Healthcare utilization and catastrophic health expenditure in rural Tanzania: does voluntary health insurance matter?

(2023) 23:1567 Kagaigai et al. BMC Public Health https://doi.org/10.1186/s12889-023-16509-7 BMC Public Health Open Access RESEARCH Healthcare utilization and catastrophic health expenditure in rural Tanzania: does voluntary health insurance matter? Alphoncina Kagaigai1,2*, Amani Anaeli2, Sverre Grepperud1 and Amani Thomas Mori2,3 Abstract Background Over 150 million people, mostly from low and middle-income countries (LMICs) suffer from catastrophic health expenditure (CHE) every year because of high out-of-pocket (OOP) payments. In Tanzania, OOP payments account for about a quarter of the total health expenditure. This paper compares healthcare utilization and the incidence of CHE among improved Community Health Fund (iCHF) members and non-members in central Tanzania. Methods A survey was conducted in 722 households in Bahi and Chamwino districts in Dodoma region. CHE was defined as a household health expenditure exceeding 40% of total non-food expenditure (capacity to pay). Concentration index (CI) and logistic regression were used to assess the socioeconomic inequalities in the distribution of healthcare utilization and the association between CHE and iCHF enrollment status, respectively. Results 50% of the members and 29% of the non-members utilized outpatient care in the previous month, while 19% (members) and 15% (non-members) utilized inpatient care in the previous twelve months. The degree of inequality for utilization of inpatient care was higher (insured, CI = 0.38; noninsured CI = 0.29) than for outpatient care (insured, CI = 0.09; noninsured CI = 0.16). Overall, 15% of the households experienced CHE, however, when disaggregated by enrollment status, the incidence of CHE was 13% and 15% among members and non-members, respectively. The odds of iCHF-members incurring CHE were 0.4 times less compared to non-members (OR = 0.41, 95%CI: 0.27–0.63). The key determinants of CHE were iCHF enrollment status, health status, socioeconomic status, chronic illness, and the utilization of inpatient and outpatient care. Conclusion The utilization of healthcare services was higher while the incidence of CHE was lower among households enrolled in the iCHF insurance scheme relative to those not enrolled. More studies are needed to establish the reasons for the relatively high incidence of CHE among iCHF members and the low degree of healthcare utilization among households with low socioeconomic status. Keywords Tanzania, Catastrophic health expenditure, Community-based health insurance scheme, Cross-sectional household survey, Out-of-pocket expenditure, Concentration index *Correspondence: Alphoncina Kagaigai Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Kagaigai et al. BMC Public Health (2023) 23:1567 Background Globally, the proportion of total health expenditure is less than 10% of the Gross Domestic Product (GDP). Additionally, the proportion of out-of-pocket (OOP) health expenditure has remained above 40% of the total health spending in low and middle-income countries (LMICs) [1]. It is commonly considered that OOP payments that exceed 10% of a household’s income or 40% of a household’s total non-food expenditure often referred to as capacity to pay, represents catastrophic health expenditures (CHE) [1–3]. From 2010 to 2015, the global population that incurred CHE at a 10% income threshold, increased from about 570 million to more than 900 million. When the 25% income threshold was used, the number of people with CHE increased from about 100 million to about 200 million in the same period. Furthermore, about 90 million people (1.2%) were pushed into extreme poverty (spending below $1.90 per person per day) due to OOP health spending in 2015 [4]. The largest number and percentage of the world population impoverished by OOP health spending are from countries in Asia and Africa [4]. The majority of people in some LMICs, particularly low-income earners rely on public health facilities for affordable services [2]. However, public health systems face many challenges including low quality of care, frequent stock-outs of essential medicines, and shortage of healthcare workers [5], hence forcing patients to seek costly services from private health facilities. Unfortunately, health insurance coverage is low in most LMICs, hence most people are unprotected from unexpectedly high healthcare costs [1]. As a result, OOP continues to be the main means of healthcare financing, thus exposing many people to CHE [6–8]. In Tanzania, OOP accounts for about 22% of the total health expenditure, while health insurance schemes (premium payment) account for about 8% [9]. The challenge of raising sufficient funds to finance healthcare is one of the major reasons for LMICs not Page 2 of 13 being able to meet the healthcare needs of their citizens [10, 11]. Community-based health insurance schemes (CBHIs) represent one important strategy for protecting rural and informal sector workers from impoverishing OOP payments [11–13]. According to the WHO, CBHIs are micro health insurance schemes primarily targeted at low-income households. Generally, the pooling of health risks occurs within a community or a group of people that share common characteristics such as geographical location or occupation. The membership premiums are typically flat rates (independent of individual health risks) and the schemes operate on a non-profit basis [14–17]. However, such schemes have not been always successful in providing an adequate level of financial protection [16, 18, 19]. Limited financing sources, the absence of scheme promotion initiatives, and the lack of governmental commitment have contributed to the limited growth of CBHIs, thus delaying the progress toward universal health coverage (UHC) [18]. In Tanzania, the CBHI scheme, commonly referred to as Community Health Fund (CHF), was introduced in 1996 to enhance (...truncated)