progress toward UHC, analysts and policymakers usually report on two summary indicators of lack of FRP: the prevalence of catastrophic health expenditures (CHE) and the prevalence of impoverishing health expenditures. In this paper, we build on the CHE indicator: we examine the distribution (density) of health OOP budget share as a way to capture both the magnitude and dispersion in the ratio of households' OOP health expenditures relative to consumption or income at the population level. We illustrate our approach with country-specific examples using data from the World Health Organization's World Health Surveys. [ABSTRACT FROM AUTHOR]

This study aims at finding and analyzing the determinants of catastrophic health expenditure (CHE) and its impact on the household economy in Indonesia, using pooled cross section data from IFLS 2007 and 2014. The study used binary logit regression for analyzing the determinants of CHE and OLS regression to see the impact of CHE on household economy. It was found that the occupational status of the head of household, size of the household, age, ownership of insurance, visits to health centers, location of residence, and the interaction variable of educated household heads with chronic disease affect the occurrences of CHE with various threshold. The OLS regression results found that households who experienced CHE with a threshold of 10% and 40% made a reduction in their basic needs (food expenditure). It implies that households that experienced CHE also experienced economic shocks and they are eventually forced to reduce their basic needs (food expenditure) to meet health needs.

Background and Objectives: One of the most important 2015-post agendas of countries’ health systems is achieving Universal Health Coverage (UHC), so the countries should monitor the taken activities. Ths study aimed to investigate the Universal UHC status two years after Health Transformation Plan in Iran. Methods: Household Income and Expenditure Survey were used to estimate financial protection indicators in 2016. Estimation for service coverage index provided by international databases was applied at the country level. Indicators of financial protection and service coverage were evaluated in relation to each other using the World Health Organization joint levels assessment method, which indicates UHC attainment in terms of a plot with four zones. The relationship was estimated for the entire population, first quintile, and fifth quintile in 2000, 2017, and 2030. Results: About 15.85% of households endured catastrophic health expenditures at the 10% threshold. Accordingly, Iran is on the border between zones 1 and 2 in 2017 in terms of achieving UHC and will move to zone 1 in 2030 with the current trend. Conclusion: Iran did not attain UHC in 2000. It seems and has not achieved UHC in 2017 either. Even with improved service coverage, achieving UHC by 2030 may seem impossible with the current trends.

Universal Health Coverage (UHC) is a widely accepted objective among entities providing development assistance for health (DAH) and DAH recipient governments. One key metric to assess progress with UHC is financial risk protection, but empirical evidence on the extent to which DAH is associated to financial risk protection (and hence UHC) is scarce. Our sample is comprised of 65 countries whose DAH per capita is above the population -weighted average DAH per capita across all countries. The sample comprises of 1.7 million household observations, for the period 2000–2016. We run country and year fixed effects regressions, and pseudo-panel models, to assess the association between DAH and three measures of financial risk protection: catastrophic health expenditure (i.e., out-of-pocket health expenditures larger than 10% of total household expenditures ['CHE10%']), out-of-pocket health expenditure as a share of total expenditure ('OOP%'), and impoverishment due to health expenditures, at the 1.90US$ per day poverty line ('IMP190'). on average, DAH investment does not appear to be significantly associated with financial risk protection outcomes. However, we find suggestive evidence that a 1 US$ increase in DAH per capita is negatively associated (i.e., an improvement) with at least one financial risk protection outcome for the poorest household quintile within countries (in fixed effects models, IMP190: 0.05 percentage points, p < 0.1; in pseudo-panel models, CHE10%: 0.12 percentage points, p < 0.01). DAH is also negatively associated (i.e., an improvement) with most financial risk protection outcomes when it is largely channelled via government systems (i.e., when it is "on-budget") (CHE10%: 0.68 percentage points, p < 0.05). Several robustness checks confirm these results. DAH investments require careful planning to improve financial risk protection. For example, positive DAH effects for the poorest quintiles of the population might be driven by DAH targeting poorer populations and doing so effectively. Our results also suggest that channelling more resources via governments might be a promising avenue to enhance the impact of DAH on financial risk protection. • The association between health aid and financial risk protection is unexplored. • On average, health aid is not associated with financial risk protection (FRP). • Health aid is negatively associated with FRP outcomes when it is largely on-budget. • We find the same negative association for low income households. • These findings might be useful to health aid policymakers and stakeholders. [ABSTRACT FROM AUTHOR]

Tracers of health system equity, neglected tropical diseases (NTDs) disproportionately affect marginalized populations. NTDs that manifest on the skin – "skin NTDs" – are associated with scarring, disfigurement, physical disability, social exclusion, psychological distress, and economic hardship. To support development and evaluation of appropriate intervention strategies, we aimed to improve understanding of the role of economic factors in shaping and constituting the burden that skin NTDs place on households. We collected data in 2021 in two predominantly rural districts: Atwima Mponua in Ghana (where Buruli ulcer, yaws, and leprosy are endemic) and Kalu in Ethiopia (where cutaneous leishmaniasis and leprosy are endemic). We conducted interviews (n = 50) and focus group discussions (n = 14) that explored economic themes with affected individuals, caregivers, and community members and analysed the data thematically using a pre-defined framework. We found remarkable commonalities across countries and diseases. We developed a conceptual framework which illustrates skin NTDs' negative economic impact, including financial costs of care-seeking and reductions in work and schooling; categorises coping strategies by their degree of risk-pooling; and clarifies the mechanisms through which skin NTDs disproportionately affect the poorest. Despite health insurance schemes in both countries, wide-ranging, often harmful coping strategies were reported. Traditional healers were often described as more accessible, affordable and offering more flexible payment terms than formal health services, except for Ethiopia's well-established leprosy programme. Our findings are important in informing strategies to mitigate the skin NTD burden and identifying key drivers of household costs to measure in future evaluations. To reduce skin NTDs' impact on households' physical, mental, and economic wellbeing, intervention strategies should address economic constraints to prompt and effective care-seeking. While financial support and incentives for referrals and promotion of insurance enrolment may mitigate some constraints, structural interventions that decentralise care may offer more equitable and sustainable access to skin NTD care. • Neglected tropical diseases (NTDs) of the skin place an economic burden on households. • Costs influence care-seeking choices and encourage use of traditional healers. • Economic coping strategies used indicate inadequate financial risk protection. • Our conceptual framework describes the role of economic factors in the skin NTD burden. • Interventions must tackle economic factors inhibiting prompt and effective treatment. [ABSTRACT FROM AUTHOR]

While Australia's health system has reached universal health coverage (UHC), recent scholarship points to its strengths and identifies ways it could be more effective and equitable, especially for tackling non-communicable diseases (NCDs). Building on the Australian experience, we add to these perspectives and present pertinent lessons for the quest towards UHC, and for policy-makers globally with regard to NCDs. Potential lessons include: the need for (i) vigilance - UHC requires ongoing monitoring and evaluation of not only financial risk protection but non-financial barriers and impacts such as forgone care; (ii) investment and action now on structural determinants of NCDs and related inequalities to avoid potentially higher (fiscal, social and health) costs in the longer term; and (iii) the opportunity for policy-makers globally and nationally to revisit their ambitions for UHC to include population health policies/programs beyond essential health services that are required for healthier, more equitable and thriving societies. [ABSTRACT FROM AUTHOR]

Background: Kidney diseases constitute an important proportion of the non-communicable disease (NCD) burden in Sub-Saharan Africa (SSA), though prevention, diagnosis and treatment of kidney diseases are less prioritized in public health budgets than other high-burden NCDs. Dialysis is not considered cost-effective, and for those patients accessing the limited service available, high out-of-pocket expenses are common and few continue care over time. This study assessed challenges faced by nephrologists in SSA who manage patients needing dialysis. The specific focus was to investigate if and how physicians respond to bedside rationing situations.Methods: A survey was conducted among a randomly selected group of nephrologists from SSA. The questionnaire was based on a previously validated survey instrument. A descriptive and narrative approach was used for analysis.Results: Among 40 respondents, the majority saw patients weekly with acute kidney injury (AKI) or end-stage kidney failure (ESKF) in need of dialysis whom they could not dialyze. When dialysis was provided, clinical compromises were common, and 66% of nephrologists reported lack of basic diagnostics and medication and > 80% reported high out-of-pocket expenses for patients. Several patient-, disease- and institutional factors influenced who got access to dialysis. Patients' financial constraints and poor chances of survival limited the likelihood of receiving dialysis (reported by 79 and 78% of nephrologists respectively), while a patient's being the family bread-winner increased the likelihood (reported by 56%). Patient and institutional constraints resulted in most nephrologists (88%) frequently having to make difficult choices, sometimes having to choose between patients. Few reported existence of priority setting guidelines. Most nephrologists (74%) always, often or sometimes felt burdened by ethical dilemmas and worried about patients out of hospital hours. As a consequence, almost 46% of nephrologists reported frequently regretting their choice of profession and 26% had considered leaving the country.Conclusion: Nephrologists in SSA face harsh priority setting at the bedside without available guidance. The moral distress is high. While publicly funded dialysis treatment might not be prioritized in essential health care packages on the path to universal health coverage, the suffering of the patients, families and the providers must be acknowledged and addressed to increase fairness in these decisions. [ABSTRACT FROM AUTHOR]

China has been making efforts to establish a universal health care coverage system through multiple social health insurance schemes. As these insurance schemes cover different populations with different financing and reimbursement levels, large disparities remain in health care access and health outcomes among people covered. The government has launched an urban-rural integration policy for social health insurance to reduce disparities in access and health outcomes. We adopt a difference-in-differences propensity score matching approach to estimate the effects of this integration policy on health care utilization, financial risk protection, and health status, using nationally representative Chinese household survey data. The results show that the integration policy has significantly improved financial risk protection and self-assessed health of rural residents in China, which could be attributed to a decline in out-of-pocket payment. The low-income rural residents benefit most from this policy. There is no evidence that it has pronounced effects among urban residents. Greater efforts to increase reimbursement rates and to expand beneficiary populations could help to mitigate remaining urban-rural disparities. The findings in this study would contribute to a better understanding of the impacts of health insurance expansion in low- and middle-income countries. JEL code: I18, I10 [ABSTRACT FROM AUTHOR]

Introduction: Ghana implemented a National Health Insurance Scheme (NHIS) in 2003 as a step toward universal health coverage. We aimed to determine the effect of the NHIS on timeliness of care, mortality, and catastrophic health expenditure (CHE) among children with serious injuries at a trauma center in Ghana. Methods: We performed a retrospective cohort study of injured children aged 0.10). Uninsured children were more likely to have a delay in care for financial reasons (17.3 vs 6.4%, p

Background: Under-five malaria in Nigeria is a leading cause of global child mortality, accounting for 95,000 annual child deaths. High out-of-pocket medical expenditure contributes to under-five malaria mortality by discouraging care-seeking and use of effective anti-malarials in the poorest households. The significant inequity in child health outcomes in Nigeria stresses the need to evaluate the outcomes of potential interventions across socioeconomic lines. Methods: Using a decision tree model, an extended cost-effectiveness analysis was done to determine the effects of subsidies covering the direct and indirect costs of case management of under-five malaria in Nigeria. This analysis estimates the number of child deaths averted, out-of-pocket (OOP) expenditure averted, cases of catastrophic health expenditure (CHE) averted, and cost of implementation. An optimization analysis was also done to determine how to optimally allocate money across wealth groups using different combinations of interventions. Results: Fully subsidizing direct medical, non-medical, and indirect costs could annually avert over 19,000 under-five deaths, 8600 cases of CHE, and US$187 million in OOP spending. Per US$1 million invested, this corresponds to an annual reduction of 76 under-five deaths, 34 cases of CHE, and over US$730,000 in OOP expenditure. Due to low initial treatment coverage in poorer socioeconomic groups, health and financial-risk protection benefits would be pro-poor, with the poorest 40% of Nigerians accounting for 72% of all deaths averted, 55% of all OOP expenditure averted, and 74% of all cases of CHE averted. Subsidies targeted to the poor would see greater benefits per dollar spent than broad, non-targeted subsidies. In an optimization scenario, the strategy of fully subsidizing direct medical costs would be dominated by a partial subsidy of direct medical costs as well as a full subsidy of direct medical, nonmedical, and indirect costs. Conclusion: Subsidizing case management of under-five malaria for the poorest and most vulnerable would reduce illness-related impoverishment and child mortality in Nigeria while preserving limited financial resources. This study is an example of how focusing a targeted policy-intervention on a single, high-burden disease can yield large health and financial-risk protection benefits in a low and middle-income country context and address equity consideration in evidence-informed policymaking. [ABSTRACT FROM AUTHOR]

Objectives: Improving health and financial risk protection (FRP, the prevention of medical impoverishment) and their distributions is a major objective of national health systems. Explicitly describing FRP and disaggregated (eg, across socioeconomic groups) impact of health interventions in economic evaluations can provide decision makers with a broader set of health and financial outcomes to compare and prioritize interventions against each other.Methods: We propose methods to synthesize such a broader set of outcomes by estimating and comparing the distributions in both health and FRP benefits procured by health interventions. We build on benefit-cost analysis frameworks and utility-based models, and we illustrate our methods with the case study of universal public finance (financing by government regardless of whom an intervention is targeting) of disease treatment in a low- and middle-income country setting.Results: Two key findings seem to emerge: FRP is critical when diseases are less lethal (eg, case fatality rates <1% or so), and quantitative valuation of inequality aversion across income groups matters greatly. We recommend the use of numerous sensitivity analyses and that all distributional health and financial outcomes be first presented in a disaggregated form (before potential subsequent aggregation).Conclusions: Estimation approaches such as the one we propose provide explicit disaggregated considerations of equity, FRP, and poverty impact for the development of health sector policies, with high relevance for population-based preventive measures. [ABSTRACT FROM AUTHOR]

Abstract Background Malaria is a public health burden and a major cause for morbidity and mortality in Ethiopia. Malaria also places a substantial financial burden on families and Ethiopia’s national economy. Economic evaluations, with evidence on equity and financial risk protection (FRP), are therefore essential to support decision-making for policymakers to identify best buys amongst possible malaria interventions. The aim of this study is to estimate the expected health and FRP benefits of universal public financing of key malaria interventions in Ethiopia. Methods Using extended cost-effectiveness analysis (ECEA), the potential health and FRP benefits were estimated, and their distributions across socio-economic groups, of publicly financing a 10% coverage increase in artemisinin-based combination therapy (ACT), long-lasting insecticide-treated bed nets (LLIN), indoor residual spraying (IRS), and malaria vaccine (hypothetical). Results ACT, LLIN, IRS, and vaccine would avert 358, 188, 107 and 38 deaths, respectively, each year at a net government cost of $5.7, 16.5, 32.6, and 5.1 million, respectively. The annual cost of implementing IRS would be two times higher than that of the LLIN interventions, and would be the main driver of the total costs. The averted deaths would be mainly concentrated in the poorest two income quintiles. The four interventions would eliminate about $4,627,800 of private health expenditures, and the poorest income quintiles would see the greatest FRP benefits. ACT and LLINs would have the largest impact on malaria-related deaths averted and FRP benefits. Conclusions ACT, LLIN, IRS, and vaccine interventions would bring large health and financial benefits to the poorest households in Ethiopia.