Assessing catastrophic health expenditure and impoverishment in adult asthma care: a cross-sectional study of patients attending six public health clinics in Klang District, Malaysia

Asthma is a chronic respiratory illness with a global prevalence of 4.3% [1]. Asthma costs have increased globally, driven by the costs of emergency care and medications [2]. In Malaysia, the prevalence of asthma among adults is approximately 6.4% [3]. The Malaysian National Health and Morbidity Survey reported that every year, 20% of adults with asthma visited the emergency department for acute exacerbations [4]. A recent local study conducted in six public health clinics in Malaysia reported that 66% of clinic attendees still had poorly controlled asthma [5]. Most patients in this study reported regular clinic follow-ups and those with poor control were associated with frequent emergency visits [5]. Although asthma is a treatable condition, the high prevalence of suboptimal asthma control and frequent clinic visits has a substantial impact both on the use of public health care resources and individual health expenditure [3] as out-of-pocket payments may impose considerable financial burden on patients and families. An earlier study carried out at a tertiary centre in Malaysia reported that the mean monthly direct cost to individuals of asthma-related care was USD23 [6]. Another local study reported the cost of asthma-related care was mainly on medications and hospital admissions [7]. These studies were conducted in hospital settings. There is limited information on the direct cost of asthma on patients encountered at the primary care level.

Suboptimal asthma control potentially increases the need for urgent health care that patients have to pay for out-of-pocket. The World Health Organization (WHO) defines ‘out-of-pocket payments’ as direct payments made by households for health care [8]. High out-of-pocket payments are associated with catastrophic and impoverished spending and can potentially lead to financial hardship, especially among the poor [8]. Some low-income countries have poor financial health systems in healthcare or do not provide adequate financial protection, resulting in a high risk of catastrophic health expenditures [9, 10]. The Malaysian national healthcare system provides financial risk protection through universal access to a comprehensive package of government-guaranteed healthcare services and charging low user fees in the public health system [11, 12]. Malaysia has a dual health sector with public and private health systems [13]. The public health system, which comprises the public health clinics, is government-funded with a fee per clinic visit capped at Malaysia Ringgit MYR1 (USD 0.24) that covers consultation, basic investigations, and medications [14]. Government employees and pensioners, school-going children, and people aged 60 years and above are eligible to receive free health services in public health clinics [14]. All other groups, including the poor, are required to pay the MYR1 fee. In instances where medications are not available in public health clinics, patients (including those eligible for free health services) are required to buy prescribed medications from private pharmacies. The private health system comprises private hospitals or clinics that operate on a fee-for-service payment system in which patients pay out-of-pocket themselves or through their private health insurance purchased individually or through an employer-sponsored health scheme (6). Each individual is free to choose the public or private health services that they wish to use. In addition, some individuals choose complementary-alternative-medicine (CAM) for asthma treatment [15, 16], which is not subsidised by the government. These co-payments, albeit small in amount, and despite the financial risk protection provided for all patients could result in catastrophic expenses and impoverishment for vulnerable households especially in people with chronic and/or relapsing conditions. The equity in financial protection could also differ for different levels of socio-economic groups [12]. We therefore aimed to estimate the incidence of catastrophic health expenditure and medical impoverishment among adult patients with asthma in primary care settings and to examine factors associated with the risk of financial catastrophe.

The World Health Organization (WHO) states that “direct payments or costs made to obtain health services should not expose people to financial hardship and should not threaten living standards” [25]. Protecting households against financial hardship has been conceptualised as ensuring financial protection [25]. Malaysia is committed to delivering the mission of the United Nations Sustainable Development Goals in achieving and sustaining universal health coverage [26] and this is illustrated by the findings of this study. It provides a free service for those working or retirees from the public sector, while others obtain treatment from public health clinics are heavily subsidised with just needing to pay a very minimal fee [26]. Asthma is a common chronic respiratory condition in Malaysia, with most patients seeking care at outpatient clinics either at the primary or secondary care level [27]. We looked at a sample of patients attending six government-funded public health clinics to determine if they had been provided with financial risk protection. Most of the patients in our study were from low-income groups (B40 category in Malaysia classification). Almost half (41.6%) of this population lived below the poverty line as defined locally. Half of these patients were working either in the private sector or self-employed. Personal savings were the main source of health payment in two-thirds of the studied population. The mean out-of-pocket payment was low at MYR22.34 (USD5.29) per month. The mean monthly out-of-pocket payments for CAM treatment were the highest at MYR8.43 (USD 1.99) among the direct costs. Although there is no or limited evidence to support its effectiveness, CAM is increasingly popular as a self-care medicine complementary to evidence-based asthma treatment [15]. A study in Malaysian health clinics revealed almost half of patients with asthma used CAM to complement their asthma medications [28]. CAM is regarded as a patient’s choice and is not subsidised in government-funded facilities, but interventions that acknowledge health beliefs on CAM could minimise out-of-pocket spending. The cost of transportation was the major direct non-medical cost incurred in a month. Previous studies have reported the bulk of catastrophic risk comes from the direct non-medical costs involving transportation and lodging [29‐31]. Transportation is often cited as a major barrier to healthcare access and reducing the costs of transportation has been shown to help better access care, especially in low-income populations [32]. A strategy to improve transportation to health facilities could further assist in protecting those patients in lower income quintile from financial catastrophic risks. This study has demonstrated that catastrophic health expenditure and impoverishment due to asthma care were infrequent. We found 17 of the 1,003 patients in our study experienced catastrophic impact. After the incursion of direct health costs for asthma, three households (0.34%) were pushed into poverty. Although these findings could be considered low, there was already a considerably larger proportion of patients (41.6%) living below the poverty line. The proportion of household income used for out-of-pocket payment amongst those in the lower quintiles was greater compared to higher-income households, demonstrating a potential risk of financial hardship. This is evidenced by the regression analysis that showed patients who were in the higher income quintiles had lower odds of financial catastrophe. The findings of catastrophic health expenditure and impoverishment for asthma in this study were similar to earlier reports of the national household survey that stated a low incidence (2%) of catastrophic expenditure in Malaysia overall [33]. However, the level of poverty in our study was much lower at 0.34% compared to the World Bank report for Malaysia in 2009 which estimated it at 3.8% of the population [34]. Other countries in Asia, for example, Vietnam, have a relatively higher catastrophic expenditure and impoverishment for chronic non-communicable diseases overall, 14.6 and 7.6%, respectively [35]. Korea reported a catastrophic health expenditure of 7.6% for chronic disease [36]. However, these differences could be due to the socio-economic background of the studied population, differences in the provision of healthcare, and variations in the costs of resources (e.g., medications and investigations). Life expectancy in Malaysia has increased to about 75 years in recent years. Hence, the burden of non-communicable diseases is expected to rise [37] challenging the highly subsidised public health care system. Government policy will need to evolve to ensure that patients with low income and living in poverty are protected from financial catastrophic risks.