Understanding variations in catastrophic health expenditure, its underlying determinants and impoverishment in Sub-Saharan African countries: a scoping review

Abstract

BackgroundTo assess the financial burden due to out of pocket (OOP) payments, two mutually exclusive approaches have been used: catastrophic health expenditure (CHE) and impoverishment. Sub-Saharan African (SSA) countries primarily rely on OOP and are thus challenged with providing financial protection to the populations. To understand the variations in CHE and impoverishment in SSA, and the underlying determinants of CHE, a scoping review of the existing evidence was conducted.MethodsThis review is guided by Arksey and O’Malley scoping review framework. A search was conducted in several databases including PubMed, EBSCO (EconLit, PsychoInfo, CINAHL), Web of Science, Jstor and virtual libraries of the World Health Organizations (WHO) and the World Bank. The primary outcome of interest was catastrophic health expenditure/impoverishment, while the secondary outcome was the associated risk factors.ResultsThirty-four (34) studies that met the inclusion criteria were fully assessed. CHE was higher amongst West African countries and amongst patients receiving treatment for HIV/ART, TB, malaria and chronic illnesses. Risk factors associated with CHE included household economic status, type of health provider, socio-demographic characteristics of household members, type of illness, social insurance schemes, geographical location and household size/composition. The proportion of households that are impoverished has increased over time across countries and also within the countries.ConclusionThis review demonstrated that CHE/impoverishment is pervasive in SSA, and the magnitude varies across and within countries and over time. Socio-economic factors are seen to drive CHE with the poor being the most affected, and they vary across countries. This calls for intensifying health policies and financing structures in SSA, to provide equitable access to all populations especially the most poor and vulnerable. There is a need to innovate and draw lessons from the ‘informal’ social networks/schemes as they are reported to be more effective in cushioning the financial burden.Electronic supplementary materialThe online version of this article (10.1186/s13643-018-0799-1) contains supplementary material, which is available to authorized users.

A review of the incidence and determinants of catastrophic health expenditure in Nigeria: Implications for universal health coverage

“…It was revealing to find that the incidence of outpatient CHE was highest for type 2 diabetes and tuberculosis while HIV care incurred the most CHE among inpatients. This could be mostly attributed to the chronic course and long‐term care associated with these diseases . Although CHE was highest in the southeastern part of Nigeria, this finding should be interpreted with caution as the region contributed the highest number of publications included in the review.…”

“…Appraisal of the quality of the studies included in this review was carried out by the first author in consultation with the other authors using the Quality Assessment Tool for Observational Cohort and Cross‐Sectional Studies. This tool for quality assessment has been used to assess the quality of studies in other systematic reviews (Appendix S3). The quality assessment tool consists of 14 questions assessing different aspects of a study including but not limited to definition of objectives, study population, sampling strategy, sample size, and statistical analyses.…”

“…Appraisal of the quality of the studies included in this review was carried out by the first author in consultation with the other authors using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. This tool for quality assessment has been used to assess the quality of studies in other systematic reviews 27,28 (Appendix S3).…”

Determinants of individual healthcare expenditure: A cross‐sectional analysis in rural Burkina Faso

“…Evidence indicates that even in case of partial user fee removal, the very poor and ill often cannot afford to pay for their treatment due to uncovered costs or have to sell assets in order to be able to do so . High rates of OOPE have been shown to perpetuate and/or generate impoverishment across sub‐Saharan African (SSA) countries . Health financing in many LMICs still relies largely on direct user payments, leaving ill people exposed to potentially high OOPE on a large scale …”

“…High rates of OOPE have been shown to perpetuate and/or generate impoverishment across sub‐Saharan African (SSA) countries . Health financing in many LMICs still relies largely on direct user payments, leaving ill people exposed to potentially high OOPE on a large scale …”