Academic journal article Bulletin of the World Health Organization

The Effectiveness of Interventions to Reduce the Household Economic Burden of Illness and Injury: A Systematic Review/ Efficacite Des Interventions Visant a Reduire la Charge Economique Des Maladies et Des Blessures Sur Les Menages: Une Revue Systematique/ la Efectividad De Las Intervenciones Para Reducir la Carga Economica Familiar De Enfermedades Y Lesiones: Una Revision Sistematica

Academic journal article Bulletin of the World Health Organization

The Effectiveness of Interventions to Reduce the Household Economic Burden of Illness and Injury: A Systematic Review/ Efficacite Des Interventions Visant a Reduire la Charge Economique Des Maladies et Des Blessures Sur Les Menages: Une Revue Systematique/ la Efectividad De Las Intervenciones Para Reducir la Carga Economica Familiar De Enfermedades Y Lesiones: Una Revision Sistematica

Article excerpt

Introduction

Each year, globally, around 150 million people struggle to meet the costs of accessing and using health care and approximately 100 million people are driven below the poverty line by such costs. (1) Many people delay or avoid health care because it is--or, at least, is perceived to be--unaffordable. (2-4) Most of those who struggle to meet the out-of-pocket costs of health care live in low-income countries that have poorly funded health systems and inadequate measures to ensure the financial protection of households against high health-care expenditure. However, the problem is not limited to such countries. In 2007, for example, 62% of the personal bankruptcies recorded in the United States of America (USA) were attributed to medical debt (5) and 11% of the individuals found insolvent in Australia cited ill-health or lack of health insurance as the primary reason for their insolvency. (6) Substantial and unpredictable one-off health-care payments and a steady flow of unbudgeted medical bills can lead many households--particularly those already marginalized by socioeconomic disadvantage--towards catastrophic health-care expenditure. (7)

The economic burden of illness in a household is only partly explained by out-of-pocket expenditure. The full evaluation of such burden requires a multidimensional framework - to move beyond absolute spending to incorporate measures that examine the broader impacts of illness or injury on the household economy--e.g. loss of employment--as well as the affordability of care, a household's response to an injury or illness and the consequences of those responses for the household. (8,9) Most research in this area has been observational and has demonstrated that households will employ several strategies--to deal with unbudgeted costs of medical care and unplanned departures from the workforce--when coping with the onset of an illness or injury, especially in the main income earner. Such coping strategies include drawing on available social resources and networks, cutting back on essential living expenses, drawing on savings, selling assets, borrowing money, entering into formal or informal loan agreements, increasing credit or debt and even moving house. (3,4) Although these strategies may help leverage the resources needed to pay for care, they can also have adverse effects on treatment-seeking behaviour and the long-term economic well-being and resilience of the household. (3,4,7)

The provision of adequate financial protection--from the costs of seeking and using medical care--is a critical marker of the effectiveness of a health-care system. (10) The World Health Organization has encouraged its Member States to provide universal health coverage in some form and the United Nations has recently passed a declaration that calls for universal access to health care that does not cause financial hardship. (11) Such a goal--like other post-2015 development goals aimed at alleviating poverty--is unlikely to be achieved without further development and implementation of national health-insurance schemes. There is considerable evidence, most notably from the RAND Health Insurance Experiments, (12) that indicates how health insurance can protect the finances of households affected by illness or injury, by restricting individual healthcare expenditure. However, although such insurance is one of the most important population-based policy interventions to mitigate the economic burden of injury or illness, it is not sufficient, on its own, to provide full protection from catastrophic health expenditure. (13,14) The effectiveness of health insurance in protecting individuals who are intense users of medical care--e.g. those with chronic illness or long-term injuries--has yet to be elucidated. Furthermore, limited coverage of services and high levels of co-payment can often mean that households with health insurance remain at risk of catastrophic health-care expenditures and economic hardship. …

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