1. Knaul, 8 de diciembre del 2006 Knaul, 8 de diciembre del 2006 Taller de consulta sobre Medición de la Calidad de Vida: SALUD: QUE SABEMOS, QUE MÁS DEBERÍAMOS DE SABER Y COMO PODEMOS AVERIGUARLO

2. CATASTROPHIC AND IMPOVERISHING HEALTH SPENDING: A GLOBAL PROBLEM LAC – high rates and increasingly important challenge for families as demographic and epidemiological transitions proceed Asia: Van Doorslaer et al An additional seventy-eight million people or 2.7% of the total population, fall below the extreme poverty threshold of $1 per day after accounting for payments for health care. (11 COUNTRIES, 79% of the Asian population), This represents a 14% increase in the rate of extreme poverty. USA, Himmelstein, HEALTH AFFAIRS, 2005. Medical problems contributed to 50% of all bankruptcy files Globally, every year (WHO): 44 million households face catastrophic expenditure 25 million households are pushed into poverty by the need to pay for services. ANNUAL, GLOBAL ESTIMATE MAY BE ?4? TIMES HIGHER

3. Relative (more than 30% of disposable income): 3.4% 3.8% Absolute (pushed below poverty line or deeper into poverty): MEXICO 2000(PRE-REFORM): THE INCIDENCE OF ABSOLUTE AND RELATIVE IMPOVERISHMENT FROM HEALTH SPENDING IS HIGH, PARTICULARLY AMONG THE UNINSURED AND THE POOR. Absolute and/or relative: 6.3%, 1.5 million families per trimester =~ 4 million per year Insured: 2.2% Uninsured: 9.6% Poorest quintile, 910,000 families per trimester : 19.6 % Quintiles 2,3,4 and 5: 3.1% In the poorest quintile, 2/3 of families are below the poverty line and spend less than 30% of disposable income, and 22% cross the poverty line due to health spending. 30%+, 20% etc

4. AMONG POOR HOUSEHOLDS, IMPOVERISHING HEALTH EXPENDITURE IS CONCENTRATED IN MEDICINES AND AMBULATORY CARE; AMONG THE RICH, IN HOSPITALIZATION Source: Authors´ calculations based on ENIGH, 2000. + poorIIIIIIV+ wealthy Medicines Ambulatory care Maternity Other Hospitalization

5. THE HIGHEST RATES OF RELATIVE AND ABSOLUTE IMPOVERISHMENT FROM HEALTH SPENDING ARE AMONG FAMILIES WITH OLDER ADULTS AND YOUNG CHILDREN, AND SINCE 2000 PARTICULARLY AMONG FAMILIES WITH OLDER ADULTS 0 5 30 1992199419961998200020022004 % of households Older adults and children Children, no older adults Neither children or older adults older adults, no children Source: Knaul F, Arreola H, Mendez O. Tendencias en la protecci ó n financiera en salud en M é xico. M é xico, D. F.: FUNSALUD,documento de trabajo, 2005. % of households with relative and/or absolute impoverishment

6. Health (care) or impoverishment Single mother earning 2 m.s. on Oaxaca, both children develop a throat infection: doctor visits and antibiotics >30% of disposable income 6-person family in Veracruz, below poverty line, agricultural worker grandmother-Type II diabetes Child with cancer

7. How do families finance health events?: often by reducing investment in other basic needs and human capital, 2001 Vivienda ALL Poorest 20% FOOD HOUSING EDUCATION ANY OF THE ABOVE 18% 12% 5% 6% 18% 20% 47% 35% Source: Authors´ calculations based on ENAGS, 2001.

8. 1.How can measurement and definition issues be improved? 2.What are the determinants of excessive, catastrophic and impoverishing health expenditure among families? 3.What is the effect on poverty, human capital and family well-being (eg. Gertler and Gruber) at the micro level and, on firms, labor markets, growth and competitiveness at the macro level? 4.Is there impact/a causal relationship between the changes in fairness of finance and the efforts to achieve financial protection that are proposed in reforms and policies? Future research

9. 1.Explaining and correcting variation across surveys health spending, total spending and family income health spending, total spending and family income 2.Defining periodicity and the timeframe of impoverishment Once per year; number of times per year Once per year; number of times per year Once per week, month, trimester Once per week, month, trimester 3.Measuring changes over time – longitudinal data 4.Expanding and improving concepts and methodologies measurement of disposable income measurement of disposable income objectively defining ´catastrophic´ and deepening impoverishment objectively defining ´catastrophic´ and deepening impoverishment Incorporating income losses due to ill health Incorporating income losses due to ill health Studies of impact Studies of impact Other indices Other indices Methodological and data-related challenges

10. 1.Registry and bank of health and health establishment surveys for LAC – especially older surveys 2.´Standardized´ questionnaires (similiar to LFP) 3.Link health surveys to other data bases: Calidad de Vida Calidad de Vida Encuestas de Ingreso y Gasto de los Hogares Encuestas de Ingreso y Gasto de los Hogares 4.Links to administrative data More, and more general requirements

11. Knaul, 8 de diciembre del 2006 Knaul, 8 de diciembre del 2006 Taller de consulta sobre Medición de la Calidad de Vida: SALUD: QUE SABEMOS, QUE MÁS DEBERÍAMOS DE SABER Y COMO PODEMOS AVERIGUARLO