INTRODUCTION Access to Liberia's health system is reliant on out-of-pocket (OOP) health expenditures which may prevent people from seeking care or result in catastrophic health expenditure (CHE). CHE and impoverishment due to OOP, which are used by the World Bank and World Health Organization as the sole measures of financial risk protection, are limited: they do not consider households who, following a health shock, do not incur expenditure because they cannot access the healthcare services they need (i.e., households forgoing healthcare (HFH) services). This paper attempts to overcome this limitation and improve financial risk protection by measuring HFH incidence and comparing it with CHE standard measures using household survey data from Liberia. METHODS Data from the Liberia Household Income and Expenditure Survey 2014 were analysed. An OOP health expenditure is catastrophic when it exceeds a total or non-food household expenditure threshold. A CHE incidence curve, representing CHE incidence at different thresholds, was developed. To overcome CHE limitations, an HFH incidence measure was developed based on CHE, OOP and health shocks data: households incurring health shocks and having negligible OOP were considered to have forgone healthcare. HFH incidence was compared with standard CHE measures. RESULTS CHE incidence and intensity levels depend on the threshold used. Using a 30% non-food expenditure threshold, CHE incidence is 2.1% (95% CI: 1.7-2.5%) and CHE intensity is 37.4% (95% CI: 22.7-52.0%). CHE incidence is approximately in line with other countries, while CHE intensity is higher than in other countries. CHE pushed 1.6% of households below the food poverty line in 2014. c approximately 4 times higher than CHE (8.0, 95% CI, 7.2-8.9%). CONCLUSION Lack of financial risk protection is a significant problem in Liberia and it may be underestimated by CHE: this study confirms that HFH incidence can complement CHE measures in providing a complete picture of financial risk protection and demonstrates a simple method that includes measures of healthcare forgone as part of standard CHE analyses. This paper provides a new methodology to measure HFH incidence and highlights the need to consider healthcare forgone in analyses of financial risk protection, as well as the need for further development of these measures.

中文翻译：

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家庭放弃医疗保健作为财务风险保护措施：利比里亚的应用。


简介 利比里亚卫生系统的使用依赖于自付费用 (OOP) 卫生支出，这可能会妨碍人们寻求护理或导致灾难性的卫生支出 (CHE)。世界银行和世界卫生组织将 CHE 和 OOP 导致的贫困作为金融风险保护的唯一措施，但其局限性是有限的：他们没有考虑在健康冲击后因无法获得支出而不会产生支出的家庭。他们需要的医疗保健服务（即放弃医疗保健 (HFH) 服务的家庭）。本文试图通过测量 HFH 发生率并将其与使用利比里亚家庭调查数据的 CHE 标准措施进行比较来克服这一局限性并改善财务风险保护。方法 对 2014 年利比里亚家庭收入和支出调查的数据进行了分析。当 OOP 医疗支出超过家庭总支出或非食品支出阈值时，就会造成灾难性的后果。绘制了代表不同阈值下 CHE 发生率的 CHE 发生率曲线。为了克服 CHE 的局限性，根据 CHE、OOP 和健康冲击数据制定了 HFH 发病率衡量标准：遭受健康冲击且 OOP 可以忽略不计的家庭被认为放弃了医疗保健。将 HFH 发生率与标准 CHE 指标进行比较。结果 CHE 发生率和强度水平取决于所使用的阈值。使用 30% 非食品支出阈值，CHE 发生率为 2.1%（95% CI：1.7-2.5%），CHE 强度为 37.4%（95% CI：22.7-52.0%）。 CHE 发生率与其他国家大致一致，而 CHE 强度则高于其他国家。 2014 年，CHE 将 1.6% 的家庭推向粮食贫困线以下。c 大约是 CHE 的 4 倍（8.0，95% CI，7.2-8.9%）。 结论 缺乏财务风险保护是利比里亚的一个重大问题，CHE 可能低估了这一问题：本研究证实 HFH 发生率可以补充 CHE 措施，提供完整的财务风险保护情况，并展示了一种包括放弃医疗保健措施的简单方法作为标准 CHE 分析的一部分。本文提供了一种衡量 HFH 发生率的新方法，并强调在金融风险保护分析中考虑放弃医疗保健的必要性，以及进一步开发这些措施的必要性。