Determining factors of catastrophic health spending in Bogota, Colombia

Author(s): Jeannette Liliana Amaya Lara and Fernando Ruiz Gómez

Source: International Journal of Health Care Finance and Economics, Vol. 11, No. 2 (June
2011), pp. 83-100
Published by: Springer
Stable URL: http://www.jstor.org/stable/23279874
Accessed: 18-09-2016 04:50 UTC

REFERENCES
Linked references are available on JSTOR for this article:
http://www.jstor.org/stable/23279874?seq=1&cid=pdf-reference#references_tab_contents
You may need to log in to JSTOR to access the linked references.

JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted
digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about
JSTOR, please contact support@jstor.org.

Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at
http://about.jstor.org/terms

Springer is collaborating with JSTOR to digitize, preserve and extend access to International Journal of
Health Care Finance and Economics

This content downloaded from 128.59.222.107 on Sun, 18 Sep 2016 04:50:50 UTC
All use subject to http://about.jstor.org/terms
Int J Health Care Finance Econ (2011) 11:83-100
DOI !0.1007/s 10754-011-9089-3

Determining factors of catastrophic health spending

in Bogota, Colombia

Jeannette Liliana Amaya Lara • Fernando Ruiz Gomez

Received: 24 November 2009 / Accepted: 16 February 2011 / Published online: 27 February 2011
© Springer Science+Business Media, LLC 2011

Abstract This study tests whether the low-income population in Bogota not insured under
the General Social Security Health System is able to economically handle unexpected health
problems or not. It used data from the Health Services Use and Expenditure Study con
ducted in Colombia in 2001, for which each household recorded its monthly out-of-pocket
health expenditure during the year and the household income was measured as the sum of
each member's contribution to the household. Payment capacity or available income and
catastrophic health spending were based on the latest methodology proposed by the World
Health Organization (WHO) in 2005. A probit model was adjusted to determine the factors
that significantly influence the likelihood of a household having catastrophic health spend
ing. The percentage of households with catastrophic health spending in Bogota was 4.9%;
incidence was higher in low-income households where none of the members were affiliated
to social security, where there had been an in-patient event, and where the heads of household
were over 60 years of age. There is no statistical evidence for rejecting the hypothesis under
study, which states that low-income households that have no health insurance are more likely
to have catastrophic health spending than higher-income households with health insurance.

Keywords Catastrophic spending ■ Out-of-pocket expenditure • Health service inequity •

Health insurance • Health economy

JEL Classification 110 • 130

Introduction

Before 1993 Law 100 was promulgated, the Colombian health system was organized into
subsystems that had their own funding and took care of population groups according to their

J. L. Amaya Lara (O) • F. Ruiz Gomez

Center for Development Projects-Cendex, Pontificia Universidad Javeriana,
Carrera 7 No. 40-62, Bogota, Colombia
e-mail: amayaj@javeriana.edu.co
F. Ruiz Gomez
e-mail: fruiz@javeriana.edu.co

*5) Springer

This content downloaded from 128.59.222.107 on Sun, 18 Sep 2016 04:50:50 UTC
All use subject to http://about.jstor.org/terms
 84 J. L. Amaya Lara, F. Ruiz Gomez

payment capacity. Therefore, there was little access to health services for the low-income
population that worked in the informal job sector, household coverage was minimal, and a
good part of the health expenses was covered through direct payments.
1993 Law 100 sought universal access to social security, to ensure efficient, equitable
service provision. Since its implementation, there has been substantial improvement in affil
iation indexes. Nevertheless, there is still a large percentage of non-insured households that
cannot deal with out-of-pocket health expenditure; that may lead to catastrophic spending
for such households depending on their payment capacity. The purpose of this study is to
verify whether low-income households in Bogota not affiliated to the General Social Security
Health System (GSSHS) have little economic capacity to resolve health problems through
out-of-pocket payments or not.
The article starts by describing the situation of the Colombian health system and defining
catastrophic health spending based on studies conducted on that topic. It then presents the
results of the probit model used to identify the factors with significant influence on the likeli
hood of catastrophic health spending. Results show evidence of the magnitude of catastrophic
health spending in Bogota, Colombia, as well as its determinants. Finally, the hypothesis that
the groups most vulnerable to out-of-pocket catastrophic health spending are non-insured
households with lower per capita income is tested for confirmation or rejection.

Background

The health system in Colombia is undergoing a transition period. It has left behind a split
scheme characterized by health service access inequity and limited affiliation to the sys
tem and is advancing toward the segmented scheme of progressiveness as set forth in 1993
Law 100. That law created the new GSSHS through which insurance for the population was
segmented into contributive and subsidized policies. The reform increased social security
affiliation by incorporating the poor population into the subsidized policy and by expand
ing coverage to the immediate family of the workers insured under the contributive pol
icy (Inter-American Development Bank 2006). Notwithstanding, in 2001 there was still a
segment of the population that was not insured; it represented 32% of the total insurable
population in Bogota (O'Meara et al. 2003), with high out-of-pocket health expenditure
(Ruiz et al. 2006).
The affiliation to contributive social health insurance, comprised of the population work
ing in the formal job sector, has been obstructed by an increasing number of workers in the
informal job sector (Universidad Externado 2001) as well as by the difficulty of targeting
the non-insured population with payment capacity. Similarly, there have not been sufficient
incentives for the non-insured population to take out insurance to cover their health expenses
and avoid financial risks. Thus, although financial protection against events of illness is
augmenting among the insured population, the non-insured do not have such protection.
Therefore, the latter have a greater risk of incurring in catastrophic health spending if they
fall ill because the related expenses must be covered through out-of-pocket payments.
Health care services may be regarded as an uncertain asset because when a person will
fall ill and how the illness will develop are unknowns that are impossible to determine;
therefore, they cannot be assured (Arrow 1963). The level of health-related out-of-pocket
expenditure is an indicator of the lack of financial protection offered by the social security
system. It is doomed to fail because it is the most inefficient and least equitable manner of
financing a health system (Knaul et al. 2005). Out-of-pocket health expenditure can lead
households to poverty (Limwattananon et al. 2007; Wagstaff and van Doorslaer 2003) but

<£) Springer

This content downloaded from 128.59.222.107 on Sun, 18 Sep 2016 04:50:50 UTC
All use subject to http://about.jstor.org/terms
Determining factors of catastrophic health 85

that can be prevented through health schemes that insure households against catastrophic
health spending.
Health insurance seeks to reduce the uncertainty arising from the financial risk associated
with health services, including out-patient, in-patient or medicine supply services (Friedman
1974; van de Ven et al. 1981). More specifically, admission to a hospital significantly influ
ences the possibility of incurring in catastrophic spending and poverty (Limwattananon et al.
2007; Perticara 2008); so can out-patient events or medicine supply (Pérez et al. 2005; Sesma
et al. 2004).
In that sense, being affiliated to one of the social security health policies becomes crucial
when the household is faced with a health problem and must make direct out-of-pocket pay
ments. Indeed, if a health problem arises and the household is not insured under the GSSHS,
the consumer must entirely bear the service costs, which can be tragic for households that
do not have sufficient economic capacity (Berki 1986; Sesma et al. 2005; Wagstaff and van
Doorslaer 2003; Xu et al. 2003a; O'Donnell et al. 2005; Wagstaff 2005, 2008).
One of the segments that are impeded from affiliating to the GSSHS is the population that
works in the informal job sector given that only formal sector workers are allowed to affiliate.
Periods of economic difficulty generally lead to a drop in formal sector jobs, which means a
loss of social security coverage and, consequently, reduced financial health protection (Knaul
et al. 2007). The absence of efficient mechanisms to ensure this population group's access
to insurance schemes decreases the possibility of protecting them against catastrophic health
spending and impoverishment.
Empirical evidence shows that household characteristics, such as household size, head
of household's educational level, and the presence in the household of elderly or disabled
persons, also affect the possibility of incurring in catastrophic health spending (Merlis 2002;
Wyszewianski 1986b). Studies show that the households with most health expenses are those
in rural areas, with some household members who are over 60 years old, children or disabled,
where the head of household is a woman or a person over 60 years old or a person with little for
mal education (Sesma et al. 2004; Torres and Knaul 2003; Hernandez et al. 2008). Also, find
ings show that households with a low economic level are more vulnerable to a drop in income
and to incurring in catastrophic out-of-pocket expenditure when faced with a health incident
that requires medical attention (Knaul et al. 2005; Cruz et al. 2006; Hernandez et al. 2008).
An international study conducted in 59 countries around the world, nine of them Latin
American countries, places Colombia number 56 with 6.26% of its households incurring
in catastrophic health spending. It was followed by Azerbaijan (7.15%), Brazil (10.27%),
and Vietnam (10.45%), the three countries with the least financial protection. Among the
Latin American countries that participated in the study, Colombia had the second highest
catastrophic spending; Brazil taking first place (Xu et al. 2003a).
In the Latin American ambit, Mexico boasts diverse studies on the magnitude of cata
strophic health spending. Indeed, the Mexican Foundation for Health (Funsalud is the Mex
ican acronym) put the first catastrophic health spending measurement methodology into
operation (Sesma et al. 2004). Those studies show that non-insured, poor rural households
run the highest risk of catastrophic health spending, as well as households with disabled
persons or elderly adults and newborns (Hernandez et al. 2008; Sesma et al. 2005).
In Mexico the relation between economic behavior and households with excessive health
spending proves the importance of being affiliated to the social security system, to enable
facing periods of illness that may lead households to catastrophic spending or impoverish
ment, particularly during periods of economic crisis (Knaul et al. 2005). The study on the
evolution of catastrophic health spending and impoverishment in Mexico during the period
1992-2004 shows that the organization and financing of the health system play an important

â Springer

This content downloaded from 128.59.222.107 on Sun, 18 Sep 2016 04:50:50 UTC
All use subject to http://about.jstor.org/terms
86 J. L. Amaya Lara, F. Ruiz Gömez

role in protecting households and reducing impoverishment during an economic crisis (Knaul
et al. 2006, 2007).
Continuing with the Latin American context, research on the impact of out-of-pocket
health spending in seven Latin American countries—Argentina, Brazil, Chile, Colombia,
Ecuador, Mexico, and Uruguay—(Perticara 2008) showed that in all of those countries cata
strophic health spending appeared to be associated with high out-of-pocket expenses rather
than with households with limited payment capacity. More specifically, in the case of Colom
bia, the burden of out-of-pocket health expenditure, measured as the ratio out-of pocket health
expenditure - payment capacity increases two to three times when there are in-patient events.
Many studies on health care service use and expenditure have been conducted in Colombia
(Mora 2000; O'Meara et al. 2003; Ruiz et al. 2006). Findings show that the population incurs
in high out-of-pocket expenditure to cover their health problems. Although the situation has
improved thanks to the 1993 health sector reform (Corcho et al. 2000), there are still high
levels of inequity and inefficiency in the Colombian health system. That may suggest the
possibility of Colombia's population running the risk of catastrophic health spending.
There are few studies on catastrophic health spending in Colombia. However, it is impor
tant to mention the research conducted in Cartagena de Indias (Alvis et al. 2004). It found that
the highest out-of-pocket expenses based on income were present among households in the
lowest socioeconomic strata, whose head of household had little schooling, was unemployed
or self-employed or not insured under the health system.
A review of such studies evidences that catastrophic health spending is generally calcu
lated as a relative measure of the household's payment capacity during a given period of
time (Berki 1986; Wagstaff and van Doorslaer 2003;Wyszewianski 1986a; Xu et al. 2003a),
not solely as an expense in which the household incurs as a result of a high-cost event.
Using the assumption that catastrophic spending is a relative measure of payment capacity,
there are households that incur in catastrophic spending due to out-of-pocket health service
payments, but that does not necessarily represent out-of-pocket expenditure of a great mag
nitude. The World Health Organization (WHO) has proposed different methodologies for
estimating financial protection; the main difference among them is how payment capacity
and catastrophic health spending are measured.
Xu (2005) presented the most recent methodology proposed by the WHO, which affirms
that "health spending is catastrophic when a household's out-of-pocket health payments are
equal to or greater than 40% of the household's payment capacity or non-subsistence expen
diture". Prior studies considered different thresholds as reference points for establishing
catastrophic spending; they vary from 10 to 50% depending on the reference country's level
of development, on the methodology used to measure catastrophic spending, on the method
employed to calculate payment capacity, and on the definition of subsistence expenditure
(Wagstaff and van Doorslaer 2003; van Doorslaer et al. 2005; Xu et al. 2003b; Xu 2005; Xu
et al. 2007; Alvis et al. 2004; O'Donnell et al. 2005,2008; Cruz et al. 2006; Hernandez et al.
2008; Pérez et al. 2005).
Bogota, Colombia has a high percentage of low-income families who do not have health
social security but who have considerable out-of-pocket health expenses (O'Meara et al.
2003; Ruiz et al. 2006). Along with other household characteristics, that means that the pos
sibility of incurring in catastrophic health spending may be lurking around the corner and
such a sudden drop in available income can result in conditions of impoverishment for some
Bogota households. As no empirical studies related to catastrophic health spending in Bogota
have been conducted, this research will enable determining the characteristics that may make
Bogota households more vulnerable to catastrophic health spending or impoverishment, for
the purpose of confirming or rejecting the hypothesis under study.

<£) Springer

This content downloaded from 128.59.222.107 on Sun, 18 Sep 2016 04:50:50 UTC
All use subject to http://about.jstor.org/terms
Determining factors of catastrophic health 87

Hypothesis and bias control

In Colombia, the health insurance scheme implemented through 1993 Law 100 largely assures
financial protection for households against health-related risks, by ensuring lower expenses
when an unforeseen health problem arises and by preventing a worsened economic situation,
mainly for poorer households. However, universal coverage has not yet been achieved and
certain groups of the population vulnerable to unforeseen health expenditure have been left
out of the system (Knaul et al. 2007).
The population group assumed to have the greatest vulnerability to catastrophic health
spending and impoverishment is the group comprising low-income households not insured
under the GSSHS, who do not have the payment capacity to deal with sudden health prob
lems. Therefore, the hypothesis under study is that the Bogota low-income population not
insured under the GSSHS does not have the economic capacity to pay for sudden health
problems.
To confirm or reject that hypothesis, monthly data from the Health Care Use and Expen
diture Survey performed by Cendex (2001 ) was analyzed. That survey was made taken using
a representative sample of 2,810 households in Bogota; it compiled monthly health care ser
vice use and expenditure as well as income during a one-year period. The survey furnished
information on the socio-demographic, socioeconomic, and social security affiliation condi
tions of each member of the household, documenting changes in residence, employment, and
social security during the period. The data was aggregated for an annual period, in order to
examine the population's problems in a consolidated manner, which could not have been done
through an evaluation of information gathered in a cross section. The data gathering process
and the periodical validation of the information enabled ensured reliability and control of
any bias generated by poor recall.
The study considers the sequential stages that consumers must go through to be insured
under the health system. First, they must decide whether to buy health insurance or not. Then,
they must evaluate the characteristics of available benefit plans. And finally, they must choose
an insurance company based on out-of-pocket expenditure (Manning et al. 1987). A biased
selection is largely mitigated by the very design of the social insurance model implemented
in Colombia; it is segmented into subsidized and contributive policies.
Under the subsidized policy, aimed primarily at informal job sector workers or the unem
ployed, the insurance depends on available resources for financing subsidies and on the
population targeting process, a responsibility of the municipality involved. Under the con
tributive policy, the decision as to what insurance to take out is in the hands of employers and
municipalities; it is a legal requirement for employers in the formal job sector to affiliate their
employees with their families to the GSSHS. The two social insurance schemes have only
one benefit plan each, so there is but one choice under each scheme. Moreover, copayments
are adjusted based on each affiliate's income; therefore, health condition, age, and gender
are not taken into account.
For private health insurance, the selection bias generally appears due to the presence of
an illness, given the fact that such insurance is voluntary, individual, and offers a choice
of several available benefit plans. A person may accede to such plans only if he or she is
under the contributive policy. To reduce the likelihood of selection bias, such plans include
pre-existing conditions and latent periods.
Now, to reduce the likelihood of selection bias in the analysis for this research, the only
households taken into consideration were those where the members' work situation did not
change. Another control factor was the household members keeping the same insurance dur
ing the period under study. For the econometric model fit, households that had some level of

<£) Springer

This content downloaded from 128.59.222.107 on Sun, 18 Sep 2016 04:50:50 UTC
All use subject to http://about.jstor.org/terms
88 J. L. Amaya Lara, F. Ruiz Gomez

health expenditure during the year under study were selected, in order to more clearly identify
the factors that influence the likelihood of catastrophic health spending for a household in
Bogota, Colombia.

Definition of variables

Under the Colombian GSSHS catastrophic spending is defined as out-of-pocket expendi

ture in high-cost events such as in-patient services or chronic illness treatment (Sesma et al.
2005). Notwithstanding, this research defines catastrophic spending as health expenditure
that exceeds a household's payment capacity threshold or a percentage that can be associated
solely with out-of-pocket payments for out-patient services or for medicine supply.
This study seeks to identify the factors that determine the presence or absence of cata
strophic spending in a household, not the effective amount paid for health services. Therefore,
the dependent variable in the model corresponds to a dummy with the value 1 if the house
hold has catastrophic spending. How to calculate that variable is clearly explained in the next
section.

Using the factors that have had significance in prior studies on this topic as a reference, the
variables that may represent conditions of vulnerability regarding the possibility of incurring
in catastrophic health spending were identified. Those variables are type of service paid,
size of household, dependence index, presence of permanently disabled persons, events of
childbirth, percentage of taxpayers out of the total number of household members, head
of household's characteristics, such as age, gender, work situation, and insurance situation.
They are listed in Table 1.
Household with out-of-pocket expenditure was obtained by classifying each one of the
health services into one of three large groups: out-patient services1, in-patient services2, and
medicine supply, and generating all possible combinations of those groups and then assign
ing each household an item or combination of items according to the type of out-of-pocket
expenditure. The outcome was four groups: (1) expenditure in out-patient services only, (2)
expenditure in medicine supply only, (3) expenditure in both out-patient services and medi
cine supply and (4) expense in some in-patient service. Using the information furnished on
income, the per capita income quintiles were built, calculated independently for the total
number of households and for households that incurred in out-of-pocket health expenditure.
The ranges for each per capita income quintile appear in Table 2.

Definition of catastrophic health spending

To calculate catastrophic health spending and impoverishment due to out-of-pocket health

expenditure, the methodology proposed by the WHO (Xu 2005) was used. Upon analyzing
the type of destination that the household income had, we found that Bogota households
invest an average of 40.4% of their income in food and that the remaining 59.6% was dis
tributed as follows: 18.2% in public utilities, 16.7% in education, 13.1% in rent and 11.6%
in others.

' Out-patient events: general medicine and specialized medicine doctor's appointments, unspecified doctor's
appointments, dentist's appointments, lab work, emergency room services, X-rays and imagery, therapies, out
patient surgery, alternative medicine, home remedies, others, other diagnostic tests, prostheses and orthopedic
apparatus.

2 In-patient events: hospitalization with or without surgery.

£) Springer

This content downloaded from 128.59.222.107 on Sun, 18 Sep 2016 04:50:50 UTC
All use subject to http://about.jstor.org/terms
 Determining factors of catastrophic health 89

Table 1 Possible vulnerability to catastrophic health spending fact

Categories of variables Definition

Household income What each person contributes to the household to sustain it,
broken down by type of destination (food, rent or house
payment, public utilities, education, etc...)
Per Capita income quintile
1: Quintile ! This variable identifies five annual per capita income groups,
2: Quintile II taking into account total population distribution. Quintile I
3: Quintile III groups 20% of the households with the lowest income whereas
4: Quintile IV Quintile V groups 20% of the households with the highest
5: Quintile V income
Household Size
1:1-2 persons Monthly average number of persons per household during
2: 3-4 persons the year under study
3 : 5 persons or more
Disability:
1: Some household member is disabled Dummy variable where 1 means that some household member
0: No household member is disabled reported disability during the year (permanent disability)
Percentage of members Percentage of persons in the household earning an income
earning an income
Dependency index Defines the relation between the inactive population (<5 and
>60 years old) and the total number of household members
Childbirths
0 : There were no childbirths Dummy variable where I means that there was childbirth
1 : There was at least one childbirth and 0 means that there were none
Head of household's gender
1 : Male Head of household's gender
2 : Female
Head of household's age
0 : Under 60 years old Dummy variable where I indicates that the head of household
1 : Over 60 years old is over 60 years old and 0 that he or she is not
Head of household's work situation
1 : Private sector employee Indicates the head of household's work situation during
2 : Government employee the study period
3: Others (Unpaid family
worker, Domestic help,
Employers)
4: Self-employed worker
5: Unemployed
Head of household's health
social security situation
1 : Non-affiliated This variable identifies the head of household's affiliation to
2 : Subsidized policy the GSSHS during the year under study.
3 : Contributive policy The last category indicates that the head of household's insurance
4 : Special policy situation changed during that year
5 : Change in insurance status
Health service for which the
household had to pay
0: None Variable indicating the combinations of types of health care
1 : Out-patient service services for which the household made out-of-pocket payments,
2 : Medicine supply broken down into the large service groups: A out-patient
3 : Out-patient service and service, / in-patient service, and D medicine supply
medicine supply
4 : Combination with in-patient service

Springer

This content downloaded from 128.59.222.107 on Sun, 18 Sep 2016 04:50:50 UTC
All use subject to http://about.jstor.org/terms
 90 J. L. Amaya Lara, F. Ruiz Gomez

Table 2 Household per capita income quintiles (i

Per capita Total number of

income households
quintile Households with health expenditure

Quintile I < 1,258,047 < 1,270,150

Quintile II > 1,258,047 and < 1,716,657 > 1,270,150 and < 1,715,659
Quintile III > 1,716,657 and < 2,373,285 > 1,715,659 and <2,375,554
Quintile IV > 2,373,285 and < 3,809,400 > 2,375,554 and < 3,800,756
Quintile V > 3,809,400 > 3,800,756

In that sense, if a household invests more than 11.6% of its total income in out-of-pocket
health expenditure, that is to say, if a household invests more than 19% of its income after
deducting food expenses in health, it would have to do without other things, which would
affect its normal economic behavior. So, we consider that a household has catastrophic spend
ing if its health expenditure is equal to or greater than 20% of its payment capacity, payment
capacity meaning the household income after deducting food expenses.
A series of steps were taken to identify catastrophic health spending. First, the payment
capacity of each of the households was generated, as is shown in Steps 1 through 6. In Step
7 the ratio out-of-pocket payment-payment capacity is calculated, to finally produce the
dummy variable that identifies if the household has catastrophic spending or not in Step 8.
Steps 9 and 10 indicate how to establish if the household is poor or has entered into a state
of impoverishment after the health expenditure.

Step 1: Food expenditure as a percentage of total spending: FoodExph =

Step 2: Equivalent household size: HhldSizeEqi, = HhldSizef]

To be comparable to other countries, we assume that 0 = 0.56 (Xu et al. 2003a),
which implies that consumption increases with additional household members
and that the increase is less than proportionate to the increase in household size.
Step 3: Equivalent food expenditure: FoodEqh = HhUi°SbeEqh
Step 4: Poverty line or equivalent per capita subsistence expenditure:

PL = Avg(FoodEqh) where FoodExp45 < FoodEqi, < FoodExp55

The poverty line is calculated as the household's average equivalent food expen
diture, which is from 45 to 55 percentiles of the food expenditure as a percentage
of the income.

Step 5: Household subsistence expenditure: SubExph — PL x HhldSizeEqi,

Step 6: Household payment capacity:

Exp/, — SubExph if SubExph < Food/,

PayCaph -
Exph — Foodh if SubExpi, > Food/,

After deducting the subsistence income, we obtain the payment capacity defined as
the non-subsistence expenditure or the effective non-subsistence income. How
ever, when households report food expenditures lower than subsistence expen
diture, the non-food expenditure is used as non-subsistence expenditure. That
situation occurs when the food expenditure in which the household incurs is lower
than the estimated poverty standard, which may be due to the fact that the food
expenditure reported in the study does not take into consideration food subsidies,
food coupons, and self-production, among others.

Spring er

This content downloaded from 128.59.222.107 on Sun, 18 Sep 2016 04:50:50 UTC
All use subject to http://about.jstor.org/terms
Determining factors of catastrophic health 91

Step 7: The ratio out-of-pocket health expenditure-pay

relation between each household's out-of-pocket ex
and its payment capacity:
OH Eh
OH E PayCapb = - -
PayCaph
Step 8: Catastrophic health spending, which occurs when out-of-pocket health ex
diture equals or exceeds 20% of the household's payment capacity, as defin
below:

1 if OHEPayCaph > 0.2

Catastrophic/, =
0 if OH EPayCaph < 0.2
Bearing in mind the above variables, we can establish if a household is poor
(Poori,) or if it has become impoverished (Impoverishment/,) after it makes a
direct out-of-pocket payment of a given amount for health events.
Step 9: Poor household
A household is considered poor if its total spending is less than its subsistence
expenditure:

1 if Exph < SubExpi,

Poorh —
0 if Exph > SubExpi,
Given that the subsistence expenditure is calculated based on a standard value
that identifies the poverty line of the population under study, it is possible to find
households whose total spending is less than its subsistence expenditure.
Step 10: Impoverishment
A household is deemed to have entered into a state of impoverishment when the
subsistence expenditure is equal to or less than the household spending and more
than the household spending after deducting out-of-pocket health expenditure:

1 if Spendingh > SubExphandSpendingh

Impoverishmenth = — OHEh < SubExph
0 if not

Model

The literature on the topic does not boast a theoretical model that enables specifying in
advance the explanatory variables that should be taken into consideration in the model.
Therefore, we will consider the variables that have had statistical significance in prior stud
ies on catastrophic health spending assessment. In the literature on the topic, the models
for estimating the likelihood of catastrophic health spending are the probit and logit binary
response models.
For this study the probit binary response model using maximum verisimilitude was
employed, using a dummy variable as the dependent variable, where 1 means that the house
hold incurred in catastrophic health spending during the study period and where 0 means that
the household did not incur in that level of expenditure. Out of the total number of independent
variables that were first submitted to a correlation and association analysis, the independent
variables with statistical significance at a bivariate level and with theoretical relevance were
selected. For the category of variables, the base category was the one representing the group
most vulnerable to catastrophic health spending.

Springer

This content downloaded from 128.59.222.107 on Sun, 18 Sep 2016 04:50:50 UTC
All use subject to http://about.jstor.org/terms
92 J. L. Amaya Lara, F. Ruiz Gomez

Unlike the linear probability model, the probit model uses the strict assumption of values
from 0 to 1 for all real numbers. That ensures the estimated likelihood being in the same
range (Wooldridge, 2002) and enables establishing the magnitude and intensity of the relation
between the independent variables and the household's state of catastrophic spending. The
probit model is defined by:

P (y = \/x) = G (£o + P\x\ H b PkXk) = G (A) + xfi)

where G is the cumulative distribution function of the standard normal, fa indicates the
constant of the model, x identifies the set of independent variables and ft corresponds to the
vector of parameters

Results

The initial descriptive analysis showed that 8.1% of the households reported zero (0) health
spending and that 4.5% incurred in catastrophic health spending during the study period.
Although one might think that zero (0) spending is due to not using health services, 52.9%
of the households without out-of-pocket expenditure did use health services. The main con
centration of those households are insured under the subsidized policy (33.3%) and under
the special policy (30.6%); under each of those policies more than 80% of the households
used health services without incurring in expenditure. Among the remaining 47.1% of the
households that did not incur in health expenditure due to the non-use of health services,
50% belong to the group not affiliated to the GSSHS, and out of that group 84.2% did not
use health services, which leads us to believe that those households' non-use of services is
associated with their non-affiliation.
The above statistics indeed lead us to believe that the health system in Bogota is protecting
the poorest households against out-of-pocket expenditure for out-patient events or medicine
supply, but that more financial protection against in-patient events is required. Likewise, there
is an evident lack of sufficient incentives that would allow reaching the point of affiliating
all of the poor population that do not have contribution capability, so that they may gain
access to health services without having to make out-of-pocket payments. That would enable
financial solidarity in which both access to services and payment of services would be more
equitable and efficient.
Upon analyzing the head of household's insurance status and work situation, we found
that, among the households where the head of household has a contributive policy, 37.7%
are private sector employees and 30.6% are unemployed, as may be appreciated in Table 3.
Among the households where the head of household has a subsidized policy or is not insured,
more than 50% are self-employed and over 20% are unemployed. Among the households
where the head of household has a special policy, they are mostly unemployed (51.4%) or
government employees (24.3%).
The more the household level of income increases, the more its catastrophic health spend
ing decreases. Whereas 5.9% of the households in Quintile 1 incur in catastrophic spending,
that percentage drops to 3.6% in Quintile IV and to 3.0% for the group of households with
the highest income. If we look solely at the households with out-of-pocket health expen
diture, the percentage of households with catastrophic spending increases to 4.9%. Out of
those households, 33.9% entered into a state of impoverishment due to health expenditure,
a situation seen mainly in low-income households with catastrophic spending, out of which
74.2% in Quintile I, 42.3% in Quintile III, and 12% in Quintile II entered into a state of

Springer

This content downloaded from 128.59.222.107 on Sun, 18 Sep 2016 04:50:50 UTC
All use subject to http://about.jstor.org/terms
 Determining factors of catastrophic health 93

Table 3 Percentage of households, by head of household's insuranc

Policy Private sector Government Self-employed Other (Unpaid Unemployed Total

employee (%) employee (%) worker (%) family worker, (%) (%)
Domestic help.
Employer. %)

Contributive 37.7 5.0 25.8 0.9 30.6 100

Subsidized 12.5 0.8 56.0 3.6 27.0 100
Non-insured 17.5 0.4 57.1 3.5 21.6 100
Special 6.8 24.3 17.6 0.0 51.4 100
Total 28.2 3.7 38.3 1.9 28.0 100

Table 4 Percentage of households with catastrophic health spending, by type of service paid, by health
insurance policy, by work situation, and by per capita income quintile

Variable Categories Quintile I Quintile II Quintile III Quintile IV Quintile V Bogoti

(%) (%) (%) (%) (%) (%)

Type of Out-patient 2.9 - - -

2.5 1.2

service paid services

Medicine supply
- - -
3.8 2.6 1.1
Out-patient 2.9 3.8 3.6 2.2 0.9 2.7
services and
medicine supply
Some in-patient 28.8 23.5 22.6 17.6 22.2 23.4
event
Total 6.7 5.4 5.6 3.9 3.2 4.9
Health insurance Contributive 3.2 2.3 4.1 2.8 2.0 2.8
policy
Non-insured 13.1 9.6 9.2 7.5 6.8 9.7
Subsidized 5.6 3.0 - - -
3.2
Total 6.7 5.4 5.6 3.9 3.2 4.9
Work situation Private sector 3.7 1.3 3.0 1.6 2.7 2.4

employee
Government -
10.0
- -
2.8 2.4
employee
Self-employed 8.3 8.1 5.5 5.9 2.8 6.2
worker
Others (unpaid 9.1 7.7 - - -
4.5

family worker,
Employers,
etc...)
Unemployed 7.6 5.6 8.5 4.4 4.4 6.1
Total 6.7 5.4 5.6 3.9 3.2 4.9

impoverishment. The opposite occurs in the two top income Quintiles where the percentages
do not exceed 7%.
The distribution of the households, considering the type of health services paid, identified
that 72.6% had expenditure in out-patient services and medicine supply, followed by 12.1%
with expenditure in some in-patient event, and 7.3 and 7.9% of households that only had
expenditure in out-patient services and only had expenditure in medicine supply, respec
tively. However, most of the households with catastrophic spending had expenditure in some
in-patient service. That behavior differs according to the level of per capita income. Indeed,
28.8% of the households in Quintile I that paid for in-patient services incurred in catastrophic
spending whereas that percentage drops to 17.6% in Quintile IV, as may be seen in Table 4.

*£) Springer

This content downloaded from 128.59.222.107 on Sun, 18 Sep 2016 04:50:50 UTC
All use subject to http://about.jstor.org/terms
94 J. L. Amaya Lara, F. Ruiz Gomez

Similarly, in the two highest quintiles, a large percentage of the households whose only
health expenditure was in medicine supply incurred in catastrophic spending. Out of the
households with expenditure only in out-patient services, 2.9% in Quintile I and 2.5% in
Quintile V incurred in catastrophic health spending. Unlike the two above cases, among the
households that had expenditure in both out-patient services and medicine supply, 3.8 and
3.6% of those in Quintiles II and III, respectively incurred in catastrophic spending.
Table 4 shows the percentage of households with catastrophic spending, considering the
head of household's insurance status. The groups with the greatest percentage of households
with catastrophic health spending correspond to non-insured heads of household, followed by
heads of household insured under the subsidized policy or the contributive policy. Whereas
9.7% of the first incurred in catastrophic spending, the percentage was only 3.2 and 2.8% for
the two other groups, respectively.
The greatest percentage of households (13.1%) with catastrophic spending is found in the
Quintile I non-insured population group and the percentage decreases as the household per
capita income increases. The subsidized policy households in Quintile III or above did not
incur in catastrophic spending whereas 5.6 and 3.0% of the households in Quintiles I and
II, respectively, incurred in catastrophic spending due to out-of-pocket health expenditure.
In the group of households insured under the contributive policy, Quintile III presents the
highest percentage of households (4.1%) with catastrophic spending, followed by 3.2% in
Quintile I.
Considering the head of household's work situation, we found an evident increase in the
percentage of households with catastrophic spending among those whose head of household
did not work or was a self-employed worker. More specifically, whereas catastrophic health
spending was incurred in by only 2.4% of the households where the head of household was a
private sector or government employee, the percentage was 6.2% for the households whose
head of household was a self-employed worker and 6.1 % for those whose head of household
was not working during the study period.
For the households in Quintile III the greatest percentage of households with catastrophic
health spending are those where the head of household was not working. In the lower quintiles,
the percentage was higher for the households whose head of household was a government
employee or a self-employed worker or others. The percentage of households with social
security health insurance that incurred in catastrophic health spending was less than 2.0% for
the households whose head of household was a government or private sector employee, 3.4%
for those whose head of household was a self-employed worker, and 4.7% for those with
a non-working head of household. Those percentages increased to more than 7.0% among
households whose head of household was not affiliated to the GSSHS.
Table 5 shows the results of the probit model in which the marginal effects of the model
or its elasticity are specified as are the robust standard errors calculated post-estimation for
each one of the independent variables. In order to test the robustness of the model, the refer
ence category of some independent variables were changed, to explore their effect. Findings
showed that the direction and magnitude of the results were consistent. The model indi
cates that variables, such as household size, type of health insurance, work situation, level of
income, and presence of in-patient events, significantly explain the likelihood of a household
having catastrophic health spending.
Upon analyzing the direction in which each variable affects the likelihood of catastrophic
spending, results show that a household with one or two persons has 2.7% more probability
of incurring in catastrophic spending than a household with five or more members. That may
be because the majority of smaller households are composed of one sole person or of one
person and his or her spouse, with an average age of 46 years old, whereas larger households

Springer

This content downloaded from 128.59.222.107 on Sun, 18 Sep 2016 04:50:50 UTC
All use subject to http://about.jstor.org/terms
 Determining factors of catastrophic health 95

Table 5 Probit model for estimating the likelihood of a househo

Independent variable Exp (f)) SE

5 persons or morea 1.000

1-2 persons 0.027** 0.012
3-4 persons 0.001 0.007
Contributive policy" 1.000
Non-insured 0.032*** 0.011
Subsidized policy -0.007 0.008
Special policy 0.045 0.035
Change in insurance status 0,020 0.014
Private sector employee11 1.000
Others (Unpaid family worker, domestic help, employers) 0.005 0.023
Government employee 0.011 0.023
Self-employed worker 0.019** 0.009
Unemployed 0.016 0.011
Quintile Va 1.000
Quintile I 0.064** 0.026
Quintile II 0.044** 0.020
Quintile III 0.024* 0.015
Quintile IV 0.010 0.011
Only medicine supply" 1.000
Only out-patient events 0.008 0.023
Out-patient and medicine supply 0.023** 0.009
An in-patient event 0.363*** 0.097
Percentage of working household members 0.035** 0.015
Head of household over 60 years old 0.024* 0.013
Head of household's gender -0.002 0.005
Disability -0.001 0,016
Dependency -0.004 0.011
Constant —4.129*** 0.435

***/?<0.01; **p<0.05; */><0.10

a Omitted
Hosmer-Lemeshow (p-value) 0.000***
Cases correctly classified (%) 94.85
Area under ROC curve 0.876
Linktest prediction value p>\'A 0.000***
Prediction squared value/?>IZI 0.470

composed of families with children have an average age of 26 years old. Therefore, the health
risk and health-related out-of-pocket expenditure tends to be higher in smaller households.
Households that did not remain affiliated to the GSSHS had a greater likelihood of incur
ring in catastrophic spending (by 3.2%) than households that remained insured under the
contributive policy. Households whose head of household was a self-employed worker had
more likelihood of incurring in catastrophic spending (1.9% more) than households whose
head of household was a government employee. A higher level of income is a determining
factor for a household to be able to handle health expenditure without affecting its economy.
Indeed, the lower the household level of income, the significantly higher the likelihood of the
household incurring in catastrophic spending, which representing an increase of from 2.4%
in Quintile III to 6.4% in Quintile I, the highest income quintile being the base reference.
Catastrophic health spending also depends on the type of health service used that generated
out-of-pocket expenditure. Undoubtedly, the presence of an in-patient event can influence
out-of-pocket health expenditure and create catastrophic spending for the household. That sit
uation leads us to believe that another type of used health service can diminish the likelihood

•5) Springer

This content downloaded from 128.59.222.107 on Sun, 18 Sep 2016 04:50:50 UTC
All use subject to http://about.jstor.org/terms
96 J. L. Amaya Lara, F. Ruiz Gomez

of catastrophic spending. In that sense, the likelihood of catastrophic health spending in

households with in-patient events was 36.6% greater than in households that had out-of
pocket expenditure only for medicine supply.
Moreover, the likelihood of catastrophic health spending increases by 3.5% when the
percentage of working persons in the household increases. This may be due to the fact
that household income increases as its percentage of working members increases; however,
the increase is less than proportionate to the average household out-of-pocket expenditure.
So, Quintile I is defined as having the 20% of the households with the lowest percentage
of working members and Quintile V is defined as having the 20% of the households with
the highest percentage and findings show that for Quintile I the ratio out-of-pocket health
expenditure—income is 2.5% and in Quintile V that ratio increases to 3.4%.
The above result may also be related to the household composition and to the level of
age-associated risk. In households where only 25% of working members, the average age is
23 years old whereas in households with 75% working members, the average age is 49 years
old. That indicates that, in households with the lowest percentage of working persons, there
are younger persons whereas households with the highest percentage of working person are
mainly comprised of older persons with more health risks and that increases the likelihood
of catastrophic spending.
Also, households with a head of household over 60 years have 0.2% more likelihood of
catastrophic spending than households where the head of household is younger. It is worth
clarifying that other studies report that the head of household's gender, the presence of a
disabled person in the household, and the level of economic dependence have a significant
influence. In this study those variables had no statistical significance in the estimated model,
which indicates that, in Bogota households, catastrophic health spending does not depend on
the head of household's gender or on the number of household members more vulnerable to
falling ill.
The variable disabled persons in the household may not have been statistically significant
due to discrepancies in the definition of disability, to the lack of underlying variables involved
in estimating disability, and to the short study period that did not permit establishing disabil
ity using the variable that identifies the person's main activity. For this study in particular,
permanent disability means a person reported unable to carry out activities during the 12
periods under study. That definition per se creates a bias.
The findings verify the situation of inequality that households in the city of Bogota face
regarding access to the GSSHS and payment of health services although there is a health
system that seeks to ensure financial protection against health-related risks by ensuring global
insurance and diminishing the level of out-of-pocket expenses. It is true that the health insur
ance system with the two policies, implemented through Law 100, has generated benefits
when it comes to access to services and service availability. Notwithstanding, there is still a
segment of the population that is not affiliated to the system and it precisely represents the
group most vulnerable group to the economic risks that can arise when faced with unexpected
illness or an accident.
That situation is also associated with the low economic level of the households, which
leads us to believe that, if low-income households had insurance, the level of out-of-pocket
expenditure would drop, especially when faced with in-patient events. That would result in
a reduced number of cases of catastrophic health spending. That is why universal health
insurance must be encouraged at a short term as well as coverage with a broader gamut of
services.

Springer

This content downloaded from 128.59.222.107 on Sun, 18 Sep 2016 04:50:50 UTC
All use subject to http://about.jstor.org/terms
Determining factors of catastrophic health 97

Discussion

The Colombian GSSHS underwent a structural change when Law 100 was implemented
in 1993. That law set forth a social health insurance scheme that enabled moving from the
former scheme characterized by low affiliation and unequal access to services to a progressive
scheme segmented into the contributive policy and the subsidized policy; the first aimed at
broadening health insurance benefits to the worker's family and the second aimed at covering
the population without payment capacity.
The health insurance segmentation into two policies has not achieved its objective of mak
ing the population's access to health services universal and equitable. To a great extent, that
is due to the fact that affiliation to the system is mandatory for the population working in the
formal job sector and that sector is diminishing more and more due to the evident increase
in persons working in the informal job sector. Another reason is the difficulty that the State
in undergoing in its efforts to affiliate low-income households and to target non-insured
households that have the economic capacity to pay for health insurance.
The Health Care Use and Expenditure Survey (Cendex 2001) enabled measuring the
level of financial health protection in the city of Bogota, Colombia. Findings showed that
4.9% of the households incurred in catastrophic spending during 2001. The poor non-insured
households with an in-patient event, among other factors, were significantly more likely to
have catastrophic health spending than the higher-income insured households without any
in-patient events.
Although the above-mentioned law has substantially augmented insurance levels, there
are still low or average income non-insured households where the head of household gener
ally works in the informal job sector. Unlike the households affiliated to the system where
the head of household works in the formal job sector, this group runs a greater financial risk
when faced with health problems. Therefore, it has more likelihood of catastrophic health
spending.
This situation has created the problem of unequal, inefficient access to health services,
which is evaluated here from the perspective of the population's out-of-pocket expenditure.
It hinders financial support for households both with and without payment capacity when
they are faced with health issues and it can lead to expenditure that exceeds the household's
payment capacity. As one of the objectives of taking out insurance is to diminish a house
hold's out-of-pocket expenses and protect it from health expenditure too high for its income,
we might be led to think that the higher the level of insurance of the likelihood of most
vulnerable segments, the lower the catastrophic health spending.
Results show that, even though there is a percentage of the households affiliated to the
GSSHS that incur in catastrophic health spending, the percentage is low as compared to the
number of non-insured households that have catastrophic health spending. Likewise, there
are substantial differences between the households where the head of household works in
the private sector where the head of household is a self-employed worker. Indeed, the latter
group proved more economically vulnerable when faced with a health problem.
Furthermore, although there is more likelihood of catastrophic spending in households
with an in-patient event, it is not unlikely that catastrophic health spending among families
with lower economic capacity may be due to medicine supply and out-patient events. That
reality leads us to believe that financial protection must be focused not only on in-patient
event expenditure but also on expenditure related to medicine supply and out-patient services,
especially for the non-insured groups without payment capacity where the head of household
is a self-employed worker or unemployed.

£) Springer

This content downloaded from 128.59.222.107 on Sun, 18 Sep 2016 04:50:50 UTC
All use subject to http://about.jstor.org/terms
98 J. L. Amaya Lara, F. Ruiz Gomez

It is important to bear in mind that the level of catastrophic spending seen in this study is
based on the group of households that incurred in some health expenditure during the year
under study. However, unequal access to the system and related out-of-pocket expenses may
actually be greater if we take into consideration that there is still a group of the population
without health expenditure simply due to geographical barriers or to a lack of economic
capacity, which hinders them from incurring in health expenditure even if they wish to do so.
At the other extreme, there is a segment of the population not affiliated to the GSSHS
although it has the payment capacity to do so. That reduces the possibility of achieving
equality among the groups that are the most fragile and those that are the least fragile in
terms of economic capacity. In that sense, to achieve universal health insurance coverage,
the population with payment capacity that is not yet covered against health risks must be
targeted and the total affiliation of households without payment capacity, the most likely to
incur in catastrophic health spending, must be achieved.
As time goes by, it becomes less and less feasible to achieve universal health coverage by
imposing it on persons working in the formal job sector, as is currently done. Unifying service
packages that represent more wellbeing to the household in economic terms would enable
greater coverage of the poor population. It would also generate incentives for the non-insured
population with the capacity to do so to enroll under the contributive policy. And those two
efforts combined would ultimately lead to achieving universal health coverage in Colombia.
The concept of wellbeing is fundamental when analyzing health from an economic point
of view. The conventional theory regarding the profits made after health service demand is
filled assumes the existence of a loss of wellbeing associated with illness and of investing
in health services to maximize the benefit. When a consumer takes out insurance, he or she
seeks to reduce the uncertainty derived from the financial risk associated with the cost of
recovering his or her health. Nonetheless, the health insurance must fit somewhere between
the actuarial population spending mean and the defined insurance premium, plus transaction
costs. Any lack of fit means a loss or a gain in wellbeing. In parallel, there is a loss or gain in
wellbeing when the risk is transferred between health insurance companies and health care
service companies.
It cannot be denied that there is always a certain level of bias when conducting health
studies because it is impossible to identify, itemize, and control all of the underlying factors
in a health system, as they may arise from incomplete information furnished by consumers
and insurance companies alike. One example may be adverse selection, which occurs when a
person knows that he or she is becoming ill and therefore decides to enroll under some health
policy. There is also moral risk, which generates among the insured an incentive to behave
differently and to start abusing the insurance coverage by using more services or buying more
medicine.

The methodology used in this study to evaluate household financial protection, as pro
posed by the WHO, is currently the state-of-the-art methodology. Nonetheless, there is not
yet a consensus on the threshold as of which a household's health expenditure is considered
catastrophic. Usually the decision is left up to the free choice of the researchers. What's more,
several research papers have presented results using different threshold levels, so the results
obtained may lead to different interpretations and distinct decision making.
It would be convenient then to explore other manners of evaluating catastrophic health
spending in a broader context, to enable measuring the actual reaction of each household to
an illness or disease. Studies with more monitoring time, which inquire about diverse types of
illnesses including chronic cases, and take into account other variables related to the house
hold and to the current context of the system would broaden the spectrum of analysis of the

<£) Springer

This content downloaded from 128.59.222.107 on Sun, 18 Sep 2016 04:50:50 UTC
All use subject to http://about.jstor.org/terms
Determining factors of catastrophic health 99

topic and would enable greater control over the explanatory variables used for catastrophic
health spending.
Along those lines, to complement the analysis discussed in this study on large health ser
vice groups, we propose future studies where analysis is based on monitoring during a longer
period of time, for example, years. That would enable identifying the actual composition of
the household income and each member's expenditure, which in turn would allow establishing
the household's change in behavior when faced with a determined event of illness.

References

Alvis, L., Alvis, N., & de la Hoz, F. (2004). Gasto privado en salud de los hogares de Cartagena de
Indias. Revista de Salud Publica, 9(1), 11-15.
Arrow, K. J. (1963). Uncertainty and the welfare economics of medical care. The American Economic
Review, 53(5), 941-973.
Berki, S. (1963). A look at catastrophic medical expenses and the poor. Health Affairs, 5(4), 138-145.
Cendex—Centro de Proyectos para el Desarrollo. (2001). Encuesta de Usos y Gastos en Salud. Colombia.
Financiaciön: BID—Banco Interamericano de Desarrollo.
Corcho, A.E., Castilla, M., & Acosta, N. (2000). Narrativa sobre la Reforma del Sistema de Salud en
Colombia. Nûcleo de Acopio, Apoyo y Difusiôn de las Iniciativas de Reforma, Instituto de Salud
Publica.
Cruz, C., Luna, G. A., Morales, R., & Coello, C. G. (2006). Gasto cataströfico en salud y elasticidades
ingreso por tipo de gasto en servicios de salud en México. Bienestar y Politico Social, 2(1), 51-73.
Friedman, B. (1974). Risk aversion and the consumer choice of health insurance options. The Review of
Economics and Statistics, 56, 209-214.
Hernandez, J., Avila, L., Valencia, A., & Poblano, O. (2008). Evaluaciön Inicial del Seguro Popular sobre
el Gasto Cataströfico en Salud en México. Revista de Salud Publica de México, 10( 1), 18-32.
Inter-American Development Bank. (2006). Colombia, Expansion of the program for the reorganization,
redesign and modernization of health service networks. PIC, CO-L1017: Loan Proposal.
Knaul, F., Arreola, H., & Méndez, O. (2005). Protecciön financiera en salud: México, 1992 a 2004. Revista
de Salud Publica de México, 47(6), 430-439.
Knaul, F., Arreola, H., Méndez, O., & Miranda, M. (2006). Preventing impoverishment promoting equity
and protecting households from financial crisis: Universal Health Insurance through Institutional
Reform in Mexico. Working Paper Series, Innovations in Health Financing.
Knaul, F., Arreola, H., Méndez, O., Bryson, C., Barofsky, J., Maguire, R., Miranda, M., & Sesma,
S. (2007). Las evidencias benefician al sistema de salud: reforma para remediar el gasto cataströfico
y empobrecedor en salud en México. Salud Publica de México, 49, S70-S87.
Limwattananon, S„ Tangcharoensathien. V., & Prakongsai, P. (2007). Catastrophic and poverty impacts of
health payments: results from national household survey in Thailand. Bulletin of the World Health
Organization, 85, 600-606.
Manning, W. G„ Newhouse, J. P., & Duan, N., et al. (1987). Health insurance and the demand for medical
care: evidence from the randomized experiment. American Economic Review, 77(3), 251-277.
Merlis, M. (2002). Family out-of-pocket spending for health services: A continuing source of financial
insecurity. The Commonwealth Fund.
Mora, H. (2000). Riesgo del aseguramiento en el sistema de salud en Colombia en 1997. Serie Financiamiento
del desarrollo, N"95. Santiago: CEPAL, Mayo.
O'Donnell, O., van Doorslaer, E„ & RananEliya, R., et al. (2005). Explaining the incidence of catastrophic
expenditures on health care: Comparative evidence from Asia. EQUITAP Project, working paper #5.
Colombo: Erasmus University, Rotterdam and IPS.
O'Donnell, 0., van Doorslaer, E., Wagstaff, A., & Lindelow, M. (2008). Catastrophic payments for health
care. Chap. 18 in: Analyzing health equity using household survey data: A guide to techniques and
their implementation. Washington, DC: The World Bank, WBI Learning Resources Series
O'Meara, G„ Ruiz, F., & Amaya, J. L. (2003). lmpacto del aseguramiento sobre uso y gasto en salud
en Colombia. Bogota: CEJA.
Pérez, R., Sesma, S., & Puentes, E. (2005). Gastos cataströficos por motivos de salud en México: estudio
comparativo por grado de marginaciön. Revista de Salud Publica de México (Suplemento), 47(1), S47
S53.

•£) Springer

This content downloaded from 128.59.222.107 on Sun, 18 Sep 2016 04:50:50 UTC
All use subject to http://about.jstor.org/terms
 100 J. L. Amaya Lara, F. Ruiz Gomez

Perticara, M. (2008). Incidencia de los gastos de bol

Serie Politicas Sociales, No. 141, Santiago de Ch
Ruiz, F., Amaya, J. L., & Venegas, S. (2006). Impa
Colombia (pp. 3-18).
Sesma, S., Pérez, R., & Gömez, O. (2004). Sîntesis E
por molivos de salud por entidad federativa: M
de México.
Sesma, S., Pérez, R., Sosa, C., & Gömez, O. (2005). Gastos catastrôficos por motivos de salud en México:
magnitud, distribuciôn y déterminantes. Revista de Salud Publica de México, 47(1), S37-S46.
Torres, A. C., & Knaul, F. (2003). Déterminantes del gasto de bolsillo en salud e implicaciones para el
aseguramiento universal en México: 1992-2000 (pp. 209-225). México: Caleidoscopio de la Salud.
Universidad Externado de Colombia. (2001). Busqueda de menores costos, calidad del empleo e infor
malidad.Boletîn del Observatorio del Mercado de Trabajo No. 3.
van de Ven, W. P. M., & van Praag, B. M. S. (1981). Risk aversion and deductibles in private health insur
ance: application of an adjusted Tobit model to family health care expenditures. Health, Economics
and Health Economics. Amsterdam: North-Holland.
van Doorslaer, E., O'Donnell, O., & Rannan, R.P., et al. (2005). Paying out-of-pocket for health care in
Asia: Catastrophic and poverty impact. EQUITAP Project: Working Paper #2.
Wagstaff, A., & van Doorslaer, E. (2003). Catastrophe and impoverishment in paying for health care:
With applications to Vietnam 1993-1998. Health Economics, 72(11), 921-934.
Wagstaff, A. (2005). The economic consequences of health shocks. World bank development research
group, Policy Research Working Paper 3644, Washington, DC, USA.
Wagstaff A. (2008). Measuring financial protection in health. World bank development research group,
Policy Research Working Paper 4554, Washington, DC, USA.
Wooldridge, J. (2002). Econometric analysis of cross section and panel data, MIT Press.
World Health Organization. (2000). Health systems: Improving performance. The World Health Report
2000, Geneva.
Wyszewianski, L. (1986a). Financially catastrophic and high cost cases: Definitions, distinctions and their
implications for policy formulation. Inquiry, 23(4), 382-394.
Wyszewianski, L. (1986b). Families with catastrophic health care expenditures. Health Services
Research, 2/(5), 617-634.
Xu, K. (2000). World Health Report 2000. Geneva, Switzerland: World Health Organization.
Xu, K., Evans, D. B., Kawabata, K„ Zeramdini, R., Klavus, J., & Murray, J. L. C. (2003a). Household
catastrophic health expenditure: A multicountry analysis. Lancet, 362, 111-117.
Xu, K., Klavus, J., & Kawabata, K„ et al. (2003b). Household health system contributions and capac
ity to pay: Definitional, empirical, and technical challenges. Chap. 39. In C. J. L. Murray &
D. B. Evans, Health systems performance assessment: Debates, methods and empiricism. Geneva: World
Health Organization.
Xu, K. (2005). Distribution of health payments and catastrophic expenditures. Methodology. Geneva:
WHO-Discussion paper No. 2.
Xu, K„ Evans, & D., Aguilar, A.M. (2005). Designing health financing systems to reduce catastrophic
health expenditure. Geneva: WHO, Technical Briefs for Policy, Makers No. 2.
Xu, K., Evans, D. B., Carrin, G., Aguilar-Rivera, A. M., & Musgrove. P., et al. (2007). Protecting
households from catastrophic health spending. Health Aff (Millwood), 26(4), 972-983.

<£) Springer

This content downloaded from 128.59.222.107 on Sun, 18 Sep 2016 04:50:50 UTC
All use subject to http://about.jstor.org/terms