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A Cross-Sectional Study of the Microeconomic Impact of Cardiovascular Disease Hospitalization in Four Low- and Middle-Income Countries

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      To estimate individual and household economic impact of cardiovascular disease (CVD) in selected low- and middle-income countries (LMIC).


      Empirical evidence on the microeconomic consequences of CVD in LMIC is scarce.

      Methods and Findings

      We surveyed 1,657 recently hospitalized CVD patients (66% male; mean age 55.8 years) from Argentina, China, India, and Tanzania to evaluate the microeconomic and functional/productivity impact of CVD hospitalization. Respondents were stratified into three income groups. Median out-of-pocket expenditures for CVD treatment over 15 month follow-up ranged from 354 international dollars (2007 INT$, Tanzania, low-income) to INT$2,917 (India, high-income). Catastrophic health spending (CHS) was present in >50% of respondents in China, India, and Tanzania. Distress financing (DF) and lost income were more common in low-income respondents. After adjustment, lack of health insurance was associated with CHS in Argentina (OR 4.73 [2.56, 8.76], India (OR 3.93 [2.23, 6.90], and Tanzania (OR 3.68 [1.86, 7.26] with a marginal association in China (OR 2.05 [0.82, 5.11]). These economic effects were accompanied by substantial decreases in individual functional health and productivity.


      Individuals in selected LMIC bear significant financial burdens following CVD hospitalization, yet with substantial variation across and within countries. Lack of insurance may drive much of the financial stress of CVD in LMIC patients and their families.

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      Most cited references 10

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      Household catastrophic health expenditure: a multicountry analysis.

      Health policy makers have long been concerned with protecting people from the possibility that ill health will lead to catastrophic financial payments and subsequent impoverishment. Yet catastrophic expenditure is not rare. We investigated the extent of catastrophic health expenditure as a first step to developing appropriate policy responses. We used a cross-country analysis design. Data from household surveys in 59 countries were used to explore, by regression analysis, variables associated with catastrophic health expenditure. We defined expenditure as being catastrophic if a household's financial contributions to the health system exceed 40% of income remaining after subsistence needs have been met. The proportion of households facing catastrophic payments from out-of-pocket health expenses varied widely between countries. Catastrophic spending rates were highest in some countries in transition, and in certain Latin American countries. Three key preconditions for catastrophic payments were identified: the availability of health services requiring payment, low capacity to pay, and the lack of prepayment or health insurance. People, particularly in poor households, can be protected from catastrophic health expenditures by reducing a health system's reliance on out-of-pocket payments and providing more financial risk protection. Increase in the availability of health services is critical to improving health in poor countries, but this approach could raise the proportion of households facing catastrophic expenditure; risk protection policies would be especially important in this situation.
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        Protecting households from catastrophic health spending.

        Many countries rely heavily on patients' out-of-pocket payments to providers to finance their health care systems. This prevents some people from seeking care and results in financial catastrophe and impoverishment for others who do obtain care. Surveys in eighty-nine countries covering 89 percent of the world's population suggest that 150 million people globally suffer financial catastrophe annually because they pay for health services. Prepayment mechanisms protect people from financial catastrophe, but there is no strong evidence that social health insurance systems offer better or worse protection than tax-based systems do.
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          Inequalities in health care use and expenditures: empirical data from eight developing countries and countries in transition.

          This paper summarizes eight country studies of inequality in the health sector. The analyses use household data to examine the distribution of service use and health expenditures. Each study divides the population into "income" quintiles, estimated using consumption expenditures. The studies measure inequality in the use of and spending on health services. Richer groups are found to have a higher probability of obtaining care when sick, to be more likely to be seen by a doctor, and to have a higher probability of receiving medicines when they are ill, than the poorer groups. The richer also spend more in absolute terms on care. In several instances there are unexpected findings. There is no consistent pattern in the use of private providers. Richer households do not devote a consistently higher percentage of their consumption expenditures to health care. The analyses indicate that intuition concerning inequalities could result in misguided decisions. It would thus be worthwhile to measure inequality to inform policy-making. Additional research could be performed using a common methodology for the collection of data and applying more sophisticated analytical techniques. These analyses could be used to measure the impact of health policy changes on inequality.

            Author and article information

            [1 ]Departments of Preventive Medicine and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
            [2 ]Centre for Chronic Disease Control, New Delhi, India
            [3 ]Public Health Foundation of India, New Delhi, India
            [4 ]Institute for Clinical Effectiveness Research and Health Policy, Buenos Aires, Argentina
            [5 ]Initiative for Cardiovascular Health Research in Developing Countries, New Delhi, India
            [6 ]Department of Epidemiology, Capital Medical University affiliated Beijing Anzhen Hospital and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
            [7 ]Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
            [8 ]Department of Internal Medicine, Shree Hindu Mandal Hospital, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
            [9 ]Cadre Ward, Navy General Hospital, Beijing, China
            [10 ]Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, United States of America
            [11 ]Division of General Medicine, Columbia University Medical Center, New York, New York, United States of America
            [12 ]Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
            [13 ]School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, United Kingdom
            [14 ]Menzies Centre for Health Policy, University of Sydney, Sydney, Australia
            Universidad Peruana Cayetano Heredia, Peru
            Author notes

            Conceived and designed the experiments: VSA KDR SG KSR SL DP. Performed the experiments: AP-R SH DZ KR SG. Analyzed the data: MDH KDR DP VSA AP-R SH DZ KR SG JIC JEC YL JL SN KRT MD JvE TAG SL AEM AM KSR MS. Contributed reagents/materials/analysis tools: MDH KDR AP-R DZ SH KR VSA SG JIC JEC SN YL JL KRT MD JvE AM AEM TAG MS KSR SL DP. Wrote the paper: VSA MDH.

            Role: Editor
            PLoS One
            PLoS ONE
            Public Library of Science (San Francisco, USA )
            14 June 2011
            : 6
            : 6
            Huffman et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
            Pages: 10
            Research Article
            Coronary Artery Disease
            Clinical Research Design
            Cross-Sectional Studies
            Cardiovascular Disease Epidemiology
            Global Health
            Non-Clinical Medicine
            Health Economics
            Socioeconomic Aspects of Health
            Public Health
            Socioeconomic Aspects of Health
            Social and Behavioral Sciences
            Human Capital
            Economics of Health
            Economics of Poverty
            Development Economics
            Health Economics



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