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Associations of lack of voluntary private insurance and out-of-pocket expenditures with health inequalities. Evidence from an international longitudinal survey in countries with universal health coverage.

ABSTRACT: OBJECTIVES:In countries with universal health coverage (UHC), national public health insurances cover 70% of health expenditures on average, but health care user fees and out-of-pocket expenditures have been neglected in empirical patient-centered health inequality research. This study is the first to investigate how health care-related factors are associated with health status among middle-aged and elderly people-vulnerable groups for the burden of illness-in countries with UHC. DESIGN:Longitudinal observational cohort study. SETTING:Population-based cohort Survey of Health, Ageing and Retirement in Europe (SHARE) in twelve countries with UHC. PARTICIPANTS:Non-institutionalized people aged 50 and older (n = 29,260). Two subsamples were also used: participants without global activity limitation at baseline (n = 16,879) and participants without depression at baseline (n = 21,178). MAIN OUTCOME MEASURES:Risk of death, risk of global activity limitations, and risk of depression. We used mixed-effects Cox proportional hazards regressions to estimate hazard ratios (HR) for all-cause mortality, physical limitations, and depression. RESULTS:Having a voluntary private insurance to cover health expenses not included in the public health care system (44.1% of the total sample) was a protective factor for all outcomes (HR?0.91), controlling for a large range of socio-economic variables. On the contrary, having out-of-pocket expenditures (62.4%) was a risk factor (HR?1.12). CONCLUSIONS:UHC systems are not free from health inequalities: there is a potential effect of lack of voluntary private insurance and out-of-pocket expenditures on mortality and health. Health care-related factors should be at focus in future researches designed to understand and address health inequalities. Reducing out-of-pocket expenditures and developing voluntary private insurance may protect against premature illness and death.

SUBMITTER: Baggio S

PROVIDER: S-EPMC6177131 | biostudies-literature | 2018

REPOSITORIES: biostudies-literature

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Associations of lack of voluntary private insurance and out-of-pocket expenditures with health inequalities. Evidence from an international longitudinal survey in countries with universal health coverage.

Baggio Stéphanie S Dupuis Marc M Wolff Hans H Bodenmann Patrick P

PloS one 20181009 10

<h4>Objectives</h4>In countries with universal health coverage (UHC), national public health insurances cover 70% of health expenditures on average, but health care user fees and out-of-pocket expenditures have been neglected in empirical patient-centered health inequality research. This study is the first to investigate how health care-related factors are associated with health status among middle-aged and elderly people-vulnerable groups for the burden of illness-in countries with UHC.<h4>Desi ...[more]

PMID: 30300369

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Project description:Research on impact of publicly financed health insurance has paid relatively little attention to the nature of healthcare provision the schemes engage. India's National Health Insurance Scheme or RSBY was made universal by Chhattisgarh State in 2012. In the State, public and private sectors provide hospital services in a context of extensive gender, social, economic and geographical inequities. This study examined enrolment, utilization (public and private) and out of pocket (OOP) expenditure for the insured and uninsured, in Chhattisgarh. The Chhattisgarh State Central sample (n = 6026 members) of the 2014 National Sample Survey (71st Round) on Health was extracted and analyzed. Variables of enrolment, hospitalization, out of pocket (OOP) expenditure and catastrophic expenditure were descriptively analyzed. Multivariate analyses of factors associated with enrolment, hospitalization (by sector) and OOP expenditure were conducted, taking into account gender, socio-economic status, residence, type of facility and ailment. Insurance coverage was 38.8%. Rates of hospitalization were 33/1000 population among the insured and 29/1000 among the uninsured. Of those insured and hospitalized, 67.2% utilized the public sector. Women, rural residents, Scheduled Tribes and poorer groups were more likely to utilize the public sector for hospitalizations. Although the insured were less likely to incur out of pocket (OOP) expenditure, 95.1% of insured private sector users and 66.0% of insured public sector users, still incurred costs. Median OOP payments in the private sector were eight times those in the public sector. Of households with at least one member hospitalized, 35.5% experienced catastrophic health expenditures (>10% monthly household consumption expenditure). The study finds that despite insurance coverage, the majority still incurred OOP expenditure. The public sector was nevertheless less expensive, and catered to the more vulnerable groups. It suggests the need to further examine the roles of public and private sectors in financial risk protection through government health insurance.

Project description:Private sector plays an import role in health service provision, therefore the engagement of private health facilities is important for ensuring access to health services. In Thailand, two of the three public health insurance schemes, Universal Coverage Scheme and Social Health Insurance, contract with private health facilities to fill gaps of public providers for the provision of health services under Universal Health Coverage. The National Health Security Office (NHSO) and Social Security Office (SSO), which manage the schemes respectively, have designed their own contractual agreements for private facilities. We aim to understand the current situation of contracting private health facilities within UHC of the two purchasing agencies. This qualitative descriptive case study was conducted through document review and in-depth interviews with key informants to understand how they contract private primary care facilities, service types, duration of contract, standard and quality requirement and renewal and termination of contracts. Private providers make a small contribution to the service provision in Thailand as a whole but they are important actors in Bangkok. The current approaches used by two purchasers are not adequate in engaging private sector to fill the gap of public provision in urban cities. One important reason is that large private hospitals do not find public contracts financially attractive. NHSO classifies contracts into 3 categories: main contracting units, primary care units, and referral units; while SSO only contracts main contracting units. Both allows subcontracting by the main contractors. Contractual agreements are effective in ensuring mandatory infrastructure and quality standards. Both purchasers have established technical capacities to enforce quality monitoring and financial compliance although there remains room for improvement especially on identifying fraud and taking legal actions. Contracting private healthcare facilities can fill the gap of public healthcare facilities, especially in urban settings. Purchasers need to balance the right level of incentives and accountability measures to ensure access to quality of care. In contracting private-for-profit providers, strong regulatory enforcement and auditing capacities are necessary. Further studies may explore various aspects contracting outcomes including access, equity, quality and efficiency impacts.

Project description:ObjectivesTo analyse the relationship between health need, insurance coverage, health service availability, service use, insurance claims and out-of-pocket spending on health across Indonesia.DesignSecondary analysis of nationally representative quantitative data. We merged four national data sets: the National Socioeconomic Survey 2018, National Census of Villages 2018, Population Health Development Index 2018 and National Insurance Records to end 2017. Descriptive analysis and linear regression were performed.SettingIndonesia has one of the world's largest single-payer national health insurance schemes. Data are individual and district level; all are representative for each of the country's 514 districts.ParticipantsAnonymised secondary data from 1 131 825 individual records in the National Socioeconomic Survey and 83 931 village records in the village census. Aggregate data for 220 million insured citizens.Primary outcome measuresHealth service use and out-of-pocket payments, by health need, insurance status and service availability. Secondary outcome: insurance claims.ResultsSelf-reported national health insurance registration (60.6%) is about 10% lower compared with the insurer's report (71.1%). Insurance coverage is highest in poorer areas, where service provision, and thus service use and health spending, are lowest. Inpatient use is higher among the insured than the uninsured (OR 2.35, 95% CI 2.27 to 2.42), controlling for health need and access), and poorer patients are most likely to report free inpatient care (53% in wealth quintile 1 vs 41% in Q5). Insured patients spend US$ 3.14 more on hospitalisation than the uninsured (95% CI 1.98 to 4.31), but the difference disappears when controlled for wealth. Lack of services is a major constraint on service use, insurance claims and out-of-pocket spending.ConclusionsThe Indonesian public insurance system protects many inpatients, especially the poorest, from excessive spending. However, others, especially in Eastern Indonesia cannot benefit because few services are available. To achieve health equity, the Indonesian government needs to address supply side constraints and reduce structural underfunding.

Dataset Information

Associations of lack of voluntary private insurance and out-of-pocket expenditures with health inequalities. Evidence from an international longitudinal survey in countries with universal health coverage.

Publications

Associations of lack of voluntary private insurance and out-of-pocket expenditures with health inequalities. Evidence from an international longitudinal survey in countries with universal health coverage.

Similar Datasets

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