Bulletin of the World Health Organization

Limitations of methods for measuring out-of-pocket and catastrophic private health expenditures

Chunling Lu a, Brian Chin b, Guohong Li c & Christopher JL Murray d

a. Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America (USA).
b. Population Studies Center, University of Pennsylvania, Philadelphia, PA, USA.
c. School of Public Health, Shanghai Jiao Tong University, Shanghai, China.
d. Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.

Correspondence to Chunling Lu (e-mail: chunling_lu@hms.harvard.edu).

(Submitted: 29 April 2008 – Revised version received: 24 September 2008 – Accepted: 30 September 2008 – Published online: 29 January 2009.)

Bulletin of the World Health Organization 2009;87:238-244. doi: 10.2471/BLT.08.054379


Valid, reliable and comparable information on national and international resource inputs for health is critical for developing health policies, managing programme implementation and evaluating efficiency and performance. Out-of-pocket payments incurred by households for medical services received (excluding transportation spending and insurance payments and reimbursements) are estimated to account for 23% of total global health expenditure and 45% of health expenditure in the developing world. Within the latter, out-of-pocket health spending ranged from 1.6% of total health expenditure in Niue to 82.9% in Guinea in 2003.1 Over the past 6 years analysts have also suggested that out-of-pocket health spending is catastrophic for many households, often pushing them below the poverty line.28 A household’s health expenditure is considered to be catastrophic if the ratio between the household’s out-of-pocket health expenditure and its disposable income reaches a certain critical point; commonly used thresholds include 30% or 40% of capacity to pay, or 10% of total expenditures.35 The problem of catastrophic and impoverishing health payments has captured policy attention9,10 and has led to major legislation11 and system reform.1218

The capacity to monitor and track meaningful change in out-of-pocket health spending and catastrophic payments is very limited. However, household surveys that include questions on different types of health expenditures and total health expenditure can help meet these information needs. Regular income and expenditure surveys – already widely used to support computation for national accounts19,20 – collect this information, as do some international survey programmes, including The World Bank’s Living Standards Measurement Study and WHO’s World Health Survey. Unfortunately, these surveys vary in the exact wording of questions, the number of disaggregated expenditure categories, the recall periods and the framing of the expenditure questions; there is also variation within the same survey across different countries and years. The validity, reliability and comparability of information on out-of-pocket health spending gathered through such disparate methods have not been established.

Studies on the reliability and validity of total expenditure data have highlighted at least two factors that influence the results: the number of expenditure categories used and the recall period.2127 Even though the results are sensitive to the level of disaggregation, the number of items collected in published consumption surveys ranges from 1 to 1300.28 Few validation studies have been undertaken in developing countries, and no studies have explored the issue of how to collect valid, reliable and comparable information on health expenditures.

In this paper we use the World Health Survey and the Living Standards Measurement Study – two household surveys which asked the same respondents about health expenditures in different ways – to explore two sources of potential bias: the number of health expenditure categories and the recall period. Based on our findings, we discuss potential solutions to the problem of comparability.


World Health Survey

The World Health Survey was conducted by WHO using a consistent survey instrument in 50 developing countries between 2002 and 2004.29 This survey first asks a single question on household health spending in the previous 4 weeks, so that recall of the disaggregated categories does not influence the response. Eight more detailed questions follow, focused on health spending in the same period. These questions elicit information on payments for outpatient services, hospitalization, traditional medicine services, dentists, medication, medical tests, health-care products and other expenditures. The health spending estimates can be derived from either the single-item or eight-item questions. Another question concerns inpatient costs in the previous 11 months (excluding the most recent month). Table 1 gives details of the health expenditure items. Countries that did not include all of the items listed in Table 1 in the survey (Hungary and Turkey) or that were missing more than 90% of the data on these items (Guatemala) were excluded from the analysis. Countries where 75% or more households reported the same amount of positive health spending with the single-item and eight-item measures (Brazil, Kazakhstan, Mauritius and Paraguay) were excluded from the analysis on the assumption that a high percentage of exact agreement between the two measures indicated a serious problem with data quality. Our final analysis thus included 43 countries. Table 2 (available at: http://www.who.int/bulletin/volumes/87/03/08-054379/en/index.html) shows the number of households surveyed and the response rates for these countries.

Since the level of disaggregation (number of questions) is the only difference between estimates of household health spending based on the single-item responses and on the eight-item responses, it is possible to detect the effect of disaggregation on the estimates of health spending for each country. We compared the average annual health spending estimate obtained from the single-item measure with that obtained from the eight-item measure by calculating the ratio of the two averages. This ratio indicates which measure generates a larger estimate. We estimated the 95% confidence interval (CI) of the ratio using “bootstrapping” – a technique for generating a description of the sampling properties of empirical estimators using the sample data. To do this, we constructed several re-samples of the observed data set (of equal size to the observed data set), each of which was obtained by random sampling with replacement from the original data set. We also compared the estimates of catastrophic spending from the two measures, and examined how the level of disaggregation may affect the estimates. In this study, a household’s expenditure was defined as catastrophic if the ratio between the household’s out-of-pocket health expenditure and its capacity to pay, defined as effective income remaining after subsistence needs had been met, reached 0.4.3,4 The numbers of observations used in the calculation are listed in Table 2.

Living Standards Measurement Study

The Living Standards Measurement Study, conducted by The World Bank,30 is an important tool for measuring poverty in developing countries. It includes questionnaires designed to study various aspects of household consumption behaviour, including spending on health care. The study collects information on health spending in all selected countries, but the way the information is collected varies substantially. For example, some Living Standards Measurement Study surveys collect health spending information at the household level using a consumption module, or at the individual level using a health module. Others collect this information only at the household level. While the Living Standards Measurement Study generally asks about household health spending over a 12-month recall period, for individual-level health spending the recall period varies from 2 weeks (Ghana 1999) to 12 months (India 1998). The number and specificity of the categories of health spending for which the study collects information also vary considerably. For example, the Living Standards Measurement Study surveys for China 1997, Guatemala 2000, India 1998 and the United Republic of Tanzania 2004 asked for an aggregate estimate of total health expenditures by household, whereas the survey for Bulgaria 2001 asked for household-level expenditure across six categories of health spending (outpatient care, inpatient care, dental care, medicines, optical equipment, and skin care and plastic surgery). These inconsistencies in the level of disaggregation are also present across the individual-level health spending modules. Such variations in how health spending information is collected enabled us to detect the sensitivity of household health spending estimates to different recall periods and levels of disaggregation.

We selected three Living Standards Measurement Study surveys with questions on health spending in both their consumption and health modules: Bulgaria 2001, Jamaica 2001 and Nepal 1997. Details on the recall period, number of items and type of modules are presented for each country in Table 3, Table 4 and Table 5, respectively. The tables show that the surveys in the three countries varied in the number of items used to collect information in the health and consumption modules, and in the timing of the recall period. We used t-tests to compare the average annual health spending from the different recall periods and items and to examine the effects of these factors.


Effect of disaggregation

Fig. 1 (available at: http://www.who.int/bulletin/volumes/87/03/08-054379/en/index.html) compares the ratio of the estimated average annual out-of-pocket health expenditure obtained from the single-item measure to that obtained from the eight-item measure in the World Health Survey. The ratio varied from 0.25 to 1.37. Among the 43 countries studied, 38 had ratios less than 1, with the difference from 1 being significant at the 0.95 confidence level in 37 of these cases. Thus, the single-item measure yielded a significantly lower estimate than the eight-item measure (the ratio in the Congo was not significantly different from 1). Among the remaining five countries (Mali, Namibia, Nepal, Sri Lanka and Uruguay), the ratio was significantly greater than 1. Thus, in most countries, a lower level of disaggregation gave a lower estimate for average health spending, a finding consistent with the results of previous studies on total household expenditure in developed and developing countries.21,31,32 However, this finding is not universally true across countries, and the degree of bias in the single-item method is highly variable.

Fig. 1. Annual out-of-pocket health spending: ratio of average derived from single-item measure to average derived from eight-item measure, World Health Survey, 2003
Fig. 1. Annual out-of-pocket health spending: ratio of average derived from single-item measure to average derived from eight-item measure, World Health Survey, 2003

Effect of recall period

The World Health Survey includes two questions on the costs of hospitalization, one with a 4-week recall period and the other with an 11-month recall period. Fig. 2 (available at: http://www.who.int/bulletin/volumes/87/03/08-054379/en/index.html) presents the ratio of the average annual household out-of-pocket spending on hospitalization derived from a 1-month recall period to that derived from an 11-month recall period. Among the 43 countries, 39 had ratios significantly greater than 1 at the 0.95 confidence level, with the highest ratio being 9.56. Four countries had ratios significantly less than 1. Thus, in most countries, a shorter recall period yielded larger estimates for average annual health spending. The variation as a function of recall period is enormous and raises serious doubts about the comparability of results from surveys that use different recall periods.

Fig. 2. Annual out-of-pocket health spending on hospitalization: ratio of average derived from single-item measure to average derived from eight-item measure, World Health Survey, 2003a
Fig. 2. Annual out-of-pocket health spending on hospitalization: ratio of average derived from single-item measure to average derived from eight-item measure, World Health Survey, 2003<sup>a</sup>
a Slovakia is not included in the figure because its ratio and confidence intervals are high (16.43+/-13.37) so excluded to show more clearly the differentials for other countries.

The Nepal Living Standards Measurement Study 1997 asked two questions on health spending twice in the consumption module, using first a 1-month and then a 12-month recall period. With a sample size of 2421, the means were 2490 Nepalese rupees (NRs) (95% CI: 2017–2962) from a 1-month recall and NRs 1887 (95% CI: 1697–2076) from a 12-month recall, a difference that is significant at the 0.95 confidence level. Thus, in Nepal, a short recall period appeared to result in a significantly larger estimate of the household health spending than a long recall period.

Effect of combined factors

In the Jamaica Living Standards Measurement Study 2001, with a sample size of 1665, the mean yearly out-of-pocket health spending at the household level was about 8944 Jamaican dollars (J$) (95% CI: 7433–10 455) from a health module with six items and a 4-week recall period. This figure was J$ 7174 (95% CI: 6270–8079) when derived from a consumption module with two items and a 12-month recall period. The means were significantly different at the 0.99 confidence level, with a t-value of 3.43.

In the Bulgaria Living Standards Measurement Study 2001, with a sample size of 2633, the average yearly out-of-pocket health spending generated from the health module with a 1-month recall and five items was 505 leva (95% CI: 440–569). This figure was significantly higher than the 138 leva (95% CI: 128–147) found in the consumption module with a 12-month recall and seven items. We suspect that when questions about health expenditure are fielded in a health module where a respondent has been primed to think about recent health experiences, the estimate may be higher than that resulting from a health-care consumption module. However, we cannot examine this effect directly with the information available.

Effect of survey instrument design

Fig. 3 (available at: http://www.who.int/bulletin/volumes/87/03/08-054379/en/index.html) illustrates the ratio of the percentage of households experiencing catastrophic health spending derived from the single-item measure to that derived from the eight-item measure in the World Health Survey.

Fig. 3. Catastrophic health spending: ratio of average derived from single-item measure to average derived from eight-item measure, World Health Survey, 2003
Fig. 3. Catastrophic health spending: ratio of average derived from single-item measure to average derived from eight-item measure, World Health Survey, 2003

The ratio ranges from 0.166 (95% CI: 0.162–0.169) in Slovakia to about 1.965 95% CI: 1.955–1.985) in Uruguay. The observed variation in the ratio suggests that the methods used to collect health expenditure information can significantly confound analyses of the determinants of catastrophic spending and their variations over time. Since reducing catastrophic spending is an important policy objective in several countries, the sensitivity of catastrophic spending to the way information on health expenditures is elicited raises doubts about our capacity to measure the level or trend of these payments.


Health expenditure estimates in the same year generated by different surveys can vary greatly.33 In addition, this paper demonstrates that estimates of household spending on health care are sensitive to the survey instrument design. Usually, a shorter recall period and a longer questionnaire appear to lead to a higher mean estimate of health spending. However, when these survey effects are combined, it is hard to predict which factor – recall period or number of questions – will have the greater effect.

Even the same instrument can generate different response patterns in different populations – a phenomenon known as “differential item functioning”.34,35 The wide variability between countries in the ratio of estimated average spending derived from the single-item question to that derived from the eight-item question in the World Health Survey data indicates that differential item functioning is an important concern. The phenomenon presents major challenges for improving our knowledge of levels and trends in private spending and catastrophic or impoverishing health spending.

The effects of survey design on estimates of spending pose technical challenges for policy discussions about the right mix of private versus public expenditure, as well as for the evaluation of health system performance in developing countries. How can better instruments and estimates of private spending and catastrophic or impoverishing health payments be developed? Progress is needed in three areas. First, new instruments that are less sensitive to the local cultural context and survey design are needed. We recommend that alternative methods be tested in settings where a reasonable approximation of the gold standard measurement of health expenditure is available. This would require selection of validation sites that would enable “true” expenditure information to be obtained, and development and implementation of validation methods to test what kind of survey design can generate estimates closest to the “true” expenditure. In lower income countries, however, creating a validation environment where “true” expenditure is known may only be possible by identifying all health-care providers, including pharmacies, and recording transactions. Considerable effort and innovation will be needed to create effective validation environments where new instruments can be developed, tested and modified.

Second, any effective new instruments for collecting information on out-of-pocket spending would need to be broadly adopted. This would require substantial efforts to convene stakeholder institutions interested in comparable information on expenditures, such as national statistical offices, The World Bank, WHO and many bilateral donors. Entities that have effectively fostered interest in comparable national health accounts in high-income countries, such as the Organisation for Economic Co-operation and Development, will be critical, as will WHO, to reaching a consensus on dissemination of any new standardized instruments.

Third, non-survey methods may also be helpful in tracking national out-of-pocket spending and other private spending on health (e.g. by nongovernment organizations or private enterprise). These methods may be based on the measurement of a proxy for private health spending (e.g. drug sales, provider surveys that capture both charges and use, tax returns for health providers, human resource data and average salaries, etc.). These methods may be useful additions to surveys but will need to be supplemented by household survey data to track catastrophic or impoverishing health payments.

Comparisons between catastrophic or impoverishing health payments across countries or in the same country over time must be interpreted with caution, given the extensive evidence of variability in instruments and in differential item functioning for a single instrument. Xu et al. report that 77.2% of the variance in catastrophic health payments could be explained by the fraction of total health expenditure due to out-of-pocket spending, the poverty index and health service utilization.3 Part of the rest of the variation could be due to measurement error. Further work on strengthening the basis for tracking catastrophic and impoverishing health payments is urgently needed. Meanwhile, the present lack of robust measurement methods should not be an excuse for not addressing the problem of high out-of-pocket spending and families facing financial catastrophe as a result of purchasing health care. ■

Funding: This study was supported by the Bill and Melinda Gates Foundation.

Competing interests: None declared.