Financial risk protection from out-of-pocket health spending in low- and middle-income countries: a scoping review of the literature

Abstract

Background Financial risk protection (FRP), defined as households’ access to needed healthcare services without experiencing undue financial hardship, is a critical health systems target, particularly in low- and middle-income countries (LMICs). Given the remarkable growth in FRP literature in recent times, we conducted a scoping review of the literature on FRP from out-of-pocket (OOP) health spending in LMICs. The objective was to review current knowledge, identify evidence gaps and propose future research directions. Methods We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines to conduct this scoping review. We systematically searched PubMed, Scopus, ProQuest and Web of Science in July 2021 for literature published since 1 January 2015. We included empirical studies that used nationally representative data from household surveys to measure the incidence of at least one of the following indicators: catastrophic health expenditure (CHE), impoverishment, adoption of strategies to cope with OOP expenses, and forgone care for financial reasons. Our review covered 155 studies and analysed the geographical focus, data sources, methods and analytical rigour of the studies. We also examined the level of FRP by disease categories (all diseases, chronic illnesses, communicable diseases) and the effect of health insurance on FRP. Results The extant literature primarily focused on India and China as research settings. Notably, no FRP study was available on chronic illness in any low-income country (LIC) or on communicable diseases in an upper-middle-income country (UMIC). Only one study comprehensively measured FRP by examining all four indicators. Most studies assessed (lack of) FRP as CHE incidence alone (37.4%) or as CHE and impoverishment incidence (39.4%). However, the LMIC literature did not incorporate the recent methodological advances to measure CHE and impoverishment that address the limitations of conventional methods. There were also gaps in utilizing available panel data to determine the length of the lack of FRP (e.g. duration of poverty caused by OOP expenses). The current estimates of FRP varied substantially among the LMICs, with some of the poorest countries in the world experiencing similar or even lower rates of CHE and impoverishment compared with the UMICs. Also, health insurance in LMICs did not consistently offer a higher degree of FRP. Conclusion The literature to date is unable to provide a reliable representation of the actual level of protection enjoyed by the LMIC population because of the lack of comprehensive measurement of FRP indicators coupled with the use of dated methodologies. Future research in LMICs should address the shortcomings identified in this review.

Financial risk protection against noncommunicable diseases: trends and patterns in Bangladesh

“…Our study broadens the knowledge base of FRP against NCDs in LMICs. Most of the nationally-representative LMIC studies were conducted in China and India, focusing primarily on subgroups of NCD-affected households (such as households with elderly NCD-affected members or those seeking hospitalized NCD care) [22]. Our study is the first to examine trends and patterns of FRP against NCD and non-NCD care in Bangladesh on a nationally representative scale.…”

Association between universal health coverage and the disease burden of acute illness and injury at the global level

“…Ostensibly, the lowest income countries have fewer services to physically access, which reduces purchasing/expenditure on those services, while the highest-income countries have enough wealth and financial protection to mitigate catastrophic expenditure. Other researchers have found similar findings, which may also reflect the limitations of heavy reliance on catastrophic health expenditure data to assess financial risk [14]. Regardless, thoroughly investigating the likely causes of this finding was outside the scope of this work and present a prime topic for future research.…”

The impact of community-based health insurance on universal health coverage in Ethiopia: a systematic review and meta-analysis

“… COC : This r efers to the “costs for individuals directly or indirectly incurred by the provision of health-care goods and services, aimed at maintaining or recovering the health of a person” [ 21 ]. FRP : It is the “access of households to needed healthcare services without experiencing undue financial hardship” [ 22 ]. It is a key component of UHC [ 23 ].…”

“…FRP : It is the “access of households to needed healthcare services without experiencing undue financial hardship” [ 22 ]. It is a key component of UHC [ 23 ].…”