Catastrophic Household Expenditure for Health Care in a Low-Income Society: A Study from Nouna District, Burkina Faso/Depenses De Sante Catastrophiques Des Menages Dans Les Societes a Faibles Revenus: Une Etude Du District De Nouna Au Burkina Faso/Gastos Catastroficos De Los Hogares En Atencion Sanitaria En Una Sociedad De Bajos Ingresos: Estudio Realizado En El Distrito De Nouna, Burkina Faso

Article excerpt

Voir page 26 le resume en francais. En la pagina 26 figura un resumen en espanol.


Any health expenditure that threatens a household's financial capacity to maintain its subsistence needs is termed as catastrophic and does not necessarily equate to high health-care costs. Even relatively small expenditures on health can be financially disastrous for poor households. This is because almost all their available resources are used for basic needs and they are thus less able to cope with even very low health expenditures compared to richer households. (1-7)

WHO estimates that families who spend 50% or more of their non-food expenditure on health care are likely to be impoverished. (8) However, there is no consensus on the catastrophic threshold and cut-off values ranging from 5-20% of the total household income have been reported in the literature. (1, 9-12) Health expenditure has been also defined as catastrophic if a household's health expenditure exceeds 40% of income remaining after subsistence needs have been met. (3)

Households in developed countries are protected from catastrophic spending by adequate health insurance coverage or a tax funded health system. In developing countries, however, high out-of-pocket payments, an absence of risk-pooling mechanisms in health financing systems and high levels of poverty can result in catastrophic health care expenditure. (3)

Certain household characteristics, such as households headed by an elderly or disabled person, families with a low income and those who have a member with chronic disease are at risk for catastrophic expenditure. (1, 12) We analysed different threshold/cut-off values for factors that affect the determinants of household catastrophic spending and attempted to answer the following questions: How much are households currently spending on health care? What percentages of households are suffering from catastrophic health expenditure? Which households are at risk of facing catastrophic payment? What factors lead to catastrophic health expenditure?


Study area

Burkina Faso, a West African country with a population of approximately 11 million, has 45.3% of its population living below the poverty line. (13) It is divided into 11 administrative health regions, comprising 53 health districts, each covering 200 000-300 000 individuals. (14) We conducted the study in Nouna District in north-west Burkina Faso. Almost most of the 230 000 inhabitants in this district are subsistence farmers. (15) User fees was implemented in this district since the early 1990s. Although a national policy on exemption exists, it was not effective in the study area. Out-of-pocket expenditure was more than 50% of the total health care expenditure. (16) There was no risk-pooling mechanism in financing health care during the data collection period.

Study design

We used the Nouna Health District Household Survey (NHDHS) to collect population-based morbidity data and socioeconomic information from 800 households (about 10% of the study population) during June 2000-June 2001. We selected 320 of 2802 households in urban Nouna and 480 of 4630 households in 41 villages (40% urban and 60% rural) by two-stage cluster sampling. In the first stage, seven clusters from urban Nouna and 20 clusters in the 41 rural villages were selected. In the second stage, respondent households were selected from each cluster. The schematic view of the sampling procedure is presented in Fig. 1.


We administered the socioeconomic module twice a year and the morbidity module four times a year to capture seasonal variations. (17) Using a recall period of one month, we collected information on past-perceived illness (reported morbidity), its severity and treatment and expenditure for treatment. Since the total cost of health care encompasses much more than out-of-pocket expenditure, we investigated the direct household costs for seeking treatment. …