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Background Monitoring the incidence and intensity of catastrophic health expenditure, as well as the impoverishing effects of out of pocket costs to access healthcare, is a key part of benchmarking Kenya’s progress towards reducing the financial burden that households experience when accessing healthcare. Methods The study relies on data from the nationally-representative Kenya Household Expenditure and Utilization Survey conducted in 2013 ( n =33,675). We undertook health equity analysis to estimate the incidence and intensity of catastrophic expenditure. Households were considered to have incurred catastrophic expenditures if their annual out of-pocket health expenditures exceeded 40% of their annual non-food expenditure. We assessed the impoverishing effects of out of pocket payments using the Kenya national poverty line. We distinguished between direct payments for healthcare such as payments for consultation, medicines, medical procedures, and total healthcare expenditure that includes direct healthcare payments and the cost of transportation to and from health facilities. We used logistic regression analysis to explore the factors associated with the incidence of catastrophic expenditures. Results When only direct payments to healthcare providers were considered, the incidence of catastrophic expenditures was 4.52%. When transport costs are included, the incidence of catastrophic expenditure increased to 6.58%. 453,470 Kenyans are pushed into poverty annually as a result of direct payments for healthcare. When the cost of transport is included, that number increases by more than one third to 619,541. Unemployment of the household head, presence of an elderly person, a person with a chronic ailment, a large household size, lower household social-economic status, and residence in marginalized regions of the country are significantly associated with increased odds of incurring catastrophic expenditures. Conclusions Kenyan policy makers should prioritize extending pre-payment mechanisms to more vulnerable groups, specifically the poor, the elderly, those suffering from chronic ailments and those living in marginalized regions of the country. The range of services covered under these mechanisms should also be extended such that the proportion of direct costs paid to access care is reduced. Policy makers should also prioritize reducing supply side bottlenecks such as availability of healthcare facilities in close proximity to the population, especially in rural and marginalized areas, and improvements in quality of care. For the poor and the vulnerable, initiatives to cover the cost of transport to and from a health facility, such as transport vouchers could also be explored.

Background Thailand, an upper-middle income country, has demonstrated exemplary outcomes of Universal Health Coverage (UHC). The country achieved full population coverage and a high level of financial risk protection since 2002, through implementing three public health insurance schemes. UHC has two explicit goals of improved access to health services and financial protection where use of these services does not create financial hardship. Prior studies in Thailand do not provide evidence of long-term UHC financial risk protection. This study assessed financial risk protection as measured by the incidence of catastrophic health spending and impoverishment in Thai households prior to and after UHC in 2002. Methods We used data from a 15-year series of annual national household socioeconomic surveys (SES) between 1996 and 2015, which were conducted by the National Statistic Office (NSO). The survey covered about 52,000 nationally representative households in each round. Descriptive statistics were used to assess the incidence of catastrophic payment as measured by the share of out-of-pocket payment (OOP) for health by households exceeding 10 and 25% of household total consumption expenditure, and the incidence of impoverishment as determined by the additional number of non-poor households falling below the national and international poverty lines after making health payments. Results Using the 10% threshold, the incidence of catastrophic spending dropped from 6.0% in 1996 to 2% in 2015. This incidence reduced more significantly when the 25% threshold was applied from 1.8 to 0.4% during the same period. The incidence of impoverishment against the national poverty line reduced considerably from 2.2% in 1996 to approximately 0.3% in 2015. When the international poverty line of US$ 3.1 per capita per day was applied, the incidence of impoverishment was 1.4 and 0.4% in 1996 and 2015 respectively; and when US$ 1.9 per day was applied, the incidence was negligibly low. Conclusion The significant decline in the incidence of catastrophic health spending and impoverishment was attributed to the deliberate design of Thailand’s UHC, which provides a comprehensive benefits package and zero co-payment at point of services. The well-founded healthcare delivery system and favourable benefits package concertedly support the achievement of UHC goals of access and financial risk protection.

Context: In India, health care is a local good, and households are the major source of financing it. Earlier studies have examined diverse determinants of health care spending, but no attempt has been made to understand the geographical variation in household and catastrophic health spending. We used multilevel modeling to assess the relative importance of villages, districts, and states to health spending in India. Methods: We used data on the health expenditures of 101,576 households collected in the consumption expenditure schedule (68th round) carried out by the National Sample Survey in 2011-2012. We examined 4 dependent variables: per-capita health spending (PHS), per-capita institutional health spending (PIHS), per-capita noninstitutional health spending (PNHS), and catastrophic health spending (CHS). CHS was defined as household health spending exceeding 40% of its capacity to pay. We used multilevel linear regression and logistic models to decompose the variation in each outcome by state, region, district, village, and household levels. Findings: The average PHS was 1,331 Indian rupees (INR), which varied by state-level economic development. About one-fourth of Indian households incurred CHS, which was equally high in both the economically developed and poorer states. After controlling for household level factors, 77.1% of the total variation in PHS was attributable to households, 10.1% to states, 9.5% to villages, 2.6% to districts, and 0.7% to regions. The pattern in variance partitioning was similar for PNHS. The largest interstate variation was found for CHS (15.9%), while the opposite was true for PIHS (3.2%). Conclusions: We observed substantial variations in household health spending at the state and village levels compared with India's districts and regions. The large variation in CHS attributable to states indicates interstate inequality in the accessibility to and cost of health care. Our findings suggest that contextual factors at the macro and micro political units are important to reduce India's household health spending and CHS.

Background Many low and middle income countries are implementing reforms to support Universal Health Coverage (UHC). Perhaps one of the most ambitious examples of this is Indonesia’s national health scheme known as the JKN which is designed to make health care available to its entire population of 255 million by end of 2019. If successful, the JKN will be the biggest single payer system in the world. While Indonesia has made steady progress, around a third of its population remains without cover and out of pocket payments for health are widespread even among JKN members. To help close these gaps, especially among the poor, the Indonesian government is currently implementing a set of UHC policy reforms that include the integration of remaining government insurance schemes into the JKN, expansion of provider networks, restructuring of provider payments systems, accreditation of all contracted health facilities and a range of demand side initiatives to increase insurance uptake, especially in the informal sector. This study evaluates the equity impact of this latest set of UHC reforms. Methods Using a before and after design, we will evaluate the combined effects of the national UHC reforms at baseline (early 2018) and target of JKN full implementation (end 2019) on: progressivity of the health care financing system; pro-poorness of the health care delivery system; levels of catastrophic and impoverishing health expenditure; and self-reported health outcomes. In-depth interviews with stakeholders to document the context and the process of implementing these reforms, will also be undertaken. Discussion As countries like Indonesia focus on increasing coverage, it is critically important to ensure that the poor and vulnerable - who are often the most difficult to reach – are not excluded. The results of this study will not only help track Indonesia’s progress to universalism but also reveal what the UHC-reforms mean to the poor.

Background Many countries have introduced health insurance schemes to accelerate progress toward Universal Health Coverage (UHC) and improve access to healthcare. However, limited awareness of catastrophic health expenditures and the risk of impoverishment from healthcare costs may hinder enrollment. In Tanzania, these gaps underscore the importance of financial health risk protection education as a strategy to enhance insurance knowledge and enrollment willingness, especially among rural households. Objective To measure the effect of financial health risk protection education on knowledge and willingness to enroll in health insurance among rural households in Tanzania. Methods The study was a cluster-randomized controlled trial. Total of 560 household heads were assigned randomly to a control or intervention group (280 in each group). A questionnaire was used to collect data. Intervention group received education for 1 month then was followed for 2 months. Outcomes measured were change in knowledge on financial health risk protection, health insurance for all and willingness to enroll. Logistic regression was conducted to establish a relationship between knowledge and willingness to enroll. Results The odds of knowledge about financial health risk protection and health insurance for all increased substantially in the intervention households at endline compared to baseline. Participants in the intervention group were two times more likely to have adequate knowledge about financial health risk protection at the endline compared to the baseline study [(OR = 0.478, p  = 0.005) baseline to (OR = 2.3, p  < 0.0001) endline]. Similarly, participants in the intervention group were more likely to have adequate knowledge about health insurance at the endline compared to the baseline study [(OR = 0.20, p  = 0.29) baseline to (OR = 1.4, p  < 0.0001) endline]. The odds of willingness to enroll in health insurance increased two times more in the intervention households at the endline compared to the baseline study [(OR=-0.28, p  = 0.18) baseline to (AOR = 2.2, p  < 0.0001) endline]. Conclusion Financial health risk protection education significantly improved knowledge and willingness to enroll in health insurance among rural households, demonstrating its potential to promote insurance uptake. Scaling up such educational interventions in rural Tanzania is recommended to address knowledge gaps, enhance enrollment, and advance progress toward Universal Health Coverage. Trial registration The trial was registered on 11th April 2023, with registry number PACTR202304503715724, Clinical trial number not applicable.

PurposeThe purpose of this study is to examine the effect of financial burden, using objective and subjective indicators, on the health-related quality of life (HRQOL) in lung cancer patients.MethodA total of 227 patients diagnosed with lung cancer (from the inpatient unit of the department of internal medicine-chest oncology, in Shanghai Chest Hospital, China) participated in the study. Financial information was measured by direct medical costs, direct nonmedical costs, healthcare-cost-to-income ratio, and perceived financial difficulty. HRQOL was measured using the Functional Assessment of Cancer Therapy-Lung (FACT-L) scale.FindingsCatastrophic health spending, defined as a healthcare-cost-to-income ratio of more than 40%, was reported in 72.7% of the participants, whereas 37.0% reported that healthcare costs exceeded annual household income. Financial difficulty was perceived in 83.7% of the participants. Patients whose healthcare costs exceeded their annual household income and who perceived financial difficulty reported a clinically meaningful difference in overall HRQOL (> 6 points on the FACT-L) compared with participants without catastrophic health spending or perceived financial difficulty. Healthcare costs did not show a significant effect on HRQOL.ConclusionHealthcare costs exceeding total annual household income and perceived financial difficulty are associated with poorer HRQOL in lung cancer patients. Subjective indicator of financial burden has a stronger effect on quality of life than objective indicators.ImplicationHealth-cost-to-income ratio and perceived financial difficulty can be implied as objective and subjective indicators of financial burden to identify the patients who may need additional assistance. Communication on deciding on cost-effective treatments can be facilitated.

Background Despite the global target of 80% glycemic control among people diagnosed with diabetes in 2030, diabetes treatment coverage and control rate were still low. Diabetes imposes a substantial economic burden on health systems, patients, and their families. Due to low health insurance coverage in developing countries, the expenses related to diabetes care often result in significant out-of-pocket costs for patients. Objective To assess the level of out–of–pocket expenditure and the effect of community-based health insurance (CBHI) on out-of-pocket (OOP) expenditure among diabetic patients on follow-up at Hawassa Comprehensive Specialized Hospital, Sidama region. Method A facility-based comparative cross-sectional was conducted among 314 randomly selected adult type 2 diabetics. Kobo Collect app and SPSS version 26 were used data collection and analysis respectively. Independent sample t-test and linear regression were used to compare OOP expenses between CBHI members and non-members, and assess the association between CBHI-enrollment and OOP expenses. Result The average monthly household expenditure among participants was 6,471.52 Ethiopian Birr (ETB) (SD ± 3,275.47). Of which, average monthly costs of 3,568.55 ETB for food and 2,902.97 ETB for non-food items. The average monthly expenditure for diabetic illness was 2,046.00 ETB (SD ± 3,173.50), of which 869.67 ETB (42.5%) were direct medical costs. Regarding incidence and severity of catastrophic health expenditure (CHE), 82.5% of patients faced CHE at the 10% threshold, while only 27.4% did so at the 40% threshold. The intensity of OOP was 67 (43.2%), and 120 (75.5%) among CBHI members and non-members, respectively ( p  = 0.000). The CBHI enrollment is significantly associated with a reduction in OOP expenses, with a coefficient of -499.410 ( p  = 0.000). Similarly, age and occupation of participants were associated with lower OOP expenses, with a coefficient of -8.756 ( p  = 0.028) and − 58.221 ( p  = 0.002), respectively. Educational status of participants was associated with higher OOP expenses, with a coefficient of 104.416 ( p  = 0.004). However, marital status, household size, and wealth percentile group did not have a significant effect on OOP expenses among diabetic patients. Conclusion A significant proportion of diabetes patients experienced CHE. Enrollment in CBHI lowered OOP costs and reduced CHE. But there are still gaps in CBHI coverage, especially when it comes to the lowest and middle wealth quantiles. To enhance CBHI effectiveness, it is important to prioritize rural and low-income households to reduce financial strain. Introduce a subsidy program to make diabetes medications more affordable for uninsured households. Incorporate beneficiary feedback to refine policies and address the diverse needs of enrollees. Future research to evaluate the long-term impacts of CBHI on diabetic patient expenses on household financial stability by involving hospitals from rural and urban sectors is important to better understand the effect of CBHI on OOP expense and catastrophic health expenditure in the region.

Background Estimates of catastrophic health expenditure (CHE) are counterintuitive to researchers, policy makers, and developmental partners due to data and methodological limitation. While inferences drawn from use of capacity-to-pay (CTP) and budget share (BS) approaches are inconsistent, the non-availability of data on food expenditure in the health survey in India is an added limitation. Methods Using data from the health and consumption surveys of National Sample Surveys over 14 years, we have overcome these limitations and estimated the incidence and intensity of CHE and impoverishment using the CTP approach. Results The incidence of CHE for health services in India was 12.5% in 2004, 13.4% in 2014 and 9.1% by 2018. Among those households incurring CHE, they spent 1.25 times of their capacity to pay in 2004 (intensity of CHE), 1.71 times in 2014 and 1.31 times by 2018. The impoverishment due to health spending was 4.8% in 2004, 5.1% in 2014 and 3.3% in 2018. The state variations in incidence and intensity of CHE and incidence of impoverishment is large. The concentration index (CI) of CHE was − 0.16 in 2004, − 0.18 in 2014 and − 0.22 in 2018 suggesting increasing inequality over time. The concentration curves based on CTP approach suggests that the CHE was concentrated among poor. The odds of incurring CHE were lowest among the richest households [OR 0.22; 95% CI: 0.21, 0.24], households with elderly members [OR 1.20; 95% CI:1.12, 1.18] and households using both inpatient and outpatient services [OR 2.80, 95% CI 2.66, 2.95]. Access to health insurance reduced the chance of CHE and impoverishment among the richest households. The pattern of impoverishment was similar to that of CHE. Conclusion In the last 14 years, the CHE and impoverishment in India has declined while inequality in CHE has increased.

Background Out-of-pocket expenditure (OOPE) and catastrophic health expenditure (CHE) on institutional deliveries in India impose significant financial burdens, disproportionately affecting socio-economically vulnerable populations and regions despite various policy interventions. Purpose This study evaluates the extent of OOPE and CHE associated with institutional deliveries across Indian states and analyse regional variations using data from National Family Health Survey -5 (2019–21). Results The findings reveal substantial inter-state and regional disparities in mean OOPE and CHE incidence, with socioeconomic and healthcare system factors significantly influencing these outcomes. Conclusion Effective interventions to reduce OOPE and CHS on deliveries can significantly improve maternal and child health outcomes thereby achieving healthcare equity in the country. Significance The study underscores the critical need for targeted policy measures to alleviate financial hardships during institutional deliveries, advancing equitable access to maternal healthcare services in India.

Background Economic burden to households due to out-of-pocket expenditure (OOPE) is large in many Asian countries. Though studies suggest increasing household poverty due to high OOPE in developing countries, studies on association of multidimensional poverty and household health spending is limited. This paper tests the hypothesis that the multidimensionally poor are more likely to incur catastrophic health spending cutting across countries. Data and methods Data from the Poverty and Vulnerability Assessment (PVA) Survey carried out by the International Center for Integrated Mountain Development (ICIMOD) has been used in the analyses. The PVA survey was a comprehensive household survey that covered the mountainous regions of India, Nepal and Myanmar. A total of 2647 households from India, 2310 households in Nepal and 4290 households in Myanmar covered under the PVA survey. Poverty is measured in a multidimensional framework by including the dimensions of education, income and energy, water and sanitation using the Alkire and Foster method. Health shock is measured using the frequency of illness, family sickness and death of any family member in a reference period of one year. Catastrophic health expenditure is defined as 40% above the household’s capacity to pay. Results Results suggest that about three-fifths of the population in Myanmar, two-fifths of the population in Nepal and one-third of the population in India are multidimensionally poor. About 47% of the multidimensionally poor in India had incurred catastrophic health spending compared to 35% of the multidimensionally non-poor and the pattern was similar in both Nepal and Myanmar. The odds of incurring catastrophic health spending was 56% more among the multidimensionally poor than among the multidimensionally non-poor [95% CI: 1.35-1.76]. While health shocks to households are consistently significant predictors of catastrophic health spending cutting across country of residence, the educational attainment of the head of the household is not significant. Conclusion The multidimensionally poor in the poorer regions are more likely to face health shocks and are less likely to afford professional health services. Increasing government spending on health and increasing households’ access to health insurance can reduce catastrophic health spending and multidimensional poverty.