The distribution of household financial contributions to the health system: A look outside Latin America and the Caribbean

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1 The distribution of household financial contributions to the health system: A look outside Latin America and the Caribbean Priyanka Saksena and Ke Xu 3 November, 2008 Santiago 1 The distribution of household financial contributions to the health system: A look outside Latin America 3 November, 2008

2 Outline Health financing mechanisms Measures of the distribution of out-of-pocket health payments General trends in health financing By region By economy size By health financing system Highlights 2 The distribution of household financial contributions to the health system: A look outside Latin America 3 November, 2008

3 Health Financing Mechanisms Financing mechanisms Tax-based financing Financing sources 1. General tax or other revenue External resource Health care services Social health insurance Other prepayment schemes 2. Payroll tax 3. Contribution or premium Household Out-of-pocket payments 4. Direct payment 3 The distribution of household financial contributions to the health system: A look outside Latin America 3 November, 2008

4 Measures of OOP distribution Theoretical bases Distribution measure Threshold measure Policy concern Policy application Income Approach Progressivity principle Change of income distribution (RE) Impoverishment (headcount) Progressivity Impoverishment Prepayment contributions Burden Approach Equal sacrifice principle Distribution of burden (FFC) Percentage of households with catastrophic expenditure Catastrophic expenditure Horizontal equity Some progressivity Catastrophic expenditure Financial burden from prepayment and out-of-pocket payment 4 The distribution of household financial contributions to the health system: A look outside Latin America 3 November, 2008

5 Specific measures Catastrophic expenditure When the medical bills of one or more household members are high in relation to a household's capacity to pay, it must reduce its expenditure on other necessities for a period of time. This is considered as catastrophic expenditure. Defined as the percentage of households whose out-of-pocket health expenditures equal or exceed a certain percentage (for example here 40% is used) of their non-subsistence expenditure (calculated from a food-based poverty line). Impoverishment As a result of out-of-pocket health expenditures, a household may fall below the poverty line. This is considered as impoverishment. Defined as the percentage of households falling below the food-based poverty line due to out-of-pocket health expenditures. 5 The distribution of household financial contributions to the health system: A look outside Latin America 3 November, 2008

6 Data sources 76 countries outside Latin America and the Caribbean presented here Data from household surveys (e.g. household budget surveys, income expenditure surveys, etc.) From (latest year available used for each country) 6 The distribution of household financial contributions to the health system: A look outside Latin America 3 November, 2008

7 Catastrophic health expenditure and impoverishment in countries outside LA/CAR, lastest year % households impoverished due to OOP CHN INDGHA SCG EGY IDN ALB BGR BGD UGA NPL UKR LAOEST GEO KEN TJK LKA LVA SENTUN POL YEM BLR ARM ZMB RWA PRT MAR KAZ BWA PHL KGZ TZA MUS NAM THA LTU HRV DJI ROU HUN CPV KOR MYS ZAF GRC CZE LUX SVK DEU GBRFIN DNK BEL CANCHE IRLISL SWE OMN AUT NOR ISRITA ESP USA FRA KHM BFA RUS LBN AZE CIV VNM MWI % households with catastrophic health expenditure

8 African Region Eastern Mediterranean Region South-East Asia Region 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% KHM VNM CHN LAO PHL KOR MYS CIV SEN BFA KEN GHA MUS UGA TZA ZMB BWA CPV MWI RWA ZAF NAM 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% LBN EGY YEM MAR TUN DJI OMN 0% 20% 40% 60% 80% 100% IDN IND BGD NPL LKA THA Western Pacific Region OOP/THE Prepayment/THE European Region AZE TJK GEO ALB SCG POL GRC BGR ARM LVA EST RUS PRT KAZ HUN ITA KGZ FIN UKR LTU ISR FRA BEL ISL ESP CHE BLR ROU SWE AUT DNK NOR CZE IRL LUX DEU HRV GBR SVK 0% 20% 40% 60% 80% 100% AZE TJK GEO ALB SCG POL GRC BGR ARM LVA EST RUS PRT KAZ HUN ITA KGZ FIN UKR LTU ISR FRA BEL ISL ESP CHE BLR ROU SWE AUT DNK NOR CZE IRL LUX DEU HRV GBR SVK E uropean Region

9 African Region Eastern Mediterranean Region South-East Asia Region MYS PHL LAO KOR CHN KHM VNM ZAF NAM SEN TZA CPV MUS GHA ZMB RWA UGA BWA KEN BFA CIV MWI MAR OMN DJI TUN YEM EGY LBN THA IND BGD LKA NPL IDN Western Pacific Region % of Households with castrophic OOP European Region CZE LUX SVK DEU GBR DNK ROU BEL IRL SWE AUT HRV NOR ISR ISL ESP BLR FIN CHE ITA HUN KGZ FRA UKR LTU POL EST BGR GRC KAZ SCG ARM GEO PRT LVA ALB TJK RUS AZE CZE LUX SVK DEU GBR DNK ROU BEL IRL SWE AUT HRV NOR ISR ISL ESP BLR FIN CHE ITA HUN KGZ FRA UKR LTU POL EST BGR GRC KAZ SCG ARM GEO PRT LVA ALB TJK RUS AZE European Region

10 African Region Eastern Mediterranean Region South-East Asia Region MYS KOR PHL LAO KHM CHN VNM ZAF CPV NAM MUS TZA BWA RWA ZMB SEN KEN BFA UGA MWI GHA CIV OMN DJI MAR YEM TUN LBN EGY THA LKA BGD NPL IDN IND Western Pacific Region % of Households impoverished European Region AUT BEL CHE CZE DEU DNK FIN GBR ISL LUX NOR SWE FRA IRL ESP SVK ISR ITA GRC ROU HRV HUN LTU KGZ KAZ BLR ARM PRT POL LVA EST GEO TJK UKR BGR ALB SCG RUS AZE AUT BEL CHE CZE DEU DNK FIN GBR ISL LUX NOR SWE FRA IRL ESP SVK ISR ITA GRC ROU HRV HUN LTU KGZ KAZ BLR ARM PRT POL LVA EST GEO TJK UKR BGR ALB SCG RUS AZE European Region

11 % Households with catastrophic OOP MWI Catastrophic expenditure by financing system and GDP per capita BFA CIV AZE KHM VNM LBN RUS SHI Mixed Tax TJK CHN KEN ALB NPL IDN BWA EGY LVA RWA UGA PRT GEO KOR ZMB ARMSCG KAZ BGR GRC YEM GHA POL LTU EST MUS BGD FRA IND LAO LKA UKR TZA KGZ CPV TUN PHLTHA HUN SEN BLR CHE DJI ESP FIN ROU HRV ISL ITA ISR USA MARNAM MYSOMN NOR SWE BEL AUT ZAF SVK CZEDEUCAN DNK GBR IRL LUX Percentage of households with catastrophic health expenditure decreases as national income increases There is no particular effect of different types of health financing systems GDP/capita, international $ (log-scale)

12 % Households impoverished Impoverishment due to OOP by financing system and GDP per capita CIV VNM SHI Mixed Tax AZE CHN RUS GHA IND MWI EGY SCG KHM ALB IDN NPL BFA BGD UGA BGR LBN UKR TJK LAOKEN GEO EST LKA TUN POL LVA SEN ZMB YEM RWA ARM PRT KAZ MAR BLR BWA KGZ TZA PHL MUS NAM THALTU DJI CPV ROU HRV HUN KOR MYS ZAF GRC SVK OMN CZEDEU ESP FRA ISR SWE CAN FIN BELCHE DNK ISL GBR NOR IRL AUT ITA USA LUX GDP/capita, international $ (log-scale) Similarly to the incidence of catastrophic health expenditure, impoverishment also decreases as national income rises Once again, no particular effect of different types of health financing systems

13 % Households with catastrophic OOP <0.01% 0.03% 0.1% 0.3% 1% 3% 8% 15% GBR SVK Catastrophic expenditure by financing system and OOP share of total health expenditure SHI Mixed NAM ZAF Tax MWI VNM AZE CIV RUS LBN BFA KEN CHN ALB TJK KHM BWA LVA NPL KOR EGY IDN RWA PRT KAZZMB UGA ARM BGR SCG GEO GRC YEM EST FRALTU MUS POL UKR GHA LAOLKA KGZ BGD HUN CPV IND TZA THA TUN PHL BLR CHE ITA FIN SEN USA ESP ISLISR DJI NOR HRV OMNAUT SWE MYS MAR DEU IRL ROU CAN DNK LUX CZE BEL * No effect of financing system * Clear effect of OOP share of THE 5% 8% 14% 22% 37% 61% 100 OOP/THE

14 Ke Xu, David B. Evans, Guido Carrin, Ana Mylena Aguilar-Rivera, Philip Musgrove and Timothy Evans. Protecting Households From Catastrophic Health Spending. Health Affairs, 26, no. 4 (2007): doi: /hlthaff

15 Highlights Reducing out-of-pocket payment is one of the key factors in protecting households form financial catastrophe No difference is found between social health insurance or tax-based financing systems in terms of protecting households against catastrophic expenditures. Income inequality associated with a high level of catastrophic health expenditure Countries at different income levels may have different focus: Increasing the availability of health services with current prepayment level may cause more households to face financial catastrophe in low and middle income countries, but not in high income countries. Demographic factors (children and elderly population) are associated with high catastrophic expenditure in middle income, but not in low and high income countries 15 The distribution of household financial contributions to the health system: A look outside Latin America 3 November, 2008

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