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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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              Coping with health-care costs: implications for the measurement of catastrophic expenditures and poverty.

              In the absence of formal health insurance, we argue that the strategies households adopt to finance health care have important implications for the measurement and interpretation of how health payments impact on consumption and poverty. Given data on source of finance, we propose to (a) approximate the relative impact of health payments on current consumption with a 'coping'-adjusted health expenditure ratio, (b) uncover poverty that is 'hidden' because total household expenditure is inflated by financial coping strategies and (c) identify poverty that is 'transient' because necessary consumption is temporarily sacrificed to pay for health care. Measures that ignore coping strategies not only overstate the risk to current consumption and exaggerate the scale of catastrophic payments but also overlook the long-run burden of health payments. Nationally representative data from India reveal that coping strategies finance as much as three-quarters of the cost of inpatient care. Payments for inpatient care exceed 10% of total household expenditure for around 30% of hospitalized households but less than 4% sacrifice more than 10% of current consumption to accommodate this spending.Ignoring health payments leads to underestimate poverty by 7-8% points among hospitalized households; 80% of this adjustment is hidden poverty due to coping.

                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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