Detecting changes in financial protection: creating evidence for policy in Estonia

Abstract

Ninety-four per cent of the Estonian population is covered by public health insurance, but private expenditure has been increasing quickly both in real terms and as a percentage of total health expenditure. To date, little attention has been given to the impact this could have on the population's financial protection. Out-of-pocket payments, which account for the bulk of the private expenditure in many low- and middle-income countries, can push people into poverty and more generally represent too high a burden for some households. It is therefore very important that governments monitor the impact of out-of-pocket payments on health. Using an example from Estonia, this paper aims to illustrate that, if household budget survey data are available, monitoring a population's financial protection is not a complex undertaking. Further, by combining simple statistical analyses of these data with a good knowledge of a country's health system, it is possible to give a fairly detailed diagnostic of the nature of the population's coverage limitation. This allows for the presentation of easily interpretable results that can raise awareness among policy-makers and help to target adequate policy responses. Using Estonian household budget surveys from 1995, 2001 and 2002, we show that the proportion of households who spend more than 20% of their capacity to pay on health increased from 3.4% in 1995 to 7.4% in 2002 and that in 2002, 1.3% of the population fell into poverty because of health payments. Logistic regression helps in identifying the population most at risk: elderly patients who belong to poor households and spend high amounts on medicines. This study, which can be replicated, did raise awareness among policy-makers about the changes in financial protection over the years in Estonia.

System-wide impacts of hospital payment reforms: Evidence from Central and Eastern Europe and Central Asia

“…But there is also evidence that out-of-pocket spending on drugs increased in some countries following the transition from the old Semashko system (Habicht et al, 2006); whether this was contemporaneous with let alone a consequence of changes to hospital payment methods is unclear, however. Whatever the explanation of the impact of hospital payment reform on private spending, the results in our paper raise concerns about the potentially pervasive effects that the joint implementation of co-payments and user charges on the one hand, and new payment methods such as FFS on the other hand, may have on access to health care and the incidence of catastrophic health spending (Wagstaff and van Doorslaer, 2003).…”

Unexpected impact of changes in out-of-pocket payments for health care on Czech household budgets

“…"Out-of-pocket financing of health is the most likely reason that would characterize unfair distributions of health financing, and to generate severe financial losses and risk of impoverishment for some families" ([10]:4). Many experts argue that out-of-pocket payments are usually the most regressive way to pay for health ( [11][12][13][14][15][16]33]) and the way that most exposes people to catastrophic financial risks [26,2].…”

“…A more recent study focusing on the burden of private expenditure was made in Turkey in 2006 [15]. Similar studies were conducted in Estonia [13,12], Latvia [16] and in France in 2006 [24]. A lot of space was also devoted to the discussion about the burden of households with health care expenditure in Belgium [7,23].…”

Investing in health: A wake up call to leaders

“…19 A recent Communication from the European Commission highlights how an accessible health system must consider affordability. 20 increase the financial burden on households and have been shown to reduce the use of care, especially among lower-income individuals 21 and older people, 22 even when the level of charges is low. Applying user charges in primary or ambulatory specialist care may worsen health outcomes and leads to increased spending in other areas (e.g.…”