ArticlesHousehold catastrophic health expenditure: a multicountry analysis
Introduction
Health systems can deliver health services, preventive and curative, that can make a difference to peoples' health. However, accessing these services can lead to individuals having to pay catastrophic proportions of their available income and push many households into poverty. The potential impact of how health systems are financed on the wellbeing of households, particularly poor households, has affected the design of health systems and insurance mechanisms in countries as diverse as the USA, Australia, India, and Indonesia.1, 2, 3, 4, 5, 6 The protecting of people from catastrophic payments is widely accepted as a desirable objective of health policy.7, 8, 9, 10, 11, 12, 13 Catastrophic health expenditure is not always synonymous with high health-care costs.14 A large bill for surgery, for example, might not be catastrophic if a household does not bear the full cost because the service is provided free or at a subsidised price, or is covered by third-party insurance. On the other hand, even small costs for common illnesses can be financially disastrous for poor households with no insurance cover.
Little, however, is known about which health-system characteristics protect households from catastrophic payments, or the factors that lead some households to face such payments while others are protected. Most of the limited evidence comes from case studies. For example, in two US studies,15, 16 households headed by older people, people with disabilities, the unemployed, or poor people, and those with reduced access to health insurance were more likely to be affected than other households.
In Georgia, the results of a survey undertaken after the transition to a decentralised, market-driven system showed that 19% of households seeking care had to borrow money or sell personal items to pay, and that 16% were unable to afford the medications prescribed.17 The characteristics of the households were not reported. In Thailand, the poor have been reported as more likely to have to pay for health services from their own household income than richer people, which, when combined with lower incomes, places these people at higher risk of catastrophic health payments.18, 19
In designing their health systems, policy makers need to understand whether any characteristics make people more vulnerable to catastrophic payments. Knowledge is also necessary of which households are more vulnerable for any set of system characteristics. We aimed to quantify the extent of catastrophic payments and explore the conditions under which they are most likely to occur, taking advantage of the increasing number of available household income and expenditure surveys.
Section snippets
Household assessments
Health spending is taken to be catastrophic when a household must reduce its basic expenditure over a period of time to cope with health costs,14 but there is no consensus on the threshold proportion of household expenditure. In past studies,14,20 the threshold has varied from 5% to 20% of total household income. We used a higher threshold of payments of at least 40% of a household's capacity of pay.
A household's capacity to pay is defined as effective income remaining after basic subsistence
Results
We considered 65 surveys for inclusion; six surveys did not meet the inclusion criteria and were excluded, leaving 59 for analysis. Table 1 provides a summary of the years, type, sample size, and key attributes of the included surveys. Some national surveys were part of international survey initiatives or were part of continuing national survey programmes including the Living Standards Measurement Studies, Household Budget Surveys, and Household Income and Expenditure Surveys. All surveys
Discussion
The results, although powerful, should be interpreted in view of several qualifications. For example, no information on the distribution of payments within households was available, so some members of households without catastrophic expenditure could, individually, be placed at financial risk because of health payments. On the other hand, although financial transfers between households are captured in the survey data, some non-financial transfers that might enable households to survive the
References (30)
- et al.
A comparative analysis of Australian health policy in the 1970s
Soc Sci Med
(1984) - et al.
The poor pay more: health-related inequality in Thailand
Soc Sci Med
(1997) - et al.
Decomposing social indicators using distributional data
J Econ
(1997) - RR Bovbjerg, Covering catastrophic health care and containing costs: preliminary lessons for policy from the US...
- et al.
Social risk management options for medical care in Indonesia
Health Econ
(2002) Reduction of catastrophic health care expenditures by a community-based health insurance scheme in Gujarat, India: current experiences and challenges
Bull World Health Organ
(2002)- et al.
The medicare catastrophic coverage act: a post mortem
Health Affairs
(1990) - et al.
Strategies for insuring catastrophic illness: financial burden, prototype plans, and cost estimates—report to DHHS
(1983) - et al.
Weak links in the chain II: a prescription for health policy in poor countries
World Bank Res Observer
(2002) - et al.
Preventing impoverishment through protection against catastrophic health expenditure
Bull World Health Organ
(2002)
Public spending on health care: how are different criteria related?
Health Policy
User fee policies to promote health service access for poor: a wolf in sheep's clothing?
Int J Health Services
The world health report 2000: health systems: improving performance
The World Health Report 2001: mental health—new understanding, new hope
The World Health Report 2002
Cited by (1540)
The association between dual sensory loss and healthcare expenditure: Mediating effect of depression
2024, Journal of Affective DisordersMeasuring health care access and its inequality: A decomposition approach
2024, Economic ModellingCatastrophic health expenditure and health-related quality of life among older adults in Shandong, China: the moderation effect of daily care by adult children
2024, International Journal for Equity in HealthRural‒urban disparities in household catastrophic health expenditure in Bangladesh: a multivariate decomposition analysis
2024, International Journal for Equity in HealthThe optimal co-insurance rate for outpatient drug expenses of Iranian health insured based on the data mining method
2024, International Journal for Equity in Health