Can we predict how much government investments on health reduce households incurring catastrophic out-of-pocket health expenditure? A systematic review and longitudinal data analysis of 72 low- and middle-income countries Público

Abstract

Reducing households incurring catastrophic out-of-pocket health expenditure (CHE) in low- and middle-income countries (LMICs) is a key measurement with respect to moving towards universal health coverage (UHC). It is not well-known how much governments should mobilize their budgets to the health sector to reduce the proportion of households with CHE. We examined the association between general government health expenditure (GGHE) and the incidence of CHE in LMICs. Our outcome, the incidence of CHE, was defined as any out-of-pocket (OOP) health payments exceeding 40% of household non-subsistence expenditure. We searched the following databases in June 2016: CENTRAL; MEDLINE; EMBASE; SCI-Expanded; SSCI; A&HCI; CCR-Expanded; and IC. We included studies that ensure national-level representation in the estimated incidences of CHE. Our exposure was GGHE as share of gross domestic product (GDP). We extracted data of the exposure and potential confounders from the following databases: World Health Organization (WHO) Global Health Expenditure Database (GHED), WHO Global Health Observatory (GHO), and World Bank Open Data. We collected 39 articles that estimated 142 incidences of CHE and data of 18 potential covariates. We fit linear mixed effect models and general estimating equation (GEE) models to estimate coefficients of the incidence of CHE adjusted for six confounders. There were significant declines of the incidence of CHE associated with the increase of GGHE as share of GDP in the mixed effect model (coefficient: -0.250, standard error (SE) 0.118, p-value: 0.037) and the GEE model (coefficient: -0.346, SE 0.102, p-value: 0.001). Although non-random selection of countries and mismeasurement of CHE may cause biases, the estimated coefficient will potentially be able to predict percent reduction in the incidence of CHE depending on the amount of GGHE in LMICs.

Table of Contents

Chapter 1: Introduction ..................................................................................................................................................................... 1 Rationale ................................................................................................................................................................................ 1 Aims and objectives ............................................................................................................................................................... 2

Definition of terms .................................................................................................................................................................. 3

Chapter 2: Literature Review ............................................................................................................................................................ 4 Sustainable Development Goals and universal health coverage ........................................................................................... 4 Figure 1: Three dimensions to consider when moving towards universal coverage ................................................... 5 Catastrophic out-of-pocket health expenditure ...................................................................................................................... 6 How CHE became important with respect to the SDGs ........................................................................................................ 10 A case study in Thailand ........................................................................................................................................................ 11 A case study in Mexico .......................................................................................................................................................... 12 Chapter 3: Manuscript ...................................................................................................................................................................... 15 Introduction ............................................................................................................................................................................ 17 Methods ................................................................................................................................................................................. 25 Criteria for considering studies for this review ............................................................................................................ 25 Search methods for identification of studies ............................................................................................................... 26 Data collection and management ............................................................................................................................... 26 Identification of exposure and predictors .................................................................................................................... 27 Table 1. Potential Covariates Considered to estimate Magnitude of Association between Incidence of CHE and GGHE as % of GDP ................................................................................................................................................................... 28 Statistical analysis ...................................................................................................................................................... 29 Sensitivity analysis ..................................................................................................................................................... 31 Results .................................................................................................................................................................................. 31 Result of search ......................................................................................................................................................... 31 Figure 2. Study flow chart .......................................................................................................................................... 32 Country characteristics .............................................................................................................................................. 32 Table 2. Economic, Demographic, and Health Related Characteristics of Countries that Estimated Incidences of CHE between 2000-2016 ..................................................................................................................................................... 33 Table 3. Distributions of Observations and Countries that estimated Incidences of CHE between 2000-2016 ........ 34 Figure 3. Collected data points of incidence of CHE by years and World Bank regions ........................................... 36 Result of statistical analysis ....................................................................................................................................... 36 Table 4. Crude and Adjusted Beta Coefficients, Standard Errors (SEs), P-value of Incidence of CHE by GGHE as % of GDP, estimated by Log Linear Mixed Effect Model and General Estimating Equation (GEE) Model by using Full Dataset ..................................................................................................................................................................................... 36 Result of sensitivity analysis ....................................................................................................................................... 37 Table 5. Crude and Adjusted Beta Coefficients, Standard Errors (SEs), P-value of the Incidence of CHE by GGHE as % of GDP, estimated by Log Linear Mixed Effect Model and General Estimating Equation (GEE) Model by using Dataset eliminated Countries containing One Observation ...................................................................................................... 37 Discussion .............................................................................................................................................................................. 37 Case study 1: How to approximate number of households averted from CHE by applying our study findings: A case study in Cambodia 2014 ........................................................................................................................................................ 39 Conclusion .............................................................................................................................................................................. 43 Chapter 4: Conclusion and Recommendations ................................................................................................................................. 44 Public health implications ........................................................................................................................................................ 44 Study limitations ...................................................................................................................................................................... 45 Future directions ..................................................................................................................................................................... 49 References ........................................................................................................................................................................................ 51 Appendix: List of included studies ..................................................................................................................................................... 55

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Epidemiology Health Sciences, Public Health
Palabra Clave	health economics catastrophic out-of-pocket health expenditure universal health coverage global health health system strengthening econometrics health financing
Committee Chair / Thesis Advisor	McFarland, Deborah A, Emory University
Partnering Agencies	Does not apply (no collaborating organization)

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