BACKGROUND Catastrophic health expenditure (CHE) is well established as an indicator of financial protection on which there is extensive literature. However, most works analyse mainly low to middle income countries and do not address the different distributional dimensions of CHE. We argue that, besides incidence, the latter are crucial to better grasp the scope and nature of financial protection problems. Our objectives are therefore to analyse the evolution of CHE in a high income country, considering both its incidence and distribution. METHODS Data are taken from the last three waves of the Portuguese Household Budget Survey conducted in 2005/2006, 2010/2011 and 2015/2016. To identify CHE, the approach adopted is capacity to pay/normative food spending, at the 40% threshold. To analyse distribution, concentration curves and indices (CI) are used and adjusted odds ratios are calculated. RESULTS The incidence of CHE was 2.57, 1.79 and 0.46%, in 2005, 2010 and 2015, respectively. CHE became highly concentrated among the poorest (the respective CI evolved from - 0.390 in 2005 to - 0.758 in 2015) and among families with elderly people (the absolute CI evolved from 0.520 in 2005 to 0.740 in 2015). Absolute CI in geographical context also increased over time (0.354 in 2015, 0.019 in 2005). Medicines represented by far the largest share of catastrophic payments, although, in this case concentration decreased (the median share of medicines diminished from 93 to 43% over the period analysed). Contrarily, the weight of expenses incurred with consultation fees has been growing (even for General Practitioners, despite the NHS coverage of primary care). CONCLUSIONS The incidence of CHE and inequality in its distribution might progress in the same direction or not, but most importantly policy makers should pay attention to the distributional dimensions of CHE as these might provide useful insight to target households at risk. Greater concentration of CHE can actually be regarded as an opportunity for policy making, because interventions to tackle CHE become more confined. Monitoring the distribution of payments across services can also contribute to early detection of emerging (and even, unexpected) drivers of catastrophic payments.

中文翻译：

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高收入国家灾难性卫生支出的演变：发生率与不平等。

背景技术 灾难性卫生支出（CHE）已被广泛认为是财务保护的指标，对此有大量文献报道。然而，大多数著作主要分析低收入和中等收入国家，并没有解决 CHE 的不同分配维度。我们认为，除了发生率之外，后者对于更好地掌握金融保护问题的范围和性质也至关重要。因此，我们的目标是分析高收入国家 CHE 的演变，同时考虑其发生率和分布。方法 数据取自 2005/2006 年、2010/2011 年和 2015/2016 年进行的最后三轮葡萄牙家庭预算调查。为了确定 CHE，采用的方法是支付能力/规范食品支出，门槛为 40%。为了分析分布，使用浓度曲线和指数 (CI) 并计算调整后的比值比。结果 2005年、2010年和2015年CHE发生率分别为2.57%、1.79%和0.46%。CHE 高度集中在最贫困人群（相应 CI 从 2005 年的 - 0.390 发展到 2015 年的 - 0.758）和有老年人的家庭（绝对 CI 从 2005 年的 0.520 发展到 2015 年的 0.740）。地理背景下的绝对 CI 也随着时间的推移而增加（2015 年为 0.354，2005 年为 0.019）。迄今为止，药品在灾难性付款中所占比例最大，不过在本例中，集中度有所下降（在分析期间，药品的中位比例从 93% 降至 43%）。相反，咨询费所产生的费用一直在增加（即使对于全科医生来说也是如此，尽管 NHS 覆盖了初级保健）。结论 CHE 的发生率及其分布的不平等可能会朝同一方向发展，也可能不同，但最重要的是，政策制定者应关注 CHE 的分布维度，因为这可能为面临风险的目标家庭提供有用的见解。CHE 的更大集中实际上可以被视为政策制定的机会，因为解决 CHE 的干预措施变得更加有限。监控支付在服务中的分布还有助于及早发现灾难性支付的新兴（甚至是意外）驱动因素。