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

Background: Financial risk protection and equity are two fundamental components of the global commitment to achieve Universal Health Coverage (UHC), which mandates health system reform based on population needs, disease incidence, and economic burden to ensure that everyone has access to health services without any financial hardship. We estimated disease-specific incidences of catastrophic out-of-pocket health expenditure and distress financing to investigate progress toward UHC financial risk indicators and investigated inequalities in financial risk protection indicators by wealth quintiles. In addition, we explored the determinants of financial hardship indicators as a result of hospitalization costs. Methods: In order to conduct this research, data were extracted from the latest Bangladesh Household Income and Expenditure Survey (HIES), conducted by the Bangladesh Bureau of Statistics in 2016–2017. Financial hardship indicators in UHC were measured by catastrophic health expenditure and distress financing (sale/mortgage, borrowing, and family support). Concentration curves (CC) and indices (CI) were estimated to measure the pattern and severity of inequalities across socio-economic classes. Binary logistic regression models were used to assess the determinants of catastrophic health expenditure and distress financing. Results: We found that about 26% of households incurred catastrophic health expenditure (CHE) and 58% faced distress financing on hospitalization in Bangladesh. The highest incidence of CHE was for cancer (50%), followed by liver diseases (49.2%), and paralysis (43.6%). The financial hardship indicators in terms of CHE (CI = -0.109) and distress financing (CI = -0.087) were more concentrated among low-income households. Hospital admission to private health facilities, non-communicable diseases, and the presence of chronic patients in households significantly increases the likelihood of higher UHC financial hardship indicators. Conclusions: The study findings strongly suggest the need for national-level social health security schemes with a particular focus on low-income households, since we identified greater inequalities between low- and high-income households in UHC financial hardship indicators. Regulating the private sector and implementing subsidized healthcare programmes for diseases with high treatment costs, such as cancer, heart disease, liver disease, and kidney disease are also expected to be effective to protect households from financial hardship. Finally, in order to reduce reliance on OOPE, the government should consider increasing its allocations to the health sector. [ABSTRACT FROM AUTHOR]

Introduction: Maternal delivery is the costliest event during pregnancy, especially if a complicated delivery occurs that requires emergency hospital services. A health financing scheme or program that covers comprehensive maternal services, including specialized hospital services in the benefits health package, enhances maternal survival and improves financial risk protection. Objectives: The objective of this study is to identify factors that enable the inclusion of comprehensive maternal services in the benefits package of emerging health financing schemes in low and middle-income countries across selected world regions. Comprehensive care is presumed if, in addition to normal delivery, primary health care, and secondary or tertiary hospital care are included. Methods: Multilevel regression analysis is performed on 220 health financing schemes and programs initiated during the period 1990–2014, in 40 countries in Sub-Saharan Africa, Asia, and Latin America. Findings: About two-thirds of emerging health financing schemes explicitly include maternal care in the benefits package, and less-than-half cover comprehensive maternal services. Provision of any type of maternal services and comprehensive services is significantly associated with the presence of donors/philanthropies as funders, and beneficiaries possessing an ID card that links them to entitled services. Other enabling factors are prepayment and risk pooling. However, private and community insurances are negatively associated with covering comprehensive maternal services, because they are subject to market failures, such as adverse and risk selection. Conclusions: Emerging health financing schemes in low and upper-middle-income countries lag in coverage of maternal care. Advancing financial protection of these services in the health package needs policy attention, including government oversight and mandatory regulations. The enabling factors identified can enrich the ongoing discourse on Universal Health Coverage. [ABSTRACT FROM AUTHOR]

We aimed to estimate the impact of a Community-Based Health Insurance (CBHI) scheme on utilization of healthcare from medically trained providers (MTP) by informal workers. A quasi-experimental study was conducted where insured households were included in the intervention group and uninsured households in comparison group. In total 1,292 (646 insured and 646 uninsured) households were surveyed from Chandpur district comprising urban and rural areas after 1 year period of CBHI introduction. Matching of the characteristics of insured and uninsured groups was performed using a propensity score matching approach to minimize the observed baseline differences among the groups. Multilevel logistic regression model, with adjustment for individual and household characteristics was used for estimating association between healthcare utilization from the MTP and insurance enrolment. The utilization of healthcare from MTP was significantly higher in the insured group (50.7%) compared to the uninsured group (39.4%). The regression analysis demonstrated that the CBHI beneficiaries were 2.111 (95% CI: 1.458–3.079) times more likely to utilize healthcare from MTP.CBHI scheme increases the utilization of MTP among informal workers. Ensuring such healthcare for these workers and their dependents is a challenge in many low and middle income countries. The implementation and scale-up of CBHI schemes have the potential to address this challenge of universal health coverage. [ABSTRACT FROM AUTHOR]

Background: Providing access to affordable health care for the informal sector remains a considerable challenge for low income countries striving to make progress towards universal health coverage. The objective of the study is to identify the factors shaping the decision to enroll in a cooperative based health scheme for informal workers in Bangladesh and also help to identify the features of informal workers without health schemes and their likelihood of being insured. Methods: Data were derived from a cross-sectional in-house survey within the catchment area of a cooperative based health scheme in Bangladesh during April–June 2014, covering a total of 784 households (458 members and 326 non-members). Multivariate logistic regression model was used to identify factors associated with cooperative based health scheme and explanatory variables. Findings: This study found that a number of factors were significant determinants of health scheme participation including sex of household head, household composition, occupational category as well as involvement social financial safety net programs. Conclusion: Findings from this study can be suggestive for policy-makers interested in scaling up health insurance for informal workers in Bangladesh. Shared funding from this large informal sector can generate new resources for healthcare, which is in line with the healthcare financing strategy of Bangladesh as well as the recommendation of the World Health Organization for developing social health insurance as part of the path to Universal Health Coverage. [ABSTRACT FROM AUTHOR]

Background: Equity in access to and utilization of healthcare is an important goal for any health system and an essential prerequisite for achieving Universal Health Coverage for any country.Objectives: This study investigated the extent to which health benefits are distributed across socioeconomic groups; and how different types of providers contribute to inequity in health benefits of Bangladesh.Methodology: The distribution of health benefits across socioeconomic groups was estimated using concentration indices. Health benefits from three types of formal providers were analysed (public, private and NGO providers), separated into rural and urban populations. Decomposition of concentration indices into types of providers quantified the relative contribution of providers to the overall distribution of benefits across socioeconomic groups. Eventually, the distribution of benefits was compared to the distribution of healthcare need (proxied by 'self-reported illness and symptoms') across socioeconomic groups. Data from the latest Household Income and Expenditure Survey, 2010 and WHO-CHOICE were used.Results: An overall pro-rich distribution of healthcare benefits was observed (CI = 0.229, t -value = 9.50). Healthcare benefits from private providers (CI = 0.237, t -value = 9.44) largely favoured the richer socioeconomic groups. Little evidence of inequity in benefits was found in public (CI = 0.044, t -value = 2.98) and NGO (CI = 0.095, t -value = 0.54) providers. Private providers contributed by 95.9% to overall inequity. The poorest socioeconomic group with 21.8% of the need for healthcare received only 12.7% of the benefits, while the richest group with 18.0% of the need accounted for 32.8% of the health benefits.Conclusion: Overall healthcare benefits in Bangladesh were pro-rich, particularly because of health benefits from private providers. Public providers were observed to contribute relatively slightly to inequity. The poorest (richest) people with largest (least) need for healthcare actually received lower (higher) benefits. When working to achieve Universal Health Coverage in Bangladesh, particular consideration should be given to ensuring that private sector care is more equitable. [ABSTRACT FROM AUTHOR]

Introduction: Reliance on out-of-pocket payment for healthcare may lead poor households to undertake catastrophic health expenditure, and risk-pooling mechanisms have been recommended to mitigate such burdens for households in Bangladesh. About 88% of the population of Bangladesh depends on work in the informal sector. We aimed to estimate willingness-to-pay (WTP) for CBHI and identify its determinants among three categories of urban informal workers rickshaw-pullers, shopkeepers and restaurant workers. Methods: The bidding game version of contingent valuation method was used to estimate weekly WTP. In three urban locations 557 workers were interviewed using a structured questionnaire during 2010 and 2011. Multiple-regression analysis was used to predict WTP by demographic and household characteristics, occupation, education level and past illness. Results: WTP for a CBHI scheme was expressed by 86.7% of informal workers. Weekly average WTP was 22.8 BDT [Bangladeshi Taka; 95% confidence interval (CI) 20.9–24.8] or 0.32 USD and varied significantly across occupational groups (p = 0.000) and locations (p = 0.003). WTP was highest among rickshaw-pullers (28.2 BDT or 0.40 USD; 95% CI: 24.7–31.7), followed by restaurant workers (20.4 BDT 0.29 USD; 95% CI: 17.0–23.8) and shopkeepers (19.2 BDT or 0.27 USD; 95% CI: 16.1–22.4). Multiple regression analysis identified monthly income, occupation, geographical location and educational level as the key determinants of WTP. WTP increased 0.196% with each 1% increase in monthly income, and was 26.9% lower among workers with up to a primary level of education versus those with higher than primary, but less than one year of education. Conclusion: Informal workers in urban areas thus are willing to pay for CBHI and socioeconomic differences explain the magnitude of WTP. The policy maker might think introducing community-based model including public-community partnership model for healthcare financing of informal workers. Decision making regarding the implementation of such schemes should consider worker location and occupation. [ABSTRACT FROM AUTHOR]

Background: Universal health coverage implies that people obtain the health services they need without experiencing financial hardship. While the factors contributing to catastrophic health expenditure (CHE) among households are well understood, few studies have examined this relationship in the context of environmentally vulnerable regions, such as tropical deltas. This study aims to examine the disparities in the prevalence of CHE and impoverishment due to out-of-pocket (OOP) healthcare payments in the Mekong Delta in comparison with rest of Vietnam. It also intends to investigate the associations between economic and environmental shocks, CHE and the impoverishment from healthcare payments. Methods: Using data from the Vietnam Household Living Standards Survey 2012, the prevalence of CHE was estimated from the fraction of healthcare costs in relation to household consumption expenditure. The poverty headcount was estimated using the total household consumption expenditure considering both with and without OOP expenditure for healthcare in comparison with the national poverty-line. Simple and multiple logistic regression models were used to examine the associations between geography, health systems, environmental and demographic variables and OOP healthcare expenditure related CHE, and impoverishment respectively. Results: Both the level of OOP household healthcare expenditure and the proportion of households suffering from impoverishment as the result of such payments were higher in the Mekong Delta region compared to rest of Vietnam. Although the results from the multiple regression analysis showed that households in the Mekong Delta region were significantly less likely to suffer from CHE, they were significantly more likely to be impoverished due to OOP healthcare expenditure. While health insurance membership did not have a significant effect on either outcomes, households that faced an economic or an environmental shock in past 5 years were considerably more likely to suffer from CHE and impoverishment from OOP healthcare payments. Conclusions: The findings suggest that the financial protection capacity of health insurance schemes in Vietnam should be improved and expanded to reduce impoverishment as the result of OOP healthcare payments, particularly in the Mekong Delta region. Additional investments in disaster preparedness strategies can further help to reduce the financial burden of households in this environmentally vulnerable region. [ABSTRACT FROM AUTHOR]