Decomposition of inequalities in out-of-pocket health expenditure burden in Saudi Arabia.

Out-of-pocket (OOP) health expenditure remains a serious welfare problem worldwide. The aim of this study was to investigate and decompose factors that are associated with inequalities in relative OOP health expenditure, estimated as the percentage of income spent on healthcare, in Saudi Arabia. Data from 10,785 respondents were obtained from a national cross-sectional survey conducted in Saudi Arabia as a part of the 2018 Family Health Survey. Inequalities in relative OOP health expenditure were measured using concentration indices and concentration curves. Moreover, the Wagstaff approach was used to decompose the concentration index of relative OOP health expenditure to assess the contribution of each of its determinants. The results revealed that relative OOP health expenditure in Saudi Arabia are concentrated among the poor (concentration index = -0.151, p < 0.01), resulting in a greater burden for the poor. Decomposition of the factors that contribute to this inequality revealed heterogeneity. Specifically, factors that increase the burden amongst the poor included aged above 60 years, and low levels of education, whereas factors that increase the burden amongst the rich included male gender, below the age of 60 years, secondary and higher education, having health insurance coverage, and suffering from chronic illnesses. Importantly, these results demonstrate that poor people might be exposed to hazardous health spending. Therefore, efforts to curbing OOP health expenditure should be framed by taking into account the specific factors that drive the burden towards the poor, such as older age and lack of education, so as to safeguard the overall welfare of the poor.

Al-Hanawi MK 《-》

Assessing the inequality in out-of-pocket health expenditure among the chronically and non-chronically ill in Saudi Arabia: a Blinder-Oaxaca decomposition analysis.

Many high-income countries have made significant progress towards achieving universal health coverage. Nevertheless, out-of-pocket (OOP) health expenditure continues to undermine the effectiveness of the universal healthcare system. In Saudi Arabia, due to the overburdened free public health services, many people opt for alternative healthcare services, risking high OOP payments. The presence of chronic illness further exacerbates this situation. However, there is limited evidence on the extent of the gap in OOP health expenditure between the chronically and non-chronically ill and the associated drivers contributing to this gap. The aim of this study was to assess inequalities in relative OOP health expenditure, estimated as the percentage of income spent on healthcare, between the chronically and non-chronically ill in Saudi Arabia and their associated drivers. Data from 10,785 respondents were obtained from a national cross-sectional survey conducted in Saudi Arabia as part of the 2018 Family Health Survey. Inequalities in relative OOP health expenditure were measured using concentration indices and curves. A Blinder-Oaxaca decomposition analysis was used to assess the differences in relative OOP health expenditure between the chronically and non-chronically ill. The results showed that the chronically ill experience a higher financial burden due to healthcare services in absolute costs and relative to their income compared to the non-chronically ill. In addition, there was higher pro-poor inequality (-0.1985) in relative OOP health expenditure among the chronically ill compared to that (-0.1195) among the non-chronically ill. There was a 2.6% gap in relative OOP health expenditure among the chronically and non-chronically ill, of which 53.8% was attributable to unexplained factors, with explained factors accounting for the 46.2% difference. Factors that significantly contributed to the overall gap (i.e. both explained and non-explained factors) included employment status, insurance status, self-rated health, and periodic check-ups. This study underscores the high financial burden due to OOP payments among the chronically ill and the existence of pro-poor inequalities. In addition, there is a significant gap in relative OOP health expenditure between the chronically and non-chronically ill, which is mainly attributable to differences in socio-economic characteristics. This indicates that the existing financial mechanisms have not been sufficient in cushioning the chronically ill and less well off in Saudi Arabia. This situation calls for health policymakers to integrate a social safety net into the health financing system and to prioritize the disadvantaged population, thereby ensuring access to health services without experiencing financial hardship.

Al-Hanawi MK ，Njagi P 《International Journal for Equity in Health》

Health Insurance and Out-Of-Pocket Expenditure on Health and Medicine: Heterogeneities along Income.

Background: Achieving universal health coverage is an important objective enshrined in the 2015 global Sustainable Development Goals. However, the rising cost of healthcare remains an obstacle to the attainment of the universal health coverage. Health insurance is considered an option to reduce out-of-pocket (OOP) expenditure on health and medicine. Nevertheless, the relationship between insurance and the OOP along welfare distributions is not well understood. This study investigates the heterogeneous association between health insurance and OOP expenditure on health and medicine, along income, using data from the Kingdom of Saudi Arabia. Methods: This study used data of 8655 individuals drawn from the Saudi Family Health Survey conducted in 2018. The study adopts Tobit models to account for possible corner solution due to individuals with zero expenditure on health. We minimize the confounding effects of non-random selection into the insurance program by estimating the Tobit equations on a sample weighted by inverse propensity scores of insurance participation. In addition, we test whether the health insurance differently relates to OOP on health and medicine amongst people with access to free medical care as opposed to those without this privilege. The study estimates separate models for OOP expenditure on health and on medicines. Results: Health insurance reduces OOP expenditure on health by 2.0% and OOP expenditure on medicine by 2.4% amongst the general population while increasing the OOP expenditure on health by 0.2% and OOP expenditure on medicine by 0.2%, once income of the insured rises. The relationship between the insurance and OOP expenditure is robust only amongst the citizens, a sub-sample that also has access to free public healthcare. Specifically, the insurance reduces OOP expenditure on health by 3.6% and OOP on medicine by 5.2% and increases OOP expenditure on health by 0.4% and OOP expenditure on medicine by 0.5% once income of the insured increases amongst Saudi citizens. In addition, targeting medicines can lead to greater changes in OOP. The relationship between insurance and OOP is stronger for medicine relative to that observed on health expenditure. Conclusion: Our findings suggest that insurance induces different effects along the income spectrum. Hence, policy needs to be aware of the possible welfare distribution impacts of upscaling or downscaling the coverage of insurance amongst the populations, while pursuing universal healthcare coverage.

Al-Hanawi MK ，Mwale ML ，Qattan AMN 《-》

Households' Direct Economic Burden Associated with Chronic Non-Communicable Diseases in Saudi Arabia.

Almalki ZS ，Alahmari AK ，Alqahtani N ，Alzarea AI ，Alshehri AM ，Alruwaybiah AM ，Alanazi BA ，Alqahtani AM ，Ahmed NJ ... -  《-》

Economic Analysis of Inequality in Preventive Health Check-Ups Uptake in Saudi Arabia.

Background: Undertaking preventive health check-ups has proven to be an important strategy in the fight against several diseases. However, various socioeconomic circumstances may hinder participating in such an important health exercise for many people. With the growth in the burden of non-communicable diseases in Saudi Arabia, it is thus essential that people take an active role in undertaking preventive health check-ups. However, the extent to which this behavior is determined by inequalities in socioeconomic circumstances remains not well-documented. The aim of this study was to examine the socioeconomic inequalities in undertaking preventive health check-ups in Saudi Arabia, using a national survey with a sample of 11,528 respondents. Methods: Data from the Saudi Family Health Survey conducted in 2018 by the General Authority for Statistics were used for the analysis of this study. Univariate, bivariate, and multivariate logistic regression analyses were employed to examine the socioeconomic factors associated with undertaking preventive health check-ups. Concentration indices were calculated, and associated concentration curves were used to assess the socioeconomic inequalities in preventive health check-ups uptake. Moreover, decomposition analysis was performed to examine the extent to which the socioeconomic variables affect uptake of preventive health check-ups. Results: The results reveal that being older adults, more educated, insured, and married increase the probability of undertaking preventive health check-ups. Regarding socioeconomic inequalities, preventive health check-ups uptake was concentrated among the wealthier (concentration index: 0.0831; P < 0.001). However, some differences were observed in terms of socioeconomic inequality across the regions. Decomposition of the Erreygers index supported the analysis of the determinants and suggested that income, and education were the primary drivers of the associated inequality. Conclusions: These results suggest that the government of Saudi Arabia should develop intervention programs and strategies that promote the uptake of health check-ups among the vulnerable group to reduce inequalities. Of particular importance is the need for more health-related education among the poor and those with lower education in order to raise their awareness on the benefits and advantages of conducting health examinations.

Al-Hanawi MK ，Chirwa GC 《Frontiers in Public Health》