Résumé

Objectif

Déterminer la nature, la portée et l'efficacité des interventions visant à réduire la charge économique des maladies ou des blessures sur les ménages.

Méthodes

Nous avons systématiquement passé en revue les rapports publiés avant le ou à la date du 31 janvier 2014, que nous avons trouvés dans les bases de données CENTRAL, CINAHL, Econlit, Embase, MEDLINE, PreMEDLINE et PsycINFO. Nous avons extrait les données à partir d'essais contrôlés prospectifs et évalué le risque de biais. Nous avons fait la synthèse des données de manière narrative.

Résultats

Parmi les 4 330 études examinées, 9 d'entre elles ont satisfait nos critères d'inclusion – 7 avaient évalué les changements dans les programmes d'assurance maladie existants et 2 avaient évalué les différents modes de diffusion des informations. Les seules interventions qui réduisaient significativement les dépenses restant à la charge des patients étaient celles qui éliminaient ou diminuaient substantiellement la participation aux frais pour une population de patients donnée. Toutefois, les réductions ne représentaient que des changements marginaux dans l'ensemble des dépenses des patients. Nous n'avons trouvé aucune étude qui n'ait été efficace dans le traitement des impacts économiques plus larges sur les ménages – comme les dépenses catastrophiques de santé – dans les populations de malades étudiées.

Conclusion

En général, les interventions visant à réduire la charge économique et complexe des maladies et des blessures sur les ménages semblent n'avoir que peu d'effet sur l'économie des ménages. Nous n'avons trouvé qu'un petit nombre d'études pertinentes qui utilisaient des modèles d'étude rigoureux et qui ont été menées sur des populations de patients définies. Les études ont été limitées dans la gamme des interventions testées et elles n'ont évalué qu'une gamme restreinte de résultats économiques sur les ménages. Il est nécessaire de développer des méthodes pour améliorer la quantification des conséquences économiques des maladies et des blessures sur les ménages et pour faciliter le développement d'interventions innovantes afin de compléter les stratégies reposant sur l'assurance maladie.

Resumen

Objetivo

Determinar la naturaleza, el alcance y la eficacia de las intervenciones para reducir la carga económica familiar de enfermedades o lesiones.

Métodos

Se revisaron sistemáticamente los informes publicados hasta el 31 de enero de 2014 (incluido) procedentes de las bases de datos CENTRAL, CINAHL, Econlit, Embase, MEDLINE, PreMEDLINE y PsycINFO. Se extrajeron los datos de ensayos controlados prospectivos y se evaluó el riesgo de sesgo. Posteriormente, se sintetizaron narrativamente las pruebas.

Resultados

Nueve de los 4330 estudios examinados cumplieron con los criterios de inclusión: siete habían evaluado los cambios en los programas de seguros de salud existentes, mientras que los otros dos habían evaluado modos diferentes de transmisión de la información. Se halló que las intervenciones que eliminaban o reducían sustancialmente los copagos para una población de pacientes concreta eran las únicas que reducían el desembolso directo de forma significativa. Sin embargo, las reducciones solo representaban cambios marginales en el gasto total de los pacientes. No se encontraron estudios que hubieran abordado con eficacia los efectos mayores en la economía familiar, como los gastos catastróficos por motivos de salud en las poblaciones de enfermedad investigadas.

Conclusión

En general, las intervenciones destinadas a reducir la complejidad de la carga económica familiar de enfermedades y lesiones parecen haber afectado poco a la economía familiar. Se encontraron pocos estudios relevantes con un diseño de estudio riguroso realizados en poblaciones de pacientes definidas. Estos estudios se limitaron a un conjunto de intervenciones probadas y únicamente evaluaban un conjunto reducido de resultados económicos para los hogares. Es necesario elaborar métodos para avanzar en la medición de las consecuencias económicas de enfermedades y lesiones para los hogares, además de facilitar el desarrollo de intervenciones innovadoras a fin de complementar las estrategias basadas en seguros de salud.

ملخص

الغرض

تحديد طبيعة ونطاق وفعالية التدخلات الرامية إلى تقليل العبء الاقتصادي للمرض أو الإصابة لدى الأسر المعيشية.

الطريقة

قمنا بإجراء مراجعة منهجية للتقارير المنشورة بتاريخ 31 كانون الثاني/ يناير 2014 أو ما بعده التي تم العثور عليها في قواعد بيانات CENTRAL وCINAHL وEconlit وEmbase وMEDLINE وPreMEDLINE وPsycINFO. وقمنا باستخلاص البيانات من التجارب الاستطلاعية التي أجريت في بيئة خاضعة للمراقبة وتقييم مخاطر التحيز. وقمنا باستخلاص البيّنات على نحو سردي.

النتائج

استوفت تسع دراسات من أصل 4330 دراسة تم فحصها معايير الإدراج المحددة من قبلنا - قامت سبع منها بتقييم التغيرات في برامج التأمين الصحي الحالية وقامت اثنتان بتقييم الأنماط المختلفة لإيتاء المعلومات. وكانت التدخلات الوحيدة التي تبين أنها تقلل النفقات التي ينفقها الفرد من جيبه الخاص بشكل كبير تلك التي ألغت المدفوعات المشتركة أو خفضتها بشكل كبير لمرضى معينين. ومع ذلك، لم تمثل الانخفاضات سوى تغيرات هامشية في إجمالي نفقات المرضى. ولم نجد دراسات فعالة في معالجة الآثار الاقتصادية الأعم على الأسر المعيشية - مثل الإنفاق الكارثي في مجال الصحة - في المرضى الذين تم تحريهم.

الاستنتاج

بشكل عام، يبدو أن التدخلات المصممة لتقليل العبء الاقتصادي المعقد للمرض والإصابة لدى الأسر المعيشية كانت ذات أثر ضئيل على اقتصاديات الأسر المعيشية. ولم نجد سوى بضع دراسات ذات صلة تستخدم تصاميم الدراسة الصارمة التي تم إجراؤها على مرضى محددين. وكانت الدراسات محدودة في نطاق التدخلات التي تم اختبارها ولم تقم إلا بتقييم نطاق ضيق من الحصائل الاقتصادية لدى الأسر المعيشية. وثمة حاجة لوضع أسلوب لإحراز تقدم في قياس الآثار الاقتصادية للمرض والإصابة لدى الأسر المعيشية وتسهيل وضع تدخلات ابتكارية لاستكمال الاستراتيجيات المستندة على التأمين الصحي.

摘要

目的

确定减少疾病或损伤的家庭经济负担的干预措施的性质、范围和有效性。

方法

我们系统地回顾了在CENTRAL、CINAHL、Econlit、Embase、MEDLINE、PreMEDLINE和PsycINFO数据库中找到的发表于2014年1月31日或之前的报告。我们提取前瞻性对照试验的数据并评估偏差的风险。我们以叙事形式合成证据。

结果

在检查的4330项研究中有九项满足我们的入选标准，其中七项研究对现有的医疗保险计划的变更做出评估，两项研究对不同信息交付模式进行评估。我们发现的唯一可显著减少自付费用的干预措施是消除或大大减少给定病人群体的共付额。然而，这种减少只代表病人总支出的边际变化。我们没有发现有效地解决所调查人口中更广泛的家庭经济影响（如灾难性卫生支出）的研究。

结论

一般来说，旨在减少疾病和损伤复合家庭经济负担的干预措施似乎对家庭经济影响不大。我们只找到了很少几项使用严格研究设计并在限定患者群体中执行的相关研究。这些研究的范围限于检测和评估狭小范围家庭经济产出的干预措施。需要发展测量疾病和损伤家庭经济后果的方法，并促进发展创新的干预措施以作为基于医疗保险的战略的补充。

Резюме

Цель

Определить характер, масштабы и эффективность мер по снижению экономического бремени болезней и травм для домохозяйств.

Методы

Проводился систематический обзор отчетов, опубликованных по состоянию на 31 января 2014 года в базах данных CENTRAL, CINAHL, Econlit, Embase, MEDLINE, PREMEDLINE и PsycInfo. Были извлечены данные из проспективных контролируемых исследований и определен риск системной ошибки. Для собранных данных была проведена описательная классификация.

Результаты

Девять из 4330 рассмотренных исследований соответствовали критериям включения в обзор — в семи из них оценивались изменения в существующих программах медицинского страхования, а в двух исследованиях оценивались различные способы доставки информации. Единственными выявленными мероприятиями, которые приводили к существенному снижению собственных расходов домохозяйств на лечение, были те, которые устраняли или значительно сокращали собственные доплаты для определенного контингента больных. Тем не менее, это снижение собственных доплат составляло лишь незначительную долю в общем объеме расходов пациентов. Не были найдены исследования, которые бы эффективно устраняли экономические воздействия на домохозяйства — такие как катастрофические расходы на здравоохранение — в исследованных группах заболеваний.

Вывод

В целом, выявленные меры, направленные на снижение сложного экономического бремени болезней и травм для домохозяйств, оказывали незначительное влияние на экономику этих домохозяйств. Были обнаружили всего несколько соответствующих исследований, использующих тщательно разработанные схемы, которые были проведены в определенных группах пациентов. Эти исследования касались ограниченного диапазона мероприятий и оценивали лишь узкий диапазон воздействий на экономику домохозяйств. Существует потребность в разработке методов измерения экономических последствий болезней и травм для домохозяйств, как и в содействии разработке инновационных мероприятий в дополнение к стратегиям, основанным на медицинском страховании.

Introduction

Each year, globally, around 150 million people struggle to meet the costs of accessing and using health care and approximately 100 million people are driven below the poverty line by such costs.¹1 Xu K, Evans DB, Carrin G, Aguilar-Rivera AM, Musgrove P, Evans T. Protecting households from catastrophic health spending. Health Aff (Millwood). 2007 Jul-Aug;26(4):972–83. doi: http://dx.doi.org/10.1377/hlthaff.26.4.972 PMID: 17630440
https://doi.org/10.1377/hlthaff.26.4.972... Many people delay or avoid health care because it is – or, at least, is perceived to be – unaffordable.²2 Gilson L. The lessons of user fee experience in Africa. Health Policy Plan. 1997 Dec;12(4):273–85. doi: http://dx.doi.org/10.1093/oxfordjournals.heapol.a018882 PMID: 10176263
https://doi.org/10.1093/oxfordjournals.h... ^–44 Sauerborn R, Ibrango I, Nougtara A, Borchert M, Hien M, Benzler J, et al. The economic costs of illness for rural households in Burkina Faso. Trop Med Parasitol. 1995 Mar;46(1):54–60. PMID: 7631130 Most of those who struggle to meet the out-of-pocket costs of health care live in low-income countries that have poorly funded health systems and inadequate measures to ensure the financial protection of households against high health-care expenditure. However, the problem is not limited to such countries. In 2007, for example, 62% of the personal bankruptcies recorded in the United States of America (USA) were attributed to medical debt⁵5 Himmelstein DU, Thorne D, Warren E, Woolhandler S. Medical bankruptcy in the United States, 2007: results of a national study. Am J Med. 2009 Aug;122(8):741–6. doi: http://dx.doi.org/10.1016/j.amjmed.2009.04.012 PMID: 19501347
https://doi.org/10.1016/j.amjmed.2009.04... and 11% of the individuals found insolvent in Australia cited ill-health or lack of health insurance as the primary reason for their insolvency.⁶6 Profiles of debtors 2011. Canberra: Commonwealth of Australia; 2012. Available from: https://www.afsa.gov.au/resources/statistics/profiles-of-debtors-documents/profiles-of-debtors-2011 [cited 2014 Nov 2].
https://www.afsa.gov.au/resources/statis... Substantial and unpredictable one-off health-care payments and a steady flow of unbudgeted medical bills can lead many households – particularly those already marginalized by socioeconomic disadvantage – towards catastrophic health-care expenditure.⁷7 Schoenberg NE, Kim H, Edwards W, Fleming ST. Burden of common multiple-morbidity constellations on out-of-pocket medical expenditures among older adults. Gerontologist. 2007 Aug;47(4):423–37. doi: http://dx.doi.org/10.1093/geront/47.4.423 PMID: 17766664
https://doi.org/10.1093/geront/47.4.423...

The economic burden of illness in a household is only partly explained by out-of-pocket expenditure. The full evaluation of such burden requires a multidimensional framework – to move beyond absolute spending to incorporate measures that examine the broader impacts of illness or injury on the household economy – e.g. loss of employment – as well as the affordability of care, a household’s response to an injury or illness and the consequences of those responses for the household.⁸8 Moreno-Serra R, Millett C, Smith PC. Towards improved measurement of financial protection in health. PLoS Med. 2011 Sep;8(9):e1001087. doi: http://dx.doi.org/10.1371/journal.pmed.1001087 PMID: 21909246
https://doi.org/10.1371/journal.pmed.100... ^,99 Ruger JP. An alternative framework for analyzing financial protection in health. PLoS Med. 2012;9(8):e1001294. doi: http://dx.doi.org/10.1371/journal.pmed.1001294 PMID: 22927799
https://doi.org/10.1371/journal.pmed.100... Most research in this area has been observational and has demonstrated that households will employ several strategies – to deal with unbudgeted costs of medical care and unplanned departures from the workforce – when coping with the onset of an illness or injury, especially in the main income earner. Such coping strategies include drawing on available social resources and networks, cutting back on essential living expenses, drawing on savings, selling assets, borrowing money, entering into formal or informal loan agreements, increasing credit or debt and even moving house.³3 McIntyre D, Thiede M, Dahlgren G, Whitehead M. What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts? Soc Sci Med. 2006 Feb;62(4):858–65. doi: http://dx.doi.org/10.1016/j.socscimed.2005.07.001 PMID: 16099574
https://doi.org/10.1016/j.socscimed.2005... ^,44 Sauerborn R, Ibrango I, Nougtara A, Borchert M, Hien M, Benzler J, et al. The economic costs of illness for rural households in Burkina Faso. Trop Med Parasitol. 1995 Mar;46(1):54–60. PMID: 7631130 Although these strategies may help leverage the resources needed to pay for care, they can also have adverse effects on treatment-seeking behaviour and the long-term economic well-being and resilience of the household.³3 McIntyre D, Thiede M, Dahlgren G, Whitehead M. What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts? Soc Sci Med. 2006 Feb;62(4):858–65. doi: http://dx.doi.org/10.1016/j.socscimed.2005.07.001 PMID: 16099574
https://doi.org/10.1016/j.socscimed.2005... ^,44 Sauerborn R, Ibrango I, Nougtara A, Borchert M, Hien M, Benzler J, et al. The economic costs of illness for rural households in Burkina Faso. Trop Med Parasitol. 1995 Mar;46(1):54–60. PMID: 7631130^,77 Schoenberg NE, Kim H, Edwards W, Fleming ST. Burden of common multiple-morbidity constellations on out-of-pocket medical expenditures among older adults. Gerontologist. 2007 Aug;47(4):423–37. doi: http://dx.doi.org/10.1093/geront/47.4.423 PMID: 17766664
https://doi.org/10.1093/geront/47.4.423...

The provision of adequate financial protection – from the costs of seeking and using medical care – is a critical marker of the effectiveness of a health-care system.¹⁰10 Health systems: improving performance. Geneva: World Health Organization; 2000. The World Health Organization has encouraged its Member States to provide universal health coverage in some form and the United Nations has recently passed a declaration that calls for universal access to health care that does not cause financial hardship.¹¹11 Agenda item 123. Global health and foreign policy. A/67/L.36. Sixty-seventh United Nations General Assembly, New York, 6 December 2012. New York: United Nations; 2012. Such a goal – like other post-2015 development goals aimed at alleviating poverty – is unlikely to be achieved without further development and implementation of national health-insurance schemes. There is considerable evidence, most notably from the RAND Health Insurance Experiments,¹²12 Newhouse NP. Free for all? Lessons from the RAND Health Insurance Experiment. Cambridge: Harvard University Press; 1993. that indicates how health insurance can protect the finances of households affected by illness or injury, by restricting individual health-care expenditure. However, although such insurance is one of the most important population-based policy interventions to mitigate the economic burden of injury or illness, it is not sufficient, on its own, to provide full protection from catastrophic health expenditure.¹³13 Wagstaff A, van Doorslaer E. Catastrophe and impoverishment in paying for health care: with applications to Vietnam 1993–1998. Health Econ. 2003 Nov;12(11):921–34. doi: http://dx.doi.org/10.1002/hec.776 PMID: 14601155
https://doi.org/10.1002/hec.776... ^,1414 Wagstaff A, Lindelow M. Can insurance increase financial risk? The curious case of health insurance in China. J Health Econ. 2008 Jul;27(4):990–1005. doi: http://dx.doi.org/10.1016/j.jhealeco.2008.02.002 PMID: 18342963
https://doi.org/10.1016/j.jhealeco.2008.... The effectiveness of health insurance in protecting individuals who are intense users of medical care – e.g. those with chronic illness or long-term injuries – has yet to be elucidated. Furthermore, limited coverage of services and high levels of co-payment can often mean that households with health insurance remain at risk of catastrophic health-care expenditures and economic hardship.¹⁴14 Wagstaff A, Lindelow M. Can insurance increase financial risk? The curious case of health insurance in China. J Health Econ. 2008 Jul;27(4):990–1005. doi: http://dx.doi.org/10.1016/j.jhealeco.2008.02.002 PMID: 18342963
https://doi.org/10.1016/j.jhealeco.2008.... ^,1515 Heeley E, Anderson CS, Huang Y, Jan S, Li Y, Liu M, et al.; ChinaQUEST Investigators. Role of health insurance in averting economic hardship in families after acute stroke in China. Stroke. 2009 Jun;40(6):2149–56. doi: http://dx.doi.org/10.1161/STROKEAHA.108.540054 PMID: 19359646
https://doi.org/10.1161/STROKEAHA.108.54...

Evidence of the effectiveness of simple education and support interventions, in both clinic- and community-based settings, has highlighted the potential value of more targeted and patient-focused strategies in reducing the household economic burden of illness. Interventions that help patients and caregivers to navigate through health and social-welfare support systems¹⁶16 Benefits access for people affected by cancer in Northern Ireland. Belfast: Social Security Agency; 2004. Available from: www.dsdni.gov.uk/benefit_access_people_with_cancer.pdf [cited 2014 Feb 1].
www.dsdni.gov.uk/benefit_access_people_w... ^,1717 Moffatt S, Noble E, White M. Addressing the financial consequences of cancer: qualitative evaluation of a welfare rights advice service. PLoS One. 2012;7(8):e42979. doi: http://dx.doi.org/10.1371/journal.pone.0042979 PMID: 22900073
https://doi.org/10.1371/journal.pone.004... and informal loan and microcredit schemes¹⁸18 Chuma J, Molyneux C. Coping with the costs of illness: the role of shops and shopkeepers as social networks in a low-income community in coastal Kenya. J Int Dev. 2009;21(2):252–70. doi: http://dx.doi.org/10.1002/jid.1546
https://doi.org/10.1002/jid.1546... ^–2020 Goudge J, Russell S, Gilson L, Molyneux C, Hanson K. Household experiences of ill-health and risk protection mechanisms. J Int Dev. 2009;21(2):159–68. doi: http://dx.doi.org/10.1002/jid.1551
https://doi.org/10.1002/jid.1551... have the potential to buffer those with illness and injury against financial hardship. As the evidence of the effectiveness and cost–effectiveness of such interventions becomes more robust, opportunities for the development and scale-up of such interventions need to be explored.

There have been few systematic reviews of interventions to reduce the household economic burden of illness or injury. The reviews that have been conducted have tended to take a population-based approach – e.g. they have examined the impact of health-insurance programmes on entire populations – and have often been based on studies that involved retrospective comparisons of before and after data. Furthermore, they have focused either on specific types of interventions – e.g. programmes for the management of chronic illness²¹21 Ofman JJ, Badamgarav E, Henning JM, Knight K, Gano AD Jr, Levan RK, et al. Does disease management improve clinical and economic outcomes in patients with chronic diseases? A systematic review. Am J Med. 2004 Aug 1;117(3):182–92. doi: http://dx.doi.org/10.1016/j.amjmed.2004.03.018 PMID: 15300966
https://doi.org/10.1016/j.amjmed.2004.03... or health-insurance schemes²²22 Ekman B. Community-based health insurance in low-income countries: a systematic review of the evidence. Health Policy Plan. 2004 Sep;19(5):249–70. doi: http://dx.doi.org/10.1093/heapol/czh031 PMID: 15310661
https://doi.org/10.1093/heapol/czh031... ^–2424 Liang X, Guo H, Jin C, Peng X, Zhang X. The effect of new cooperative medical scheme on health outcomes and alleviating catastrophic health expenditure in China: a systematic review. PLoS ONE. 2012;7(8):e40850. doi: http://dx.doi.org/10.1371/journal.pone.0040850 PMID: 22916098
https://doi.org/10.1371/journal.pone.004... – or have focused, narrowly, on out-of-pocket payments, as the sole measure of the economic impact of illness.²⁴24 Liang X, Guo H, Jin C, Peng X, Zhang X. The effect of new cooperative medical scheme on health outcomes and alleviating catastrophic health expenditure in China: a systematic review. PLoS ONE. 2012;7(8):e40850. doi: http://dx.doi.org/10.1371/journal.pone.0040850 PMID: 22916098
https://doi.org/10.1371/journal.pone.004... We decided to conduct a systematic review to try to determine the nature, scope and effectiveness of all interventions that have been designed to reduce the household economic burden of illness or injury.

Methods

We searched electronic databases, using a predefined search strategy and confining the search to reports published on or before 31 January 2014 (Box 1). The reference lists of retrieved articles were screened to identify additional studies, and investigators known to be carrying out relevant research were contacted for unpublished data. Non-English articles were translated where necessary.

To be included in our review, a study (i) had to be a prospective controlled trial of one or more interventions – i.e. a randomized or nonrandomized controlled trial, an interrupted time series study with control, or a controlled before-and-after study; (ii) involve a study population with any, chronic or acute, communicable or noncommunicable disease or injury; and (iii) use a study outcome that was a measure of the household economic burden of illness or injury – e.g. out-of-pocket expenditure or level of economic hardship.

Interventions directed at the individual, household or population and delivered in any setting were eligible for inclusion. Studies that were primarily treatment or medical interventions – e.g. cataract surgery or chemotherapy – were excluded even if they included economic measures as additional outcomes.

Two authors carried out the literature search and screened titles and abstracts using a standardized eligibility assessment form based on our inclusion criteria. The full texts of articles of potential interest were reviewed by two authors and a final decision on which studies to include was confirmed by consensus. A third author provided arbitration if consensus was not reached. One author used a predefined form²⁵25 Higgins J, Altman D. Chapter 8: Assessing risk of bias in included studies. In: Higgins J, Green S, editors. Cochrane handbook for systematic reviews of interventions version 501 (updated September 2008). Oxford: The Cochrane Collaboration; 2008. doi: http://dx.doi.org/10.1002/9780470712184.ch8
https://doi.org/10.1002/9780470712184.ch... ^,2626 Quality assessment tool for quantitative studies method (updated 13 April, 2010). Hamilton: National Collaborating Centre for Methods and Tools; 2008. Available from: http://www.nccmt.ca/registry/view/eng/15.html [cited 2013 Feb 1].
http://www.nccmt.ca/registry/view/eng/15... to extract data from each included study. The data extraction was verified by a second author. Authors of included studies were contacted for any missing information or data. Where possible, effect estimates were calculated as standardized mean differences between the intervention and control groups, with 95% confidence intervals.²⁷27 Schunemann HJ, Oxman AD, Higgins JPT, Vist GE, Glasziou O, Guyatt GH. Chapter 11: Presenting results and ‘summary of findings’ tables. In: Higgins J, Green S, editors. Cochrane handbook for systematic reviews of interventions version 501 (updated September 2008). Oxford: The Cochrane Collaboration; 2008. doi: http://dx.doi.org/10.1002/9780470712184.ch11
https://doi.org/10.1002/9780470712184.ch... Where reported, data on the impact of the interventions on health-service-utilization – e.g. numbers of hospital admissions or medical appointments – and medication adherence were also collected.

The risk of bias in each of the included studies was assessed by one author –using the criteria suggested for Effective Practice and Organisation of Care reviews²⁸28 Suggested risk of bias criteria for EPOC reviews. Oslo: Norwegian Knowledge Centre for the Health Services; 2013. Available from: http://epocoslo.cochrane.org/sites/epocoslo.cochrane.org/files/uploads/14%20Suggested%20risk%20of%20bias%20criteria%20for%20EPOC%20reviews%202013%2008%2012_0.pdf [cited 2014 Nov 3].
http://epocoslo.cochrane.org/sites/epoco... – and verified by a second author.

Quantitative analysis of the data was deemed inappropriate because of the heterogeneity in the collected data, designs and settings of the included studies.

Results

The initial literature search identified 4330 citations. There were 90 articles of potential interest and, after examination of the full texts, nine articles described studies that met all of our inclusion criteria (Fig. 1). Each of the nine articles – seven conducted in the USA,²⁹29 Barry CL, Chien AT, Normand SL, Busch AB, Azzone V, Goldman HH, et al. Parity and out-of-pocket spending for children with high mental health or substance abuse expenditures. Pediatrics. 2013 Mar;131(3):e903–11. doi: http://dx.doi.org/10.1542/peds.2012-1491 PMID: 23420919
https://doi.org/10.1542/peds.2012-1491... ^–3535 Van Houtven CH, Thorpe JM, Chestnutt D, Molloy M, Boling JC, Davis LL. Do nurse-led skill training interventions affect informal caregivers’ out-of-pocket expenditures? Gerontologist. 2013 Feb;53(1):60–70. doi: http://dx.doi.org/10.1093/geront/gns045 PMID: 22459694
https://doi.org/10.1093/geront/gns045... one in Finland³⁶36 Heikkinen K, Salanterä S, Suomi R, Lindblom A, Leino-Kilpi H. Ambulatory orthopaedic surgery patient education and cost of care. Orthop Nurs. 2011 Jan-Feb;30(1):20–8. doi: http://dx.doi.org/10.1097/NOR.0b013e318205747f PMID: 21278551
https://doi.org/10.1097/NOR.0b013e318205... and one in China³⁷37 Jing S, Yin A, Shi L, Liu J. Whether New Cooperative Medical Schemes reduce the economic burden of chronic disease in rural China. PLoS ONE. 2013;8(1):e53062. doi: http://dx.doi.org/10.1371/journal.pone.0053062 PMID: 23326382
https://doi.org/10.1371/journal.pone.005... – described a single study. Most of the included studies had investigated adult urban patients with noncommunicable disease (6/9) and had involved data from more than 1000 participants (7/9; Table 1). Illness and injury inclusion criteria had been assessed using diagnostic codes, the health-service use reported in insurance claims, clinical presentations or self-reporting.

Seven of our included studies had evaluated policy interventions that involved health-insurance schemes (Table 2). Of these, three had involved the reduction or elimination of co-payments for disease-specific medications or outpatient care.³¹31 Choudhry NK, Avorn J, Glynn RJ, Antman EM, Schneeweiss S, Toscano M, et al.; Post-Myocardial Infarction Free Rx Event and Economic Evaluation (MI FREEE) Trial. Full coverage for preventive medications after myocardial infarction. N Engl J Med. 2011 Dec 1;365(22):2088–97. doi: http://dx.doi.org/10.1056/NEJMsa1107913 PMID: 22080794
https://doi.org/10.1056/NEJMsa1107913... ^,3232 Choudhry NK, Fischer MA, Avorn JL, Lee JL, Schneeweiss S, Solomon DH, et al. The impact of reducing cardiovascular medication copayments on health spending and resource utilization. J Am Coll Cardiol. 2012 Oct 30;60(18):1817–24. doi: http://dx.doi.org/10.1016/j.jacc.2012.06.050 PMID: 23040581
https://doi.org/10.1016/j.jacc.2012.06.0... ^,3737 Jing S, Yin A, Shi L, Liu J. Whether New Cooperative Medical Schemes reduce the economic burden of chronic disease in rural China. PLoS ONE. 2013;8(1):e53062. doi: http://dx.doi.org/10.1371/journal.pone.0053062 PMID: 23326382
https://doi.org/10.1371/journal.pone.005... Another three studies had evaluated the effectiveness of a similar intervention – that offered parity in service coverage for mental health and substance use disorders – in different subgroups.²⁹29 Barry CL, Chien AT, Normand SL, Busch AB, Azzone V, Goldman HH, et al. Parity and out-of-pocket spending for children with high mental health or substance abuse expenditures. Pediatrics. 2013 Mar;131(3):e903–11. doi: http://dx.doi.org/10.1542/peds.2012-1491 PMID: 23420919
https://doi.org/10.1542/peds.2012-1491... ^,3030 Busch AB, Yoon F, Barry CL, Azzone V, Normand SL, Goldman HH, et al. The effects of mental health parity on spending and utilization for bipolar, major depression, and adjustment disorders. Am J Psychiatry. 2013 Feb 1;170(2):180–7. doi: http://dx.doi.org/10.1176/appi.ajp.2012.12030392 PMID: 23377639
https://doi.org/10.1176/appi.ajp.2012.12... ^,3434 Goldman HH, Frank RG, Burnam MA, Huskamp HA, Ridgely MS, Normand SL, et al. Behavioral health insurance parity for federal employees. N Engl J Med. 2006 Mar 30;354(13):1378–86. doi: http://dx.doi.org/10.1056/NEJMsa053737 PMID: 16571881GoldmanHHFrankRGBurnamMAHuskampHARidgelyMSNormandSLet al.Behavioral health insurance parity for federal employees.N Engl J Med2006Mar303541313788610.1056/NEJMsa05373716571881
https://doi.org/10.1056/NEJMsa053737... One study had investigated the extension of coverage of an existing health-insurance scheme to a new patient population.³³33 Davidoff A, Kenney G, Dubay L. Effects of the State Children’s Health Insurance Program Expansions on children with chronic health conditions. Pediatrics. 2005 Jul;116(1):e34–42. doi: http://dx.doi.org/10.1542/peds.2004-2297 PMID: 15958662
https://doi.org/10.1542/peds.2004-2297...

The other two studies trialled different models of delivering patient-focused education and support – e.g. by web- or telephone-based communication or in-person.³⁵35 Van Houtven CH, Thorpe JM, Chestnutt D, Molloy M, Boling JC, Davis LL. Do nurse-led skill training interventions affect informal caregivers’ out-of-pocket expenditures? Gerontologist. 2013 Feb;53(1):60–70. doi: http://dx.doi.org/10.1093/geront/gns045 PMID: 22459694
https://doi.org/10.1093/geront/gns045... ^,3636 Heikkinen K, Salanterä S, Suomi R, Lindblom A, Leino-Kilpi H. Ambulatory orthopaedic surgery patient education and cost of care. Orthop Nurs. 2011 Jan-Feb;30(1):20–8. doi: http://dx.doi.org/10.1097/NOR.0b013e318205747f PMID: 21278551
https://doi.org/10.1097/NOR.0b013e318205...

Out-of-pocket expenditure had been the primary outcome in six of our included studies – including one post-hoc analysis – and a supplementary outcome in another two (Table 1). The researchers involved in most of the studies had ascertained out-of-pocket expenditures from databases of insurance claims. Household economic burden had also been measured in terms of the likelihood of a household paying any out-of-pocket costs for care, the prevalence of catastrophic health expenditure – i.e. out-of-pocket costs that were greater than 40% of the maximum amount that a household could pay – and the prevalence of cost-related delays in seeking care. None of the studies had evaluated the effectiveness of an intervention in reducing economic hardship.

Six of the studies had also investigated the effectiveness of an intervention on clinical and health-system outcomes, health-service use, adherence to pharmaceuticals, direct costs to private health insurers or the indirect costs to patients and household caregivers in terms of the time spent seeking health care.

There was a high or unclear risk of bias in the randomized and nonrandomized controlled trials and controlled before-and-after studies (Fig. 2; available from: http://www.who.int/bulletin/volumes/93/2/14-139287). In these studies, inadequate allocation-sequence generation and concealment could have resulted in an overestimate of the effects of an intervention on the household economic burden – particularly since absolute out-of-pocket expenditure was often the main outcome and such expenditure was self-reported in three studies.³⁵35 Van Houtven CH, Thorpe JM, Chestnutt D, Molloy M, Boling JC, Davis LL. Do nurse-led skill training interventions affect informal caregivers’ out-of-pocket expenditures? Gerontologist. 2013 Feb;53(1):60–70. doi: http://dx.doi.org/10.1093/geront/gns045 PMID: 22459694
https://doi.org/10.1093/geront/gns045... ^–3737 Jing S, Yin A, Shi L, Liu J. Whether New Cooperative Medical Schemes reduce the economic burden of chronic disease in rural China. PLoS ONE. 2013;8(1):e53062. doi: http://dx.doi.org/10.1371/journal.pone.0053062 PMID: 23326382
https://doi.org/10.1371/journal.pone.005... Attrition bias due to incomplete reporting of outcome data – which may also lead to overestimates of an intervention – was potentially an issue in three studies.³⁵35 Van Houtven CH, Thorpe JM, Chestnutt D, Molloy M, Boling JC, Davis LL. Do nurse-led skill training interventions affect informal caregivers’ out-of-pocket expenditures? Gerontologist. 2013 Feb;53(1):60–70. doi: http://dx.doi.org/10.1093/geront/gns045 PMID: 22459694
https://doi.org/10.1093/geront/gns045... ^–3737 Jing S, Yin A, Shi L, Liu J. Whether New Cooperative Medical Schemes reduce the economic burden of chronic disease in rural China. PLoS ONE. 2013;8(1):e53062. doi: http://dx.doi.org/10.1371/journal.pone.0053062 PMID: 23326382
https://doi.org/10.1371/journal.pone.005... There was also a high risk of reporting bias in two of the studies.³⁵35 Van Houtven CH, Thorpe JM, Chestnutt D, Molloy M, Boling JC, Davis LL. Do nurse-led skill training interventions affect informal caregivers’ out-of-pocket expenditures? Gerontologist. 2013 Feb;53(1):60–70. doi: http://dx.doi.org/10.1093/geront/gns045 PMID: 22459694
https://doi.org/10.1093/geront/gns045... ^,3636 Heikkinen K, Salanterä S, Suomi R, Lindblom A, Leino-Kilpi H. Ambulatory orthopaedic surgery patient education and cost of care. Orthop Nurs. 2011 Jan-Feb;30(1):20–8. doi: http://dx.doi.org/10.1097/NOR.0b013e318205747f PMID: 21278551
https://doi.org/10.1097/NOR.0b013e318205...

The data we reviewed from interrupted time series studies (3/9) had a generally low risk of bias (Fig. 3; available from: http://www.who.int/bulletin/volumes/93/2/14-139287). However, in such studies, there is some risk that the intervention effect may not have occurred independently of other changes occurring over time and that the outcome observed may have been influenced by confounding factors. These two issues may have resulted in an overestimate of the effect of the intervention. Attrition bias may also be an issue in these studies since there is unclear bias introduced by the incomplete reporting of outcome data.

The outcomes of the interventions investigated in all of our included studies are summarized in Table 3.

Two studies conducted in the USA evaluated the effectiveness of reducing or eliminating co-payments and found statistically significant reductions in out-of-pocket costs for cardiovascular pharmaceuticals and medical services.³¹31 Choudhry NK, Avorn J, Glynn RJ, Antman EM, Schneeweiss S, Toscano M, et al.; Post-Myocardial Infarction Free Rx Event and Economic Evaluation (MI FREEE) Trial. Full coverage for preventive medications after myocardial infarction. N Engl J Med. 2011 Dec 1;365(22):2088–97. doi: http://dx.doi.org/10.1056/NEJMsa1107913 PMID: 22080794
https://doi.org/10.1056/NEJMsa1107913... ^,3232 Choudhry NK, Fischer MA, Avorn JL, Lee JL, Schneeweiss S, Solomon DH, et al. The impact of reducing cardiovascular medication copayments on health spending and resource utilization. J Am Coll Cardiol. 2012 Oct 30;60(18):1817–24. doi: http://dx.doi.org/10.1016/j.jacc.2012.06.050 PMID: 23040581
https://doi.org/10.1016/j.jacc.2012.06.0... Another three studies conducted in the USA evaluated the effectiveness of parity in service coverage for mental health problems and substance use disorders.²⁹29 Barry CL, Chien AT, Normand SL, Busch AB, Azzone V, Goldman HH, et al. Parity and out-of-pocket spending for children with high mental health or substance abuse expenditures. Pediatrics. 2013 Mar;131(3):e903–11. doi: http://dx.doi.org/10.1542/peds.2012-1491 PMID: 23420919
https://doi.org/10.1542/peds.2012-1491... ^,3030 Busch AB, Yoon F, Barry CL, Azzone V, Normand SL, Goldman HH, et al. The effects of mental health parity on spending and utilization for bipolar, major depression, and adjustment disorders. Am J Psychiatry. 2013 Feb 1;170(2):180–7. doi: http://dx.doi.org/10.1176/appi.ajp.2012.12030392 PMID: 23377639
https://doi.org/10.1176/appi.ajp.2012.12... ^,3434 Goldman HH, Frank RG, Burnam MA, Huskamp HA, Ridgely MS, Normand SL, et al. Behavioral health insurance parity for federal employees. N Engl J Med. 2006 Mar 30;354(13):1378–86. doi: http://dx.doi.org/10.1056/NEJMsa053737 PMID: 16571881GoldmanHHFrankRGBurnamMAHuskampHARidgelyMSNormandSLet al.Behavioral health insurance parity for federal employees.N Engl J Med2006Mar303541313788610.1056/NEJMsa05373716571881
https://doi.org/10.1056/NEJMsa053737... In these three studies, statistically significant reductions in out-of-pocket expenditure were reported for the whole study population,³⁴34 Goldman HH, Frank RG, Burnam MA, Huskamp HA, Ridgely MS, Normand SL, et al. Behavioral health insurance parity for federal employees. N Engl J Med. 2006 Mar 30;354(13):1378–86. doi: http://dx.doi.org/10.1056/NEJMsa053737 PMID: 16571881GoldmanHHFrankRGBurnamMAHuskampHARidgelyMSNormandSLet al.Behavioral health insurance parity for federal employees.N Engl J Med2006Mar303541313788610.1056/NEJMsa05373716571881
https://doi.org/10.1056/NEJMsa053737... among children with high expenditure²⁹29 Barry CL, Chien AT, Normand SL, Busch AB, Azzone V, Goldman HH, et al. Parity and out-of-pocket spending for children with high mental health or substance abuse expenditures. Pediatrics. 2013 Mar;131(3):e903–11. doi: http://dx.doi.org/10.1542/peds.2012-1491 PMID: 23420919
https://doi.org/10.1542/peds.2012-1491... and in specific disease groups.³⁰30 Busch AB, Yoon F, Barry CL, Azzone V, Normand SL, Goldman HH, et al. The effects of mental health parity on spending and utilization for bipolar, major depression, and adjustment disorders. Am J Psychiatry. 2013 Feb 1;170(2):180–7. doi: http://dx.doi.org/10.1176/appi.ajp.2012.12030392 PMID: 23377639
https://doi.org/10.1176/appi.ajp.2012.12... For example, the reported mean annual reductions in out-of-pocket costs per patient were 148, United States dollars (US$) for bipolar disease, US$ 100 for major depression and US$ 68 for adjustment disorder.³⁰30 Busch AB, Yoon F, Barry CL, Azzone V, Normand SL, Goldman HH, et al. The effects of mental health parity on spending and utilization for bipolar, major depression, and adjustment disorders. Am J Psychiatry. 2013 Feb 1;170(2):180–7. doi: http://dx.doi.org/10.1176/appi.ajp.2012.12030392 PMID: 23377639
https://doi.org/10.1176/appi.ajp.2012.12... A sixth study in the USA found a statistically significant association between the expansion of health-insurance coverage and the proportion of people who had moderate out-of-pocket costs of US$ 1–2000 per person.³³33 Davidoff A, Kenney G, Dubay L. Effects of the State Children’s Health Insurance Program Expansions on children with chronic health conditions. Pediatrics. 2005 Jul;116(1):e34–42. doi: http://dx.doi.org/10.1542/peds.2004-2297 PMID: 15958662
https://doi.org/10.1542/peds.2004-2297...

In rural China, the implementation of a voluntary community-based insurance programme that offered higher reimbursement for outpatient services for a poor population was not found to reduce the prevalence of catastrophic health expenditure significantly.³⁷37 Jing S, Yin A, Shi L, Liu J. Whether New Cooperative Medical Schemes reduce the economic burden of chronic disease in rural China. PLoS ONE. 2013;8(1):e53062. doi: http://dx.doi.org/10.1371/journal.pone.0053062 PMID: 23326382
https://doi.org/10.1371/journal.pone.005...

In Finland, the web-based delivery of information to patients was not associated with any change in out-of-pocket expenditure.³⁶36 Heikkinen K, Salanterä S, Suomi R, Lindblom A, Leino-Kilpi H. Ambulatory orthopaedic surgery patient education and cost of care. Orthop Nurs. 2011 Jan-Feb;30(1):20–8. doi: http://dx.doi.org/10.1097/NOR.0b013e318205747f PMID: 21278551
https://doi.org/10.1097/NOR.0b013e318205... In the USA, an intervention that targeted information at caregivers was found to increase the care-associated spending of the caregivers and had no significant effect on total out-of-pocket expenditure on health for the patients.³⁵35 Van Houtven CH, Thorpe JM, Chestnutt D, Molloy M, Boling JC, Davis LL. Do nurse-led skill training interventions affect informal caregivers’ out-of-pocket expenditures? Gerontologist. 2013 Feb;53(1):60–70. doi: http://dx.doi.org/10.1093/geront/gns045 PMID: 22459694
https://doi.org/10.1093/geront/gns045...

Outcomes other than out-of-pocket expenditure were assessed in several studies (Table 4; available from: http://www.who.int/bulletin/volumes/93/2/14-139287). Two insurance interventions were adequately powered to measure their effect on clinical and health-service outcomes. One study found significant reductions in the rates of total major vascular events or revascularization.³¹31 Choudhry NK, Avorn J, Glynn RJ, Antman EM, Schneeweiss S, Toscano M, et al.; Post-Myocardial Infarction Free Rx Event and Economic Evaluation (MI FREEE) Trial. Full coverage for preventive medications after myocardial infarction. N Engl J Med. 2011 Dec 1;365(22):2088–97. doi: http://dx.doi.org/10.1056/NEJMsa1107913 PMID: 22080794
https://doi.org/10.1056/NEJMsa1107913... ^,3232 Choudhry NK, Fischer MA, Avorn JL, Lee JL, Schneeweiss S, Solomon DH, et al. The impact of reducing cardiovascular medication copayments on health spending and resource utilization. J Am Coll Cardiol. 2012 Oct 30;60(18):1817–24. doi: http://dx.doi.org/10.1016/j.jacc.2012.06.050 PMID: 23040581
https://doi.org/10.1016/j.jacc.2012.06.0... None of the other seven studies we included in our systematic review appeared to show a significant impact on the clinical or health-service outcomes assessed – probably because they were underpowered to assess the effect.

Discussion

To the authors’ knowledge this is the only systematic review to synthesize published evidence on the effectiveness of interventions that address the diverse ways that illness and injury adversely affect household economics. In the reviewed studies, the economic burden of illness at household level was measured predominantly in terms of out-of-pocket costs. The interventions that were found to be most effective at mitigating the burden of illness were implemented in the context of existing health-insurance schemes and involved reducing or eliminating co-payments for disease-specific treatments. Offering parity in the benefits for specific illnesses also significantly reduced out-of-pocket costs.

However, any reductions in out-of-pocket expenditure should be interpreted in the context of total spending – by the individual and the household – for the management of an illness or injury.³⁰30 Busch AB, Yoon F, Barry CL, Azzone V, Normand SL, Goldman HH, et al. The effects of mental health parity on spending and utilization for bipolar, major depression, and adjustment disorders. Am J Psychiatry. 2013 Feb 1;170(2):180–7. doi: http://dx.doi.org/10.1176/appi.ajp.2012.12030392 PMID: 23377639
https://doi.org/10.1176/appi.ajp.2012.12... One study reported that, although the 21% reduction in out-of-pocket expenditure found in their study was statistically significant, the absolute annual reduction – of US$ 100–148 per patient – was unlikely to confer protection from catastrophic expenditure.³⁰30 Busch AB, Yoon F, Barry CL, Azzone V, Normand SL, Goldman HH, et al. The effects of mental health parity on spending and utilization for bipolar, major depression, and adjustment disorders. Am J Psychiatry. 2013 Feb 1;170(2):180–7. doi: http://dx.doi.org/10.1176/appi.ajp.2012.12030392 PMID: 23377639
https://doi.org/10.1176/appi.ajp.2012.12... Total household expenditure on health-related care – including the costs of transport, home assistance, medical equipment and accommodation – can be much greater than the direct out-of-pocket costs of medicines and surgery.³⁸38 Jan S, Essue BM, Leeder SR. Falling through the cracks: the hidden economic burden of chronic illness and disability on Australian households. Med J Aust. 2012 Jan 16;196(1):29–31. doi: http://dx.doi.org/10.5694/mja11.11105 PMID: 22256924
https://doi.org/10.5694/mja11.11105... Moreover, such indirect costs of care are seldom covered by health-insurance schemes, particularly in low-income settings. Few of our included studies incorporated other categories of out-of-pocket expenditure beyond the direct costs of medical care. Interventions that solely reduce co-payments for specific aspects of care will only be effective if the care that is covered represents the main economic burden of the illness or injury at household level. Furthermore, many households may have more than one member with illness or injury. Therefore, interventions will need to move beyond targeting disease-specific aspects of treatment and, instead, take a holistic view of the multiple and diverse ways that illness and injury affect household economic circumstances.

Of the nine studies we reviewed, seven involved changes to – or extensions of – an existing package of health-insurance benefits, with the sole aim of shifting the costs of care to the insurer and minimizing the costs to the patient. Only one of these health-insurance studies was conducted in a low- or middle-income country. Although most of the health-insurance interventions were associated with statistically significant effects within the study period, such interventions will not be put into widespread practice unless they can be shown to be economically viable. To the authors’ knowledge, only one of the health-insurance studies was accompanied by a published cost–effectiveness investigation of the type needed to inform priority setting and resource planning for any sustainable intervention. In low- and middle-income countries, the financial sustainability of such measures is critical. If the post-2015 development goals relating to poverty reduction are to be achieved, good evidence is needed to inform the development of stronger and more financially sustainable health systems in these settings.

There is a general scarcity of evaluations of innovative interventions to address the economic burden of illness and injury. Such interventions have the potential to supplement existing health-insurance policies, particularly those being rolled out to achieve universal health coverage in low- and middle-income settings. The interventions uncovered in this review tended to be health-insurance-based or, to a lesser extent, involve some form of patient education. If used in isolation, such interventions cannot resolve the fundamental issues of social disadvantage and poverty and overlook the multidimensional pathways in which illnesses or injuries are linked to economic outcomes. For instance, there appear to have been few attempts to examine the role of strategies such as income support or programmes to support household consumption in addressing the financial challenges of long-term chronic illness. This might be due to the narrow disciplinary perspectives of the relevant researchers.³⁹39 Jan S, Wiseman V. What have economists ever done for global health? Lancet. 2014 May 24;383(9931):1801. doi: http://dx.doi.org/10.1016/S0140-6736(14)60872-2 PMID: 24856019
https://doi.org/10.1016/S0140-6736(14)60...

This review highlights a need for method development in this field, to take account of the capacity of households to afford out-of-pocket expenditure and the impact of coping strategies on household economic outcomes. There is an interconnection and, potentially, a vicious cycle between poor economic circumstances and illness.³3 McIntyre D, Thiede M, Dahlgren G, Whitehead M. What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts? Soc Sci Med. 2006 Feb;62(4):858–65. doi: http://dx.doi.org/10.1016/j.socscimed.2005.07.001 PMID: 16099574
https://doi.org/10.1016/j.socscimed.2005... ^,4040 Hanratty B, Holland P, Jacoby A, Whitehead M. Financial stress and strain associated with terminal cancer – a review of the evidence. Palliat Med. 2007 Oct;21(7):595–607. doi: http://dx.doi.org/10.1177/0269216307082476 PMID: 17942498
https://doi.org/10.1177/0269216307082476... Social disadvantages can predispose individuals to a risk of illness. This, in turn, can predispose individuals and their households to illness-related poverty and economic hardship. These economic consequences can further perpetuate poor health, through impaired quality of life, depression and non-adherence to treatment. Interventions to address the economic burden of illness have the potential to break this nexus. However, research has been slow to adopt tools for measuring outcomes in this field beyond out-of-pocket expenditure, and the relevant studies that have been conducted have been of variable quality and rarely randomized controlled trials. There have also been inconsistencies in the measurement and reporting of outcomes such as out-of-pocket costs and catastrophic health expenditures.⁴¹41 Reddy SR, Ross-Degnan D, Zaslavsky AM, Soumerai SB, Wagner AK. Health care payments in the Asia Pacific: validation of five survey measures of economic burden. Int J Equity Health. 2013;12(1):49. doi: http://dx.doi.org/10.1186/1475-9276-12-49 PMID: 23822552
https://doi.org/10.1186/1475-9276-12-49... ^,4242 Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJ. Household catastrophic health expenditure: a multicountry analysis. Lancet. 2003 Jul 12;362(9378):111–7. doi: http://dx.doi.org/10.1016/S0140-6736(03)13861-5 PMID: 12867110
https://doi.org/10.1016/S0140-6736(03)13... Once a consistent approach to measuring outcomes has been developed, research in this area will allow for greater comparability between studies⁸8 Moreno-Serra R, Millett C, Smith PC. Towards improved measurement of financial protection in health. PLoS Med. 2011 Sep;8(9):e1001087. doi: http://dx.doi.org/10.1371/journal.pmed.1001087 PMID: 21909246
https://doi.org/10.1371/journal.pmed.100... ^,99 Ruger JP. An alternative framework for analyzing financial protection in health. PLoS Med. 2012;9(8):e1001294. doi: http://dx.doi.org/10.1371/journal.pmed.1001294 PMID: 22927799
https://doi.org/10.1371/journal.pmed.100... and offer opportunities for the routine assessment of household expenditures within research on clinical interventions.⁴³43 Finger RP, Kupitz DG, Fenwick E, Balasubramaniam B, Ramani RV, Holz FG, et al. The impact of successful cataract surgery on quality of life, household income and social status in South India. PLoS One. 2012;7(8):e44268. doi: http://dx.doi.org/10.1371/journal.pone.0044268 PMID: 22952945
https://doi.org/10.1371/journal.pone.004... ^,4444 Kuper H, Polack S, Mathenge W, Eusebio C, Wadud Z, Rashid M, et al. Does cataract surgery alleviate poverty? Evidence from a multi-centre intervention study conducted in Kenya, the Philippines and Bangladesh. PLoS One. 2010;5(11):e15431. doi: http://dx.doi.org/10.1371/journal.pone.0015431 PMID: 21085697
https://doi.org/10.1371/journal.pone.001...

This review has limitations. First, the authors of excluded studies were not contacted to determine if they had collected data on relevant outcomes but not reported them. Second, the household economic burden of illness or injury was not the primary outcome in all of the included studies. It is possible that some included studies were not sufficiently powered to detect a change in this outcome. Third, this review was limited to studies published in the peer-reviewed literature. Fourth, most of the included studies were conducted in the USA and so low- and middle-income settings were underrepresented. Finally, there were few randomized controlled trials included. As a result of the two latter issues, our findings are unlikely to be representative of all health systems.

Conclusion

Health-insurance programmes that reduce or eliminate co-payments for defined illness-specific treatments can effectively provide some financial protection, by reducing out-of-pocket expenditure. However, little is known about the cost–effectiveness of such programmes and about other forms of intervention that may provide relief from adverse economic outcomes to households. Given the multiple and diverse ways that illness and injury can affect the economic circumstances of households, this review highlights the need for method development in this field – above and beyond the limited focus on out-of-pocket expenditure. Additionally, especially in low- and middle-income countries, there is wide scope for research on the effectiveness of innovative non-insurance interventions that could provide low-cost and better-targeted support.

Acknowledgements

BME is also affiliated with the Menzies Centre for Health Policy, University of Sydney, Australia. MLH, SJ and TLL have affiliations with the University of Sydney, Australia.

References

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