Financial Risk Protection and Universal Health Coverage: Evidence and Measurement Challenges

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Abstract

As part of a PLOS Collection on universal health coverage, Priyanka Saksena and colleagues examine existing measures of financial risk protection and suggest future developments that could be valuable in monitoring progress towards universal health coverage.

Abstract

Financial risk protection is a key component of universal health coverage (UHC), which is defined as access to all needed quality health services without financial hardship. As part of the PLOS Medicine Collection on measurement of UHC, the aim of this paper is to examine and to compare and contrast existing measures of financial risk protection. The paper presents the rationale behind the methodologies for measuring financial risk protection and how this relates to UHC as well as some empirical examples of the types of measures. Additionally, the specific challenges related to monitoring inequalities in financial risk protection are discussed. The paper then goes on to examine and document the practical challenges associated with measurement of financial risk protection. This paper summarizes current thinking on the area of financial risk protection, provides novel insights, and suggests future developments that could be valuable in the context of monitoring progress towards UHC.

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Most cited references 17

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Coping with health-care costs: implications for the measurement of catastrophic expenditures and poverty.

Owen O'Donnell, J Krishnakumar, Eddy van Roon … (2008)

In the absence of formal health insurance, we argue that the strategies households adopt to finance health care have important implications for the measurement and interpretation of how health payments impact on consumption and poverty. Given data on source of finance, we propose to (a) approximate the relative impact of health payments on current consumption with a 'coping'-adjusted health expenditure ratio, (b) uncover poverty that is 'hidden' because total household expenditure is inflated by financial coping strategies and (c) identify poverty that is 'transient' because necessary consumption is temporarily sacrificed to pay for health care. Measures that ignore coping strategies not only overstate the risk to current consumption and exaggerate the scale of catastrophic payments but also overlook the long-run burden of health payments. Nationally representative data from India reveal that coping strategies finance as much as three-quarters of the cost of inpatient care. Payments for inpatient care exceed 10% of total household expenditure for around 30% of hospitalized households but less than 4% sacrifice more than 10% of current consumption to accommodate this spending.Ignoring health payments leads to underestimate poverty by 7-8% points among hospitalized households; 80% of this adjustment is hidden poverty due to coping.

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The availability and affordability of selected essential medicines for chronic diseases in six low- and middle-income countries.

Richard Laing, Jerzy Leowski, Margaret Ewen … (2007)

To assess the availability and affordability of medicines used to treat cardiovascular disease, diabetes, chronic respiratory disease and glaucoma and to provide palliative cancer care in six low- and middle-income countries. A survey of the availability and price of 32 medicines was conducted in a representative sample of public and private medicine outlets in four geographically defined areas in Bangladesh, Brazil, Malawi, Nepal, Pakistan and Sri Lanka. We analysed the percentage of these medicines available, the median price versus the international reference price (expressed as the median price ratio) and affordability in terms of the number of days wages it would cost the lowest-paid government worker to purchase one month of treatment. In all countries

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Catastrophic and poverty impacts of health payments: results from national household surveys in Thailand.

Viroj Tangcharoensathien, Supon Limwattananon, Phusit Prakongsai (2007)

To estimate the incidence and describe the profile of catastrophic expenditures and impoverishment due to household out-of-pocket payments, comparing the periods before and after the introduction of universal health care coverage (UC). Secondary data analyses of socioeconomic surveys on nationally representative households pre-UC in 2000 (n = 24,747) and post-UC in 2002 (n = 34,785) and 2004 (n = 34,843). Households using inpatient care experienced catastrophic expenditures most often (31.0% in 2000, compared with 15.1% and 14.6% in 2002 and 2004, respectively). During the two post-UC periods, the incidence of catastrophic expenditures for inpatient services at private hospitals was 32.1% for 2002 and 27.8% for 2004. For those using inpatient care at district hospitals, the corresponding catastrophic expenditures figures were 6.5% and 7.3% in 2002 and 2004, respectively. The catastrophic expenditures incidence for outpatient services from private hospitals moved from 27.9% to 28.5% between 2002 and 2004. In 2000, before universal coverage was introduced, the percentages of Thai households who used private hospitals and faced catastrophic expenditures were 35.8% for inpatient care and 36.0% for outpatient care. Impoverishment increased for poor households because of payments for inpatient services by 84.0% in 2002, by 71.5% in 2004 and by 95.6% in 2000. The relative increase in out-of-pocket impoverishment was found in 98.8% to 100% of those who were poor following payments made to private hospitals, regardless of type of care. Households using inpatient services, especially at private hospitals, were more likely to face catastrophic expenditures and impoverishment from out-of-pocket payments. Use of services not covered by the UC benefit package and bypassing the designated providers (prohibited under the capitation contract model without proper referrals) are major causes of catastrophic expenditures and impoverishment.

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Journal

Journal ID (nlm-ta): PLoS Med

Journal ID (iso-abbrev): PLoS Med

Journal ID (publisher-id): PLoS

Journal ID (pmc): plosmed

Title: PLoS Medicine

Publisher: Public Library of Science (San Francisco, USA )

ISSN (Print): 1549-1277

ISSN (Electronic): 1549-1676

Publication date Collection: September 2014

Publication date (Electronic): 22 September 2014

Volume: 11

Issue: 9

Electronic Location Identifier: e1001701

Affiliations

[1 ]Department of Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland

[2 ]Swiss Tropical and Public Health Institute, University of Basel, Basel Switzerland

Author notes

* E-mail: saksenap@ 123456who.int

The authors have declared that no competing interests exist.

Wrote the first draft of the manuscript: PS JH DBE. Contributed to the writing of the manuscript: PS JH DBE. ICMJE criteria for authorship read and met: PS JH DBE. Agree with manuscript results and conclusions: PS JH DBE.

Article

Publisher ID: PMEDICINE-D-13-04150

DOI: 10.1371/journal.pmed.1001701

PMC ID: 4171370

PubMed ID: 25244520

SO-VID: 0cc57664-9b79-45cf-9b2d-1356947e1e71

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This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Pages: 11

Funding

This work was funded in part by a grant from the Rockefeller Foundation. The Rockefeller Foundation had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors alone are responsible for the views expressed in this publication, and this publication does not represent the views of the institutions the authors are affiliated with in any way whatsoever.

Financial Risk Protection and Universal Health Coverage: Evidence and Measurement Challenges

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Most cited references 17

Coping with health-care costs: implications for the measurement of catastrophic expenditures and poverty.

The availability and affordability of selected essential medicines for chronic diseases in six low- and middle-income countries.

Catastrophic and poverty impacts of health payments: results from national household surveys in Thailand.

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