Socioeconomic inequality in catastrophic health expenditure in Brazil

Boing, Alexandra Crispim; Bertoldi, Andréa Dâmaso; Barros, Aluísio Jardim Dornellas de; Posenato, Leila Garcia; Peres, Karen Glazer

doi:10.1590/S0034-8910.2014048005111

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Brasil

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Sumário

Original Articles • Rev. Saúde Pública 48 (4) • Aug 2014 • https://doi.org/10.1590/S0034-8910.2014048005111 copy

Socioeconomic inequality in catastrophic health expenditure in Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

OBJECTIVE

To analyze the evolution of catastrophic health expenditure and the inequalities in such expenses, according to the socioeconomic characteristics of Brazilian families.

METHODS

Data from the National Household Budget 2002-2003 (48,470 households) and 2008-2009 (55,970 households) were analyzed. Catastrophic health expenditure was defined as excess expenditure, considering different methods of calculation: 10.0% and 20.0% of total consumption and 40.0% of the family’s capacity to pay. The National Economic Indicator and schooling were considered as socioeconomic characteristics. Inequality measures utilized were the relative difference between rates, the rates ratio, and concentration index.

RESULTS

The catastrophic health expenditure varied between 0.7% and 21.0%, depending on the calculation method. The lowest prevalences were noted in relation to the capacity to pay, while the highest, in relation to total consumption. The prevalence of catastrophic health expenditure increased by 25.0% from 2002-2003 to 2008-2009 when the cutoff point of 20.0% relating to the total consumption was considered and by 100% when 40.0% or more of the capacity to pay was applied as the cut-off point. Socioeconomic inequalities in the catastrophic health expenditure in Brazil between 2002-2003 and 2008-2009 increased significantly, becoming 5.20 times higher among the poorest and 4.17 times higher among the least educated.

CONCLUSIONS

There was an increase in catastrophic health expenditure among Brazilian families, principally among the poorest and those headed by the least-educated individuals, contributing to an increase in social inequality.

Income; Health Expenditure; Health Inequality; Social Inequity; Health Economics

Variable	2002-2003		2008-2009

Catastrophic health expenditure	%	95%CI	%	95%CI
Total consumption
≥ 10.0%	14.6	14.1;15.2	18.2	17.7;18.7
≥ 20.0%	3.6	3.4;3.9	5.8	5.5;6.1
Total consumption net of food
≥ 10.0%	21.1	20.6;21.9	25.0	24.4;25.6
≥ 20.0%	6.5	6.2;6.9	8.9	8.5;9.2
Capacity to pay
≥ 20.0%	5.9	5.6;6.3	8.3	8.0;8.7
≥ 40.0%	0.7	0.6;0.8	1.4	1.3;1.5

Variable	2002-2003

Catastrophic Health expenditure	Q1^a		Q2		Q3		Q4		Q5		p^b

	%	95%CI	%	95%CI	%	95%CI	%	95%CI	%	95%CI
Total consumption
≥ 10.0%	12.9	12.2;13.7	14.3	13.1;15.6	14.2	13.0;15.5	16.8	15.3;18.4	16.3	14.4;18.2	< 0.001
≥ 20.0%	4.0	3.6;4.5	3.9	3.2;4.6	3.7	3.0;4.4	3.1	2.5;3.8	2.6	2.0;3.3	0.141
Total consumption net of food
≥ 10.0%	20.9	20.0;21.8	20.8	19.4;22.2	21.1	19.6;22.6	22.3	20.5;24.0	20.9	18.8;22.9	0.42
≥ 20.0%	7.6	7.0;8.2	7.0	6.2;7.9	6.4	5.5;7.3	5.6	4.6;6.5	3.9	3.1;4.7	< 0.001
Capacity to pay
≥ 20.0%	7.2	6.6;6.8	6.5	5.6;7.3	5.7	4.8;6.6	4.7	3.8;5.5	3.4	2.6;4.1	< 0.001
≥ 40.0%	1.0	0.8;1.2	0.9	0.6;1.2	0.6	0.4;0.8	0.3	0.1;0.4	0.3	0.08;0.6	< 0.001

	2008-2009

Total consumption
≥ 10.0%	18.4	17.5;19.4	18.3	17.2;19.3	18.3	17.2;19.4	18.4	17.2;19.7	17.7	16.4;19.0	0.122
≥ 20.0%	7.3	6.6;7.9	6.2	5.5;6.8	6.2	5.5;7.0	5.5	4.7;6.2	3.7	3.2;4.3	< 0.001
Total consumption net of food
≥ 10.0%	28.0	26.9;29.0	25.6	24.5;26.8	24.8	23.6;26.0	23.9	22.6;25.3	22.7	21.2;24.2	< 0.001
≥ 20.0%	12.0	11.2;12.8	9.8	9.0;10.5	9.3	8.5;10.1	7.9	7.0;8.7	5.5	4.7;6.2	< 0.001
Capacity to pay
≥ 20.0%	11.4	10.6;12.2	9.2	8.4;10.0	8.7	7.9;9.5	7.2	6.4;8.0	5.0	4.2;5.6	< 0.001
≥ 40.0%	2.6	2.2;2.9	1.6	1.3;1.9	1.4	1.0;1.7	0.9	0.6;1.2	0.5	0.3;0.7	< 0.001

Variable	2002-2003

Catastrophic health expenditure	E1^a		E2		E3		E4		p^b

	%	95%CI	%	95%CI	%	95%CI	%	95%CI
Total consumption
≥ 10.0%	16.1	15.3;16.9	12.9	11.7;14.1	12.4	11.2;13.5	15.4	13.6;17.3	0.003
≥ 20.0%	4.6	4.2;5.0	2.6	2.0;3.1	2.6	2.0;3.1	3.3	2.4;4.3	< 0.001
Total consumption net of food
≥ 10.0%	23.8	22.9;24.6	19.0	17.7;20.4	18.4	17.0;19.8	19.3	17.3;21.4	< 0.001
≥ 20.0%	8.7	8.1;9.2	4.6	3.9;5.2	4.5	3.8;5.2	4.2	3.3;5.2	< 0.001
Capacity to pay
≥ 20.0%	8.0	7.4;8.5	4.2	3.5;4.8	3.8	3.2;4.4	3.8	2.8;4.7	< 0.001
≥ 40.0%	1.2	1.0;1.3	0.4	0.2;0.5	0.4	0.2;0.5	0.2	0.0;0.5	< 0.001

	2008-2009

Total consumption
≥ 10.0%	23.5	22.7;24.3	16.2	14.3;18.0	11.1	10.1;12.1	17.5	16.1;19.0	< 0.001
≥ 20.0%	8.7	8.2;9.2	4.6	3.5;5.6	3.2	2.6;3.8	4.5	3.8;5.2	< 0.001
Total consumption net of food
≥ 10.0%	32.1	31.2;33.0	23.7	21.6;25.8	16.7	15.5;17.9	22.4	20.8;23.9	< 0.001
≥ 20.0%	13.5	12.8;14.1	6.8	5.6;8.0	5.0	4.3;5.7	6.3	5.4;7.2	< 0.001
Capacity to pay
≥ 20.0%	12.7	12.1;13.3	6.4	5.2;7.6	4.7	4.0;5.4	5.6	4.8;6.4	< 0.001
≥ 40.0%	2.5	2.2;2.8	1.0	0.6;1.4	0.7	0.4;1.0	0.6	0.4;0.9	< 0.001

Variable	DEI^a

Catastrophic health expenditure	Difference between rates (Q1-Q5)		Ratio of rates (Q1/Q5)

	2002-2003	2008-2009	2002-2003	2008-2009
Total consumption
≥ 10.0%	-3.4	0.7	0.8	1.0
≥ 20.0%	1.4	3.6	1.5	2.0
Total consumption net of food
≥ 10.0%	0.0	5.3	1.0	1.2
≥ 20.0%	3.7	6.5	2.0	2.2
Capacity to pay
≥ 20.0%	3.8	6.4	2.1	2.3
≥ 40.0%	0.7	2.1	3.3	5.2

	Schooling^b

Total consumption
≥ 10.0%	0.7	6.0	1.0	1.3
≥ 20.0%	1.3	4.2	1.4	1.9
Total consumption net of food
≥ 10.0%	4.5	9.7	1.2	1.4
≥ 20.0%	4.5	7.2	2.1	2.1
Capacity to pay
≥ 20.0%	4.2	7.1	2.1	2.3
≥ 40.0%	1.0	1.9	6.0	4.2

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[1] Correspondence Alexandra Crispim Boing. Universidade Federal de Santa Catarina. Centro de Ciências da Saúde. Campus Universitário – Trindade. 88034-500 Florianópolis, SC, Brasil. E-mail: acboing@gmail.com