Crowding-Out Effect of Out-of-Pocket Health Expenditures on Consumption Among Households in Mongolia

Document Type : Original Article

Authors

1 Ach Medical University, Ulaanbaatar, Mongolia

2 Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan

3 School of Medicine, Etugen University, Ulaanbaatar, Mongolia

4 Mongolian Institute of Certified Public Accountants, Ulaanbaatar, Mongolia

5 National Statistics Office of Mongolia, Ulaanbaatar, Mongolia

Abstract

Background 
High out-of-pocket (OOP) health expenditures are a common problem in developing countries. Studies rarely investigate the crowding-out effect of OOP health expenditures on other areas of household consumption. OOP health costs are a colossal burden on families and can lead to adjustments in other areas of consumption to cope with these costs.

Methods 
This cross-sectional study used self-reported household consumption data from the nationally representative Household Socioeconomic Survey (HSES), collected in 2018 by the National Statistical Office of Mongolia. We estimated a quadratic conditional Engel curves system to determine intrahousehold resource allocation among 12 consumption variables. The 3-stage least squared method was used to deal with heteroscedasticity and endogeneity problems to estimate the causal crowding-out effect of OOP.

Results 
The mean monthly OOP health expenditure per household was ₮64 673 (standard deviation [SD] = 259 604), representing approximately 6.9% of total household expenditures. OOP health expenditures were associated with crowding out durables, communication, transportation, and rent, and with crowding in education and heating for all households. The crowding-out effect of ₮10 000 in OOP health expenditures was the largest for food (₮5149, 95% CI = -8582; -1695) and crowding-in effect was largest in heating (₮2691, 95% CI = 737; 4649) in the lowest-income households. The effect of heating was more than 10 times greater than that in highest-income households (₮261, 95% CI = 66; 454); in the highest-income households, food had a crowding-in effect (₮179, 95% CI = -445; 802) in absolute amounts. In terms of absolute amount, the crowding-out effect for food was up to 5 times greater in households without social health insurance (SHI) than in those with SHI.

Conclusion 
Our findings suggest that Mongolia’s OOP health expenses are associated with reduced essential expenditure on items such as durables, communication, transportation, rent, and food. The effect varies by household income level and SHI status, and the lowest- income families were most vulnerable. SHI in Mongolia may not protect households from large OOP health expenditures.

Keywords

References

  1. Obermann K, Jowett M, Kwon S. The role of national health insurance for achieving UHC in the Philippines: a mixed methods analysis. Glob Health Action. 2018;11(1):1483638. doi:10.1080/16549716.2018.1483638
  2. World Health Organization (WHO). The World Health Report: Health Systems Financing: The Path to Universal Coverage: Executive Summary. WHO; 2010.
  3. Lozano R, Fullman N, Mumford JE, et al. Measuring universal health coverage based on an index of effective coverage of health services in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396(10258):1250-1284. doi:10.1016/s0140-6736(20)30750-9
  4. World Health Organization (WHO). World Health Statistics 2019: Monitoring Health for the SDGs, Sustainable Development Goals. Geneva: WHO; 2019.
  5. Wagstaff A, Eozenou P, Smitz M. Out-of-pocket expenditures on health: a global stocktake. World Bank Res Obs. 2020;35(2):123-157. doi:10.1093/wbro/lkz009
  6. World Health Organization (WHO). Global Monitoring Report on Financial Protection in Health 2019. WHO; 2020.
  7. Aregbeshola BS, Khan SM. Out-of-pocket payments, catastrophic health expenditure and poverty among households in Nigeria 2010. Int J Health Policy Manag. 2018;7(9):798-806. doi:10.15171/ijhpm.2018.19
  8. Shet N, Qadiri GJ, Kalal BS, Saldanha S. Impact of out-of-pocket health care financing and health insurance utilization among the population: a systematic review. Int J Health Sci Res. 2018;8(2):249-257.
  9. Kim W, Park EC. Catastrophic health expenditure status and trend of Korea in 2015. Health Policy Manag. 2017;27(1):84-87. doi:10.4332/kjhpa.2017.27.1.84
  10. Van Minh H, Kim Phuong NT, Saksena P, James CD, Xu K. Financial burden of household out-of pocket health expenditure in Vietnam: findings from the National Living Standard Survey 2002-2010. Soc Sci Med. 2013;96:258-263. doi:10.1016/j.socscimed.2012.11.028
  11. Li Y, Wu Q, Liu C, et al. Catastrophic health expenditure and rural household impoverishment in China: what role does the new cooperative health insurance scheme play? PLoS One. 2014;9(4):e93253. doi:10.1371/journal.pone.0093253
  12. Bayarbat U, Li Y. Empirical analysis of relationship between per capita health expenditure and economic growth based on vector autoregressive model (VAR) in Mongolia. Theor Econ Lett. 2020;10(1):154-168. doi:10.4236/tel.2020.101010
  13. Zahoor Z. Socioeconomic Inequality in Primary Health Care Utilization Among the Elderly People: Evidence from Mongolia [dissertation]. University of Eastern Finland; 2019.
  14. Dugee O, Sugar B, Dorjsuren B, Mahal A. Economic impacts of chronic conditions in a country with high levels of population health coverage: lessons from Mongolia. Trop Med Int Health. 2019;24(6):715-726. doi:10.1111/tmi.13231
  15. Erdenee O, Narula IS, Yamazaki C, Kameo S, Koyama H. Mongolian Health Sector Strategic Master Plan (2006-2015): a foundation for achieving universal health coverage. Int J Health Plann Manage. 2019;34(1):e314-e326. doi:10.1002/hpm.2651
  16. Yip W. Healthcare system challenges in Asia. In: Oxford Research Encyclopedia of Economics and Finance. Oxford University Press; 2019.
  17. Onoka CA, Hanson K, Hanefeld J. Towards universal coverage: a policy analysis of the development of the National Health Insurance Scheme in Nigeria. Health Policy Plan. 2015;30(9):1105-1117. doi:10.1093/heapol/czu116
  18. Jigjidsuren A, Byambaa T, Altangerel E, et al. Free and universal access to primary healthcare in Mongolia: the service availability and readiness assessment. BMC Health Serv Res. 2019;19(1):129. doi:10.1186/s12913-019-3932-5
  19. Dorjdagva J, Batbaatar E, Svensson M, Dorjsuren B, Kauhanen J. Catastrophic health expenditure and impoverishment in Mongolia. Int J Equity Health. 2016;15(1):105. doi:10.1186/s12939-016-0395-8
  20. Vian T, Feeley FG, Domente S, Negruta A, Matei A, Habicht J. Barriers to universal health coverage in Republic of Moldova: a policy analysis of formal and informal out-of-pocket payments. BMC Health Serv Res. 2015;15:319. doi:10.1186/s12913-015-0984-z
  21. Taazan B, Yamamoto E, Baatar B, et al. Estimating cost of hospitalization for childbirth at a tertiary hospital in Mongolia. Nagoya J Med Sci. 2020;82(1):47-57. doi:10.18999/nagjms.82.1.47
  22. Bayarsaikhan D, Kwon S, Chimeddagva D. Social health insurance development in Mongolia: opportunities and challenges in moving towards Universal Health Coverage. Int Soc Secur Rev. 2015;68(4):93-113. doi:10.1111/issr.12089
  23. Dorjdagva J, Batbaatar E, Svensson M, Dorjsuren B, Kauhanen J. Catastrophic health expenditure and impoverishment in Mongolia. Int J Equity Health. 2016;15(1):105. doi:10.1186/s12939-016-0395-8
  24. Dorj G, Sunderland B, Sanjjav T, Dorj G, Gendenragchaa B. Drug pricing and reimbursement decision making systems in Mongolia. J Pharm Policy Pract. 2017;10:11. doi:10.1186/s40545-017-0098-6
  25. World Health Organization (WHO). Global Health Expenditure Database (GHED). WHO; 2020.
  26. Dugee O, Palam E, Dorjsuren B, Mahal A. Who is bearing the financial burden of non-communicable diseases in Mongolia? J Glob Health. 2018;8(1):010415. doi:10.7189/jogh.08.010415
  27. Dorjdagva J. Socioeconomic-Related Health Inequalities and Health Care Utilization in Mongolia [dissertation]. University of Eastern Finland; 2017.
  28. Nguyen NM, Nguyen A. Crowding-out effect of tobacco expenditure in Vietnam. Tob Control. 2020;29(Suppl 5):s326-s330. doi:10.1136/tobaccocontrol-2019-055307
  29. Pal R. Out-of-pocket health expenditure: impact on the consumption of Indian households. Oxf Dev Stud. 2013;41(2):258-279. doi:10.1080/13600818.2013.794897
  30. Datta BK, Husain MJ, Fatehin S. The crowding out effect of out-of-pocket medication expenses of two major non-communicable diseases in Pakistan. Int Health. 2020;12(1):50-59. doi:10.1093/inthealth/ihz07
  31. John R, Chelwa G, Vulovic V, Chaloupka F. Using Household Expenditure Surveys for Research in the Economics of Tobacco Control. A Tobacconomics Toolkit. Chicago, IL: Tobacconomics, Health Policy Center, Institute for Health Research and Policy, University of Illinois at Chicago; 2019.
  32. Aronson JR, Johnson P, Lambert PJ. Redistributive effect and unequal income tax treatment. Econ J. 1994;104(423):262-270. doi:10.2307/2234747
  33. Koch SF. Catastrophic health payments: does the equivalence scale matter? Health Policy Plan. 2018;33(8):966-973. doi:10.1093/heapol/czy072
  34. Arsenijevic J, Pavlova M, Groot W. Measuring the catastrophic and impoverishing effect of household health care spending in Serbia. Soc Sci Med. 2013;78:17-25. doi:10.1016/j.socscimed.2012.11.014
  35. Schmidt H, Gostin LO, Emanuel EJ. Public health, universal health coverage, and Sustainable Development Goals: can they coexist? Lancet. 2015;386(9996):928-930. doi:10.1016/s0140-6736(15)60244-6
  36. Odeyemi IA, Nixon J. The role and uptake of private health insurance in different health care systems: are there lessons for developing countries? Clinicoecon Outcomes Res. 2013;5:109-118. doi:10.2147/ceor.s40386
  37. Erlangga D, Suhrcke M, Ali S, Bloor K. The impact of public health insurance on health care utilisation, financial protection and health status in low- and middle-income countries: a systematic review. PLoS One. 2019;14(8):e0219731. doi:10.1371/journal.pone.0219731
  38. Dieleman J, Campbell M, Chapin A, et al. Evolution and patterns of global health financing 1995-2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries. Lancet. 2017;389(10083):1981-2004. doi:10.1016/s0140-6736(17)30874-7
  39. Bayati M, Mehrolhassani MH, Yazdi-Feyzabadi V. A paradoxical situation in regressivity or progressivity of out of pocket payment for health care: which one is a matter of the health policy maker's decision to intervention? Cost Eff Resour Alloc. 2019;17:28. doi:10.1186/s12962-019-0197-0
  40. Banzragch O, Mizunoya S, Bayarjargal M. Education inequality in Mongolia: measurement and causes. Int J Educ Dev. 2019;68:68-79. doi:10.1016/j.ijedudev.2019.04.010
  41. Koch SF, Setshegetso N. Catastrophic health expenditures arising from out-of-pocket payments: evidence from South African income and expenditure surveys. PLoS One. 2020;15(8):e0237217. doi:10.1371/journal.pone.0237217
  42. Somi MF, Butler JR, Vahid F, Njau JD, Abdulla S. Household responses to health risks and shocks: a study from rural Tanzania raises some methodological issues. J Int Dev. 2009;21(2):200-211. doi:10.1002/jid.1555
  43. United Nations Statistics Division. Household Sample Surveys in Developing and Transition Countries. Vol 96. New York: United Nations Publications; 2005.
  44. Bhandari A, Wagner T. Self-reported utilization of health care services: improving measurement and accuracy. Med Care Res Rev. 2006;63(2):217-235. doi:10.1177/1077558705285298
  45. Ssewanyana S, Kasirye I. Estimating Catastrophic Health Expenditures from Household Surveys: Evidence from Living Standard Measurement Surveys (LSMS)-Integrated Surveys on Agriculture (ISA) from Sub-Saharan Africa. Appl Health Econ Health Policy. 2020;18(6):781-788. doi:10.1007/s40258-020-00609-1
  46. Khan JA, Ahmed S, Sultana M, et al. The effect of a community-based health insurance on the out-of-pocket payments for utilizing medically trained providers in Bangladesh. Int Health. 2020;12(4):287-298. doi:10.1093/inthealth/ihz083
  47. Munkh-Erdene L. An Assessment of Mongolian Health Insurance Coverage Among Two Vulnerable Groups: Herdsmen and Students [dissertation]. American University of Armenia (AUA); 2014.
  48. Grigorakis N, Floros C, Tsangari H, Tsoukatos E. Out of pocket payments and social health insurance for private hospital care: Evidence from Greece. Health Policy. 2016;120(8):948-959. doi:10.1016/j.healthpol.2016.06.011
International Journal of Health Policy and Management
Volume 11, Issue 9
September 2022
Pages 1874-1882

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History

  • Receive Date: 21 January 2021
  • Revise Date: 13 June 2021
  • Accept Date: 19 July 2021
  • First Publish Date: 25 August 2021

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