Ichd 2004 H Pol 6 Catastrophic Health Expenditure


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  • Ichd 2004 H Pol 6 Catastrophic Health Expenditure

    1. 1. Catastrophic Health Expenditure Wim Van Damme Institute of Tropical Medicine, Antwerp ICHD, March 2004
    2. 2. Overview <ul><li>What is Catastrophic Health Expenditure? </li></ul><ul><li>What is the evidence? </li></ul><ul><li>What are the determinants? </li></ul><ul><li>What can be done? </li></ul>
    3. 3. What is Catastrophic Health Expenditure? <ul><li>Health care costs </li></ul><ul><li> can cause a “shock” in the household economy </li></ul><ul><li> sometimes: “catastrophic” </li></ul><ul><ul><li>Leading to poverty; or </li></ul></ul><ul><ul><li>Pushing households deeper in poverty </li></ul></ul>
    4. 4. What is the evidence? <ul><li>Anecdotal </li></ul><ul><li>Household expenditure surveys (WHO  Lancet 2003) </li></ul><ul><ul><li>Definition: “ Households that used </li></ul></ul><ul><ul><li>>40% of household’s capacity to pay” </li></ul></ul><ul><ul><li>Some countries: very high </li></ul></ul><ul><ul><li>Many countries: very low </li></ul></ul><ul><ul><li>African countries: “low”? but few data </li></ul></ul>
    5. 5. Highest <ul><li>Countries in transition </li></ul><ul><li>Latin America </li></ul><ul><li>Lebanon </li></ul>?? China 5.02% Cambodia 5.17% Lebanon 5.77% Argentina 6.26% Colombia 7.15% Azerbaijan 10.27% Brazil 10.45% Vietnam
    6. 6. Comparison with rich countries 0.55% USA 0.04% UK 0.03% Germany 0.02% Belgium 0.01% France
    7. 7. Comparison with other developing countries 1.30% Ghana 0.03% South-Africa 0.55% Senegal 0.80% Thailand 1.26% Indonesia 2.29% Zambia
    8. 8. Determinants <ul><li>Proportion of health expenditure “out-of-pocket” </li></ul><ul><li>Attractive for-profit health system & weak non-for-profit health system </li></ul><ul><li>Weakness of safety nets (formal or informal) </li></ul><ul><li>(Alternative = forego treatment) </li></ul>
    9. 9. Catastrophic health expenditure related to out-of-pocket expenditure
    10. 11. Mechanism <ul><li>To cover health care costs households use: </li></ul><ul><ul><li>Cash </li></ul></ul><ul><ul><li>Assets </li></ul></ul><ul><ul><li>Gifts </li></ul></ul><ul><ul><li>Purchase care on credit </li></ul></ul><ul><ul><li>Borrow cash (hard loans or soft loans) </li></ul></ul><ul><ul><li> interest payments </li></ul></ul><ul><ul><li>at a time that income often decreases (due to illness of income earner) </li></ul></ul>
    11. 12. As a result <ul><ul><li>Reduced consumption of e.g. food </li></ul></ul><ul><ul><li>Reduced expenditure for schooling of children… </li></ul></ul><ul><ul><li>Loss of productive assets (incl. land!!, if “land market”) </li></ul></ul><ul><ul><ul><li>… . i atrogenic poverty </li></ul></ul></ul>
    12. 13. Not well documented: <ul><li>Type of expenditure? </li></ul><ul><ul><li>Pharmaceuticals!! </li></ul></ul><ul><ul><li>Private clinics or hospitals </li></ul></ul><ul><ul><li>Fees in public facilities? </li></ul></ul><ul><li>Type of health problem? </li></ul><ul><ul><li>Anything needing hospitalisation? </li></ul></ul><ul><ul><li>Chronic diseases: TB – AIDS … </li></ul></ul><ul><li>Was care needed??? </li></ul>
    13. 14. “ Health sector” <ul><li>Individual costs </li></ul><ul><ul><li>Highly unpredictable (risk) </li></ul></ul><ul><ul><li>Highly skewed to </li></ul></ul><ul><ul><ul><li>Unlucky – unhealthy </li></ul></ul></ul><ul><ul><ul><li>Very young & very old </li></ul></ul></ul><ul><li>Asymmetry of information </li></ul><ul><li>Market failure </li></ul>
    14. 15. To reduce catastrophic expenditure: <ul><li>Reduce out-of-pocket expenditure, especially for </li></ul><ul><ul><li>Potentially catastrophic expenditures </li></ul></ul><ul><ul><li>For poor </li></ul></ul><ul><li>How? </li></ul><ul><ul><li>More subsidies: government (tax) – donors </li></ul></ul><ul><ul><li>Pooling of resources: insurance (tax) </li></ul></ul><ul><ul><li>Rationalise offer of care; improve health seeking behaviour, … </li></ul></ul><ul><ul><li>Do not ignore hospitals!! / private sector!!! </li></ul></ul><ul><li>Context-specific strategy </li></ul>
    15. 16. Examples, depends on context <ul><li>Good service for free & accessible </li></ul><ul><li>Good service cheap & accessible </li></ul><ul><ul><li>Who will pay? Donor? Or government? </li></ul></ul><ul><li>Development of social health insurance / community-based health insurance (?) </li></ul><ul><li>Safety net (e.g. health equity fund) </li></ul><ul><ul><li>Who will pay? Donor? Or government? </li></ul></ul><ul><li>Combination of supply-side & demand-side interventions… </li></ul>
    16. 17. Short and long routes of accountability
    17. 18. Use of donor money…