Financial Risk Protection, Decomposition and Inequality Analysis of Household Out-of-Pocket Health Payments

This research examines equity trends in financing health care through out-of-pocket payments (OOP) using South African Income and Expenditure Surveys for the periods 1995, 2000, 2005-06 and 2010-11. South Africa is interesting to examine for a variety of reasons. In 1994, South Africa removed user charges at public health facilities (clinics) for children aged below six years, pregnant and nursing mothers and the elderly (as long as they were not covered by any medical aid scheme) with the aim of increasing access to public health care facilities. The policy was extended to the entire population in 1996. These initiatives, even though they were targeted at promoting access, were also an effort on the part of policy makers to cushion households against the financial costs associated with the consumption of medical care – something that is likely to influence the distribution of household OOP. Whether, this indeed has been the case remains relatively unknown. Within the scope of the investigation, this thesis tries to answer three broad questions: (i) What is the incidence of catastrophic health care expenditures (CHE) arising from OOP health care financing in South Africa from 1995 to 2011? (ii) What are the factors influencing the incidence of CHE among male and female headed households? and (iii) Who pays for health care in South Africa? In investigating the incidence of catastrophic health expenditure, the research has employed two approaches, which are: the financial burden approach and the income approach – the income approach is derived from the equity measures of public finance where progressivity is the main concern, while the financial burden approach argues that the burden should be equally distributed across all households (see Carrin et al., 2009). Both approaches relate health payments incurred by households to households’ capacity (ability) to pay and not to households’ risks of illness, albeit with different definitions of the capacity (ability) to pay. The research has found that in 1995, around 0.03 percent of households incurred health expenses that are likely to force them to cut back on consumption of other basic needs, while for the years 2000, 2005-06 and 2010-11, the incidence is 0.06 percent, 0.09 percent and 0.07 percent, respectively. Given such a low incidence of CHE, the research evaluated the utilisation of health care facilities by households when confronted with illness. This was only done for the year 1995, as it is only year in which data was collected on the illness status of each household member, whether or not they consulted when ill and where they consulted. The results suggest that a negligible percentage of households did not seek treatment when ill. Of those who consulted, it was found that a relatively higher percentage sought treatment in public health care facilities (0.21 percent) than in private facilities (0.13 percent). Having established the incidence of CHE, the second analysis examined the factors associated with CHE and then decomposed the difference between male-headed and female-headed households to establish whether the gap between the two groups had widened or narrowed. The results suggest that the gender gap in the incidence of CHE narrowed by 0.4 percent between 1995 and 2010-11. This reduction in the gender gap is attributable to education, access to piped water and residing in urban areas. Across the different surveys (as well as over the entire time period) education, having access to piped water and residing in urban areas narrowed the gender gap. These results are consistent with existing evidence documenting the important role played by access to basic amenities, such as water and sanitation, as well as human capital (education), in explaining gendered inequalities in health care. Finally, the research examined the distribution of health payments relative to income, focusing on who incurs OOP for their health care needs to establish OOP concentration and quantify its magnitude. The levels of concentation were compared over time, and decomposed to see if it was possible to attribute changes in social determinants of health to the level of concentration in OOP payments for health care. In general, health care payments are concentrated among non-poor households, suggesting that there is progressivity in health care financing, at least as it pertains to OOP. Such results are corroborated by the corresponding concentration indices. When the analysis occurs across the 15-year time period from 1995 to 2010-11, the research finds that changing inequalities across age groups, racial groups, education (particularly completion of secondary education), well-being quintiles and type of toilet used, as well as water source for drinking, explained changes in OOP concentration. It was also found that changing elasticities with respect to OOP payments also play a crucial role in explaining differences over time. Overall, most of the changes in OOP payment inequality are attributable to inequality in the social determinants.Thesis (PhD)--University of Pretoria, 2020.EconomicsPhDUnrestricte

Catastrophic health expenditures arising from out-of-pocket payments : evidence from South African income and expenditure surveys

This study examines catastrophic health expenditures and the potential for such payments to impoverish South African households. The analysis applies three different catastrophic expenditure measurements, and we apply them across four South African Income and Expenditure Surveys. Since households have limited resources, they are also limited in their capacity to purchase health care. Thus, if a household devotes a large share of that capacity to health care, it may not be able to cover other necessary expenses, which could be catastrophic. The measurements differ in their definition of household capacity. Despite the differences in measurements, and, therefore, results, we find limited incidence of health care expenditure catastrophe, although larger shares of capacity are being devoted to health care in more recent years. In line with the finding that catastrophe is rare, we find that very few households are subsequently impoverished, because of health care costs.S1 File. R File for descriptive tables. This file provides the R code for developing the descriptive statistics tables. https://doi.org/10.1371/journal.pone.0237217.s001S2 File. R File for catastrophic health expenditure and impoverishment tables. This file provides the R code for developing the information placed into the catastrophic health expenditure and impoverishment tables; paper-cheimp.R. https://doi.org/10.1371/journal.pone.0237217.s002http://www.plosone.orgam2021Economic

Global investments in pandemic preparedness and COVID-19: development assistance and domestic spending on health between 1990 and 2026

Background The COVID-19 pandemic highlighted gaps in health surveillance systems, disease prevention, and treatment globally. Among the many factors that might have led to these gaps is the issue of the financing of national health systems, especially in low-income and middle-income countries (LMICs), as well as a robust global system for pandemic preparedness. We aimed to provide a comparative assessment of global health spending at the onset of the pandemic; characterise the amount of development assistance for pandemic preparedness and response disbursed in the first 2 years of the COVID-19 pandemic; and examine expectations for future health spending and put into context the expected need for investment in pandemic preparedness. Methods In this analysis of global health spending between 1990 and 2021, and prediction from 2021 to 2026, we estimated four sources of health spending: development assistance for health (DAH), government spending, out-of-pocket spending, and prepaid private spending across 204 countries and territories. We used the Organisation for Economic Co-operation and Development (OECD)'s Creditor Reporting System (CRS) and the WHO Global Health Expenditure Database (GHED) to estimate spending. We estimated development assistance for general health, COVID-19 response, and pandemic preparedness and response using a keyword search. Health spending estimates were combined with estimates of resources needed for pandemic prevention and preparedness to analyse future health spending patterns, relative to need. Findings In 2019, at the onset of the COVID-19 pandemic, US$9·2 trillion (95$7·3 trillion (95% UI 7·2–7·4) in 2019; 293·7 times the $24·8 billion (95$43·1 billion in development assistance was provided to maintain or improve health. The pandemic led to an unprecedented increase in development assistance targeted towards health; in 2020 and 2021, $1·8 billion in DAH contributions was provided towards pandemic preparedness in LMICs, and$37·8 billion was provided for the health-related COVID-19 response. Although the support for pandemic preparedness is 12·2% of the recommended target by the High-Level Independent Panel (HLIP), the support provided for the health-related COVID-19 response is 252·2% of the recommended target. Additionally, projected spending estimates suggest that between 2022 and 2026, governments in 17 (95% UI 11–21) of the 137 LMICs will observe an increase in national government health spending equivalent to an addition of 1% of GDP, as recommended by the HLIP. Interpretation There was an unprecedented scale-up in DAH in 2020 and 2021. We have a unique opportunity at this time to sustain funding for crucial global health functions, including pandemic preparedness. However, historical patterns of underfunding of pandemic preparedness suggest that deliberate effort must be made to ensure funding is maintained

Progressivity of out-of-pocket payments and its determinants decomposed over time

This study estimates progressivity of out-of-pocket (OOP) health payments and their determinants using South African Income and Expenditure Surveys. Concentration is decomposed to examine the effect of household determinants on OOP inequality, shedding light on how progressivity/regressivity is related to changes in the concentration and elasticities of the determinants over time. Our results suggest that actual OOP health expenditures are concentrated among non-poor households, although less so now than in the recent past. When OOP health payments are viewed from the perspective of affordability, which instead focuses on the share of payments relative to capacity-to-pay, they are regressive; However, they have become less concentrated amongst poor households, although still regressive, recently. These results appear to be independent of the measure of socioeconomic status employed in the analysis. The results highlight large income and education-related disparities and also suggest continued gender and ethnic differences that deserve further attention in policymaking.http://www.tandfonline.com/loi/cdsa202022-08-05hj2021Economic

Catastrophic health expenditures arising from out-of-pocket payments: Evidence from South African income and expenditure surveys.

This study examines catastrophic health expenditures and the potential for such payments to impoverish South African households. The analysis applies three different catastrophic expenditure measurements, and we apply them across four South African Income and Expenditure Surveys. Since households have limited resources, they are also limited in their capacity to purchase health care. Thus, if a household devotes a large share of that capacity to health care, it may not be able to cover other necessary expenses, which could be catastrophic. The measurements differ in their definition of household capacity. Despite the differences in measurements, and, therefore, results, we find limited incidence of health care expenditure catastrophe, although larger shares of capacity are being devoted to health care in more recent years. In line with the finding that catastrophe is rare, we find that very few households are subsequently impoverished, because of health care costs