Rural‒urban disparities in household catastrophic health expenditure in Bangladesh: a multivariate decomposition analysis.

BACKGROUND: Rural‒urban disparity in catastrophic healthcare expenditure (CHE) is a well-documented challenge in low- and middle-income countries, including Bangladesh, limiting financial protection and hindering the achievement of the Universal Health Coverage target of the United Nations Sustainable Development Goals. However, the factors driving this divide remain poorly understood. Therefore, this study aims to identify the key determinants of the rural‒urban disparity in CHE incidence in Bangladesh and their changes over time. METHODS: We used nationally representative data from the latest three rounds of the Bangladesh Household Income and Expenditure Survey (2005, 2010, and 2016). CHE incidence among households seeking healthcare was measured using the normative food, housing, and utilities method. To quantify covariate contributions to the rural‒urban CHE gap, we employed the Oaxaca-Blinder multivariate decomposition approach, adapted by Powers et al. for nonlinear response models. RESULTS: CHE incidence among rural households increased persistently during the study period (2005: 24.85%, 2010: 25.74%, 2016: 27.91%) along with a significant (p-value ≤ 0.01) rural‒urban gap (2005: 9.74%-points, 2010: 13.94%-points, 2016: 12.90%-points). Despite declining over time, substantial proportions of CHE disparities (2005: 87.93%, 2010: 60.44%, 2016: 61.33%) are significantly (p-value ≤ 0.01) attributable to endowment differences between rural and urban households. The leading (three) covariate categories consistently contributing significantly (p-value ≤ 0.01) to the CHE gaps were composition disparities in the lowest consumption quintile (2005: 49.82%, 2010: 36.16%, 2016: 33.61%), highest consumption quintile (2005: 32.35%, 2010: 15.32%, 2016: 18.39%), and exclusive reliance on informal healthcare sources (2005: -36.46%, 2010: -10.17%, 2016: -12.58%). Distinctively, the presence of chronic illnesses in households emerged as a significant factor in 2016 (9.14%, p-value ≤ 0.01), superseding the contributions of composition differences in household heads with no education (4.40%, p-value ≤ 0.01) and secondary or higher education (7.44%, p-value ≤ 0.01), which were the fourth and fifth significant contributors in 2005 and 2010. CONCLUSIONS: Rural‒urban differences in household economic status, educational attainment of household heads, and healthcare sources were the key contributors to the rural‒urban CHE disparity between 2005 and 2016 in Bangladesh, with chronic illness emerging as a significant factor in the latest period. Closing the rural‒urban CHE gap necessitates strategies that carefully address rural‒urban variations in the characteristics identified above.

Economic burden of non-communicable diseases on households in Nigeria: evidence from the Nigeria living standard survey 2018-19.

BACKGROUND: The importance of non-communicable diseases (NCDs) in Nigeria is reflected in their growing burden that is fast overtaking that of infectious diseases. As most NCD care is paid for through out-of-pocket (OOP) expenses, and NCDs tend to cause substantial income losses through chronic disabilities, the rising NCD-related health burden may also be economically detrimental. Given the lack of updated national-level evidence on the economic burden of NCDs in Nigeria, this study aims to produce new evidence on the extent of financial hardship experienced by households with NCDs in Nigeria due to OOP expenditure and productivity loss. METHODS: This study analysed cross-sectional data from the most recent round (2018-19) of the Nigeria Living Standard Survey (NLSS). Household-level health and consumption data were used to estimate catastrophic health expenditure (CHE) and impoverishing effects due to OOP health spending, using a more equitable method recently developed by the World Health Organization European region in 2018. The productivity loss by individuals with NCDs was also estimated from income and work-time loss data, applying the input-based human capital approach. RESULTS: On average, a household with NCDs spent ₦ 122,313.60 or $ 398.52 per year on NCD care, representing 24% of household food expenditure. The study found that OOP on cancer treatment, mental problems, and renal diseases significantly contribute to the cost of NCD care. The OOP expenditure led to catastrophic and impoverishing outcomes for households. The estimations showed that about 30% of households with NCDs experienced CHE in 2018, using the WHO Europe method at the 40% threshold. The study also found that the cost of NCD medications was a significant driver of CHE among NCD-affected households. The results showed heterogeneity in CHE and impoverishment across states and geographical regions in Nigeria, with a higher concentration in rural and North East geopolitical locations. The study also found that 20% of NCD-affected households were impoverished or further impoverished by OOP payment, and another 10% were on the verge of impoverishment. The results showed a negligible rate of unmet needs among households with NCDs. CONCLUSIONS: The study highlights the significant effect of NCDs on Nigerian households and the need for effective policy interventions to address this challenge, particularly among the poor and vulnerable.

Financial risk protection against noncommunicable diseases: trends and patterns in Bangladesh.

BACKGROUND: Demographic and epidemiological transitions are changing the disease burden from infectious to noncommunicable diseases (NCDs) in low- and middle-income countries, including Bangladesh. Given the rising NCD-related health burdens and growing share of household out-of-pocket (OOP) spending in total health expenditure in Bangladesh, we compared the country's trends and socioeconomic disparities in financial risk protection (FRP) among households with and without NCDs. METHODS: We used data from three recent waves of the Bangladesh Household Income and Expenditure Survey (2005, 2010, and 2016) and employed the normative food, housing (rent), and utilities method to measure the levels and distributions of catastrophic health expenditure (CHE) and impoverishing effects of OOP health expenditure among households without NCDs (i.e. non-NCDs only) and with NCDs (i.e. NCDs only, and both NCDs and non-NCDs). Additionally, we examined the incidence of forgone care for financial reasons at the household and individual levels. RESULTS: Between 2005 and 2016, OOP expenses increased by more than 50% across all households (NCD-only: USD 95.6 to 149.3; NCD-and-non-NCD: USD 89.5 to 167.7; non-NCD-only: USD 45.3 to 73.0), with NCD-affected families consistently spending over double that of non-affected households. Concurrently, CHE incidence grew among NCD-only families (13.5% to 14.4%) while declining (with fluctuations) among non-NCD-only (14.4% to 11.6%) and NCD-and-non-NCD households (12.9% to 12.2%). Additionally, OOP-induced impoverishment increased among NCD-only and non-NCD-only households from 1.4 to 2.0% and 1.1 to 1.5%, respectively, affecting the former more. Also, despite falling over time, NCD-affected individuals more frequently mentioned prohibiting treatment costs as the reason for forgoing care than the non-affected (37.9% vs. 13.0% in 2016). The lowest quintile households, particularly those with NCDs, consistently experienced many-fold higher CHE and impoverishment than the highest quintile. Notably, CHE and impoverishment effects were more pronounced among NCD-affected families if NCD-afflicted household members were female rather than male, older people, or children instead of working-age adults. CONCLUSIONS: The lack of FRP is more pronounced among households with NCDs than those without NCDs. Concerted efforts are required to ensure FRP for all families, particularly those with NCDs.

Financial risk protection from out-of-pocket health spending in low- and middle-income countries: a scoping review of the literature.

BACKGROUND: Financial risk protection (FRP), defined as households' access to needed healthcare services without experiencing undue financial hardship, is a critical health systems target, particularly in low- and middle-income countries (LMICs). Given the remarkable growth in FRP literature in recent times, we conducted a scoping review of the literature on FRP from out-of-pocket (OOP) health spending in LMICs. The objective was to review current knowledge, identify evidence gaps and propose future research directions. METHODS: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines to conduct this scoping review. We systematically searched PubMed, Scopus, ProQuest and Web of Science in July 2021 for literature published since 1 January 2015. We included empirical studies that used nationally representative data from household surveys to measure the incidence of at least one of the following indicators: catastrophic health expenditure (CHE), impoverishment, adoption of strategies to cope with OOP expenses, and forgone care for financial reasons. Our review covered 155 studies and analysed the geographical focus, data sources, methods and analytical rigour of the studies. We also examined the level of FRP by disease categories (all diseases, chronic illnesses, communicable diseases) and the effect of health insurance on FRP. RESULTS: The extant literature primarily focused on India and China as research settings. Notably, no FRP study was available on chronic illness in any low-income country (LIC) or on communicable diseases in an upper-middle-income country (UMIC). Only one study comprehensively measured FRP by examining all four indicators. Most studies assessed (lack of) FRP as CHE incidence alone (37.4%) or as CHE and impoverishment incidence (39.4%). However, the LMIC literature did not incorporate the recent methodological advances to measure CHE and impoverishment that address the limitations of conventional methods. There were also gaps in utilizing available panel data to determine the length of the lack of FRP (e.g. duration of poverty caused by OOP expenses). The current estimates of FRP varied substantially among the LMICs, with some of the poorest countries in the world experiencing similar or even lower rates of CHE and impoverishment compared with the UMICs. Also, health insurance in LMICs did not consistently offer a higher degree of FRP. CONCLUSION: The literature to date is unable to provide a reliable representation of the actual level of protection enjoyed by the LMIC population because of the lack of comprehensive measurement of FRP indicators coupled with the use of dated methodologies. Future research in LMICs should address the shortcomings identified in this review.

Financial risk protection in health care in Bangladesh in the era of Universal Health Coverage.

BACKGROUND: Ensuring financial risk protection in health care and achieving universal health coverage (UHC) by 2030 is one of the crucial Sustainable Development Goals (SDGs) targets for many low- and middle-income countries (LMICs), including Bangladesh. We examined the critical trajectory of financial risk protection against out-of-pocket (OOP) health expenditure in Bangladesh. METHODS: Using Bangladesh Household Income and Expenditure Survey data from 2005, 2010, and 2016, we examined the levels and distributions of catastrophic health expenditure (CHE) and impoverishment incidences. We used the normative food, housing, and utilities method, refining it by categorizing households with zero OOP expenses by reasons. RESULTS: OOP expenditure doubled between 2005 and 2016 (USD 115.6 in 2005, USD 162.1 in 2010, USD 242.9 in 2016), accompanied by rising CHE (11.5% in 2005, 11.9% in 2010, 16.6% in 2016) and impoverishment incidence (1.5% in 2005, 1.6% in 2010, 2.3% in 2016). While further impoverishment of the poor households due to OOP expenditure (3.6% in 2005, 4.1% in 2010, 3.9% in 2016) was a more severe problem than impoverishment of the non-poor, around 5.5% of non-poor households were always at risk of impoverishment. The poorest households were the least financially protected throughout the study period (lowest vs. highest quintile CHE: 29.5% vs. 7.6%, 33.2% vs. 7.2%, and 37.6% vs. 13.0% in 2005, 2010, and 2016, respectively). The disparity in CHE among households with and without chronic illness was also remarkable in 2016 (25.0% vs. 9.1%). CONCLUSION: Financial risk protection in Bangladesh exhibits a deteriorated trajectory from 2005 to 2016, posing a significant challenge to achieving UHC and, thus, the SDGs by 2030. The poorest and chronically ill households disproportionately lacked financial protection. Reversing the worsening trends of CHE and impoverishment and addressing the inequities in their distributions calls for implementing UHC and thus providing financial protection against illness.

The orphan G protein-coupled receptor, Gpr161, encodes the vacuolated lens locus and controls neurulation and lens development.

The vacuolated lens (vl) mouse mutant causes congenital cataracts and neural tube defects (NTDs), with the NTDs being caused by abnormal neural fold apposition and fusion. Our positional cloning of vl indicates these phenotypes result from a deletion mutation in an uncharacterized orphan G protein-coupled receptor (GPCR), Gpr161. Gpr161 displays restricted expression to the lateral neural folds, developing lens, retina, limb, and CNS. Characterization of the vl mutation indicates that C-terminal tail of Gpr161 is truncated, leading to multiple effects on the protein, including reduced receptor-mediated endocytosis. We have also mapped three modifier quantitative trait loci (QTL) that affect the incidence of either the vl cataract or NTD phenotypes. Bioinformatic, sequence, genetic, and functional data have determined that Foxe3, a key regulator of lens development, is a gene responsible for the vl cataract-modifying phenotype. These studies have extended our understanding of the vl locus in three significant ways. One, the cloning of the vl locus has identified a previously uncharacterized GPCR-ligand pathway necessary for neural fold fusion and lens development, providing insight into the molecular regulation of these developmental processes. Two, our QTL analysis has established vl as a mouse model for studying the multigenic basis of NTDs and cataracts. Three, we have identified Foxe3 as a genetic modifier that interacts with Gpr161 to regulate lens development.

Misregulation of the kinesin-like protein Subito induces meiotic spindle formation in the absence of chromosomes and centrosomes.

Bipolar spindles assemble in the absence of centrosomes in the oocytes of many species. In Drosophila melanogaster oocytes, the chromosomes have been proposed to initiate spindle assembly by nucleating or capturing microtubules, although the mechanism is not understood. An important contributor to this process is Subito, which is a kinesin-6 protein that is required for bundling interpolar microtubules located within the central spindle at metaphase I. We have characterized the domains of Subito that regulate its activity and its specificity for antiparallel microtubules. This analysis has revealed that the C-terminal domain may interact independently with microtubules while the motor domain is required for maintaining the interaction with the antiparallel microtubules. Surprisingly, deletion of the N-terminal domain resulted in a Subito protein capable of promoting the assembly of bipolar spindles that do not include centrosomes or chromosomes. Bipolar acentrosomal spindle formation during meiosis in oocytes may be driven by the bundling of antiparallel microtubules. Furthermore, these experiments have revealed evidence of a nuclear- or chromosome-based signal that acts at a distance to activate Subito. Instead of the chromosomes directly capturing microtubules, signals released upon nuclear envelope breakdown may activate proteins like Subito, which in turn bundles together microtubules.

Kinesin 6 family member Subito participates in mitotic spindle assembly and interacts with mitotic regulators.

Drosophila Subito is a kinesin 6 family member and ortholog of mitotic kinesin-like protein (MKLP2) in mammalian cells. Based on the previously established requirement for Subito in meiotic spindle formation and for MKLP2 in cytokinesis, we investigated the function of Subito in mitosis. During metaphase, Subito localized to microtubules at the center of the mitotic spindle, probably interpolar microtubules that originate at the poles and overlap in antiparallel orientation. Consistent with this localization pattern, subito mutants improperly assembled microtubules at metaphase, causing activation of the spindle assembly checkpoint and lagging chromosomes at anaphase. These results are the first demonstration of a kinesin 6 family member with a function in mitotic spindle assembly, possibly involving the interpolar microtubules. However, the role of Subito during mitotic anaphase resembles other kinesin 6 family members. Subito localizes to the spindle midzone at anaphase and is required for the localization of Polo, Incenp and Aurora B. Genetic evidence suggested that the effects of subito mutants are attenuated as a result of redundant mechanisms for spindle assembly and cytokinesis. For example, subito double mutants with ncd, polo, Aurora B or Incenp mutations were synthetic lethal with severe defects in microtubule organization.