Loading…
 None
String updated in the repository |
|
|
None
Source string changed |
<p>It is feasible to monitor indicator 3.8.2 on a regular basis using the same household survey data that is used to monitor SDG targets 1.1 and 1.2 on poverty<sup><sup><a href="#footnote-
<p>First, challenges to track out-of-pocket health spending (numerator): indicator 3.8.2 attempts to identify financial hardship that individuals face when using their income, savings or taking loans to pay for health care. However, most household surveys fail to identify the source of funding used by a household <p> <p>Clearly, more work is needed to ensure that survey instruments gather information on the sources of funding used by the household to pay for health care <p>Second, the sensitivity of the indicator to the choice of the welfare metric for disaggregation (consumption or income in the denominator): in the current definition of indicator 3.8.2, large health expenditures can be identified by comparing how much household spend on health to either household income or total household expenditure. Expenditure is the recommended measure of a household’s resources (see concept section), but recent empirical work has demonstrated that while statistics on 3.8.2 at the country level are fairly robust to such choice, their disaggregation by income group is pretty sensitive to it. Income <p>Third, cut-off values to identify large health expenditures: indicator 3.8.2. relies on a single cut-off point to identify what constitutes ‘large health expenditure as a share of total household expenditure or income’. People just below such threshold are not taken into account, which is always the problem with measures based on cut-offs. This is simply avoided by plotting the cumulative distribution function of the health expenditure ratio behind 3.8.2. By doing so, it is possible to identify for any threshold the proportion of the population that is devoting any share of its household’s budget to health. </p> <p>Fourth, there are other indicators used to measure financial hardship, all based on the same data sources <p>Fifth, SDG indicator 3.8.2. needs to be tracked jointly with SDG indicator 3.8.1, as well as indicators of barriers to access |
|
None
String updated in the repository |
<p>It is feasible to monitor indicator 3.8.2 on a regular basis using the same household survey data that is used to monitor SDG target 1.1 and 1.2 on poverty<sup><sup><a href="#footnote-6" id="footnote-ref-6">[5]</a></sup></sup>. These surveys are also regularly conducted for other purposes such as calculating weights for the Consumer Price Index. These surveys are conducted typically by NSOs. Thus, monitoring the proportion of the population with large household expenditures on health as a share of total household consumption or income does not add any additional data collection burden so long as the health expenditure component of the household non-food consumption data can be identified. While this is an advantage, indicator 3.8.2 suffers from the same challenges of timeliness, frequency, data quality and comparability of surveys than SDG indicator 1.1.1. However, indicator 3.8.2 has its own conceptual and empirical limitations.</p>
<p>First, challenges to track out-of-pocket health spending (numerator): indicator 3.8.2 attempts to identify financial hardship that individuals face when using their income, savings or taking loans to pay for health care. However, most household surveys fail to identify the source of funding used by a household who is reporting health expenditure. In countries where there is no retrospective reimbursement of household spending on health this is not a problem. If a household does report any expenditure on health, it would be because it is not going to be reimbursed by any third-party payer. It is therefore consistent with the definition given for direct health care payments (the numerator). </p> <p>For those countries on the other hand where there is retrospective reimbursement – for example, via a contributory health insurance scheme - the amount reported by a household on health expenditures might be totally or partially reimbursed at some later point, perhaps outside the recall period of the household survey. </p> <p>Clearly, more work is needed to ensure that survey instruments gather information on the sources of funding used by the household to pay for health care, or the household survey instrument always specifies that health expenditures should be net of any reimbursement. Survey instrument and sample design should also be carefully reviewed to minimize measurement errors due to both non-sampling errors such as a very short or very long recall periods precluding proper data collection of all health care components (overnight stay, medicines, etc..); or sampling errors such as over-sample of areas with a particularly low burden of disease.</p> <p>Second, sensitivity of the indicator to the choice of the welfare metric for disaggregation (consumption or income in the denominator): in the current definition of indicator 3.8.2 large health expenditures can be identified by comparing how much household spend on health to either household income or total household expenditure. Expenditure is the recommended measure of household’s resources (see concept section) but recent empirical work has demonstrated that while statistics on 3.8.2 at country level are fairly robust to such choice, their disaggregation by income group is pretty sensitive to it. Income based measures show a greater concentration of the proportion of the population with large household expenditure on health among the poor than expenditure based measures (see chapter 2 in the WHO and World Bank 2017 report on tracking universal health coverage as well as Wagstaff et al 2018) .</p> <p>Third, cut-off values to identify large health expenditures: indicator 3.8.2. relies on a single cut-off point to identify what constitutes ‘large health expenditure as a share of total household expenditure or income’. People just below such threshold are not taken into account, which is always the problem with measures based on cut-offs. This is simply avoided by plotting the cumulative distribution function of the health expenditure ratio behind 3.8.2. By doing so, it is possible to identify for any threshold the proportion of the population that is devoting any share of its household’s budget to health. </p> <p>Fourth, there are other indicators used to measure financial hardship, all based on the same data sources: The current definition of SDG indicator 3.8.2 is based on methodologies dating back to the 1990s developed in collaboration with academics at the World Bank and the World Health Organization and corresponds to an indicator of the incidence of catastrophic health spending using a budget share approach (see references). In addition to indicator 3.8.2, WHO also defines large health expenditure in relation to non-subsistence spending<sup><sup><a href="#footnote-7" id="footnote-ref-7">[6]</a></sup>,<sup><a href="#footnote-8" id="footnote-ref-8">[7]</a></sup>,<sup><a href="#footnote-9" id="footnote-ref-9">[8]</a></sup>,</sup> and both WHO and the World Bank use indicators of impoverishing health spending to assess to what extent OOP health spending deters efforts to “End poverty in all its form everywhere” (SDG 1). </p> <p>Fifth, indicator 3.8.2. needs to be tracked jointly with SDG indicator 3.8.1 as well as indicators of barriers to access: Two indicators have been chosen to monitor target 3.8 on Universal Health Coverage within the SDG framework. Indicator 3.8.1 is for the health service coverage dimension of UHC and Indicator 3.8.2 to track the financial protection dimensions. These two indicators should be always monitored jointly. Indeed, some of the people seeking care face barriers to access related to financial constraints, acceptability issues, unavailability of services, or accessibility. Those unable to overcome such barriers (financial and non-financial ones) will not report any spending on health which will tend to reduce SDG 3.8.2 rates. When this happens, SDG 3.8.1 levels should also be low as the tracer indicators of service coverage should reflect that large fractions of the population are unable to get the services they needed. But specific indicators on barriers to access ought to be tracked to understand which type of barriers is precluding access to needed services. </p><div class="footnotes"><div><sup class="footnote-number" id="footnote-6">5</sup><p> <a href="http://unstats.un.org/sdgs/metadata/files/Metadata-01-01-01a.pdf">http://unstats.un.org/sdgs/metadata/files/Metadata-01-01-01a.pdf</a> <a href="#footnote-ref-6">↑</a></p></div><div><sup class="footnote-number" id="footnote-7">6</sup><p> Chapter 2 in “Tracking universal health coverage: 2017 global monitoring report”, World Health Organization and International Bank for Reconstruction and Development/ The World Bank; 2017; <a href="http://www.who.int/healthinfo/indicators/2015/en/">http://www.who.int/healthinfo/indicators/2015/en/</a> ; <a href="#footnote-ref-7">↑</a></p></div><div><sup class="footnote-number" id="footnote-8">7</sup><p>Xu, K., Evans, D. B., Carrin, G., Aguilar-Rivera, A. M., Musgrove, P., and Evans, T. (2007), “Protecting Households From Catastrophic Health Spending,” <em>Health Affairs</em>, 26, 972–983. Xu, K., Evans, D., Kawabata, K., Zeramdini, R., Klavus, J., and Murray, C. (2003), “Households Catastrophic Health Expenditure: A Multi-Country Analysis,” <em>The Lancet</em>, 326, 111–117. <a href="#footnote-ref-8">↑</a></p></div><div><sup class="footnote-number" id="footnote-9">8</sup><p> <a href="http://www.euro.who.int/en/health-topics/Health-systems/health-systems-financing/publications/clusters/universal-health-coverage-financial-protection">http://www.euro.who.int/en/health-topics/Health-systems/health-systems-financing/publications/clusters/universal-health-coverage-financial-protection</a>;<a href="http://applications.emro.who.int/dsaf/EMROPUB_2016_EN_19169.pdf?ua=1">http://applications.emro.who.int/dsaf/EMROPUB_2016_EN_19169.pdf?ua=1</a> ; <a href="http://apps.searo.who.int/uhc">http://apps.searo.who.int/uhc</a><a href="http://www.paho.org/hq/index.php?option=com_content&view=article&id=11065%3A2015-universal-health-coverage-latin-america-caribbean&catid=3316%3Apublications&Itemid=3562&lang=en">http://www.paho.org/hq/index.php?option=com_content&view=article&id=11065%3A2015-universal-health-coverage-latin-america-caribbean&catid=3316%3Apublications&Itemid=3562&lang=en</a> <a href="#footnote-ref-9">↑</a></p></div></div>
<h2>Comentarios y limitaciones:</h2>
<p>Es posible realizar un seguimiento periódico del indicador 3.8.2 utilizando los mismos datos de las encuestas a hogares que se utilizan para el seguimiento de las metas 1.1 y 1.2 de los ODS sobre la pobreza<sup><a href="#footnote-10" id="footnote-ref-10">[10]</a></sup>. Estas encuestas también se realizan periódicamente para otros fines, como el cálculo de las ponderaciones para el Índice de Precios al Consumo. Estas encuestas suelen ser realizadas por las ONEs. Por lo tanto, el monitoreo de la proporción de la población con grandes gastos del hogar en salud como proporción del consumo o ingreso total del hogar no agrega ninguna carga adicional de recolección de datos, siempre y cuando se pueda identificar el componente de gasto en salud de los datos de consumo no alimentario del hogar. Si bien esto es una ventaja, el indicador 3.8.2 sufre los mismos problemas de puntualidad, frecuencia, calidad de los datos y comparabilidad de las encuestas que el indicador 1.1.1 de los ODS. Sin embargo, el indicador 3.8.2 tiene sus propias limitaciones conceptuales y empíricas.</p> <p>En primer lugar, el indicador 3.8.2 trata de identificar las dificultades financieras a las que se enfrentan los individuos cuando utilizan sus ingresos, ahorros o toman préstamos para pagar la atención sanitaria. Sin embargo, la mayoría de las encuestas a hogares no identifican la fuente de financiación utilizada por un hogar que declara gastos de salud. En los países en los que no existe un reembolso retrospectivo del gasto de los hogares en salud, esto no es un problema. Si un hogar notifica algún gasto en salud, será porque no va a ser reembolsado por ningún tercero. Por lo tanto, es coherente con la definición dada para los pagos directos de asistencia sanitaria (el numerador).</p> <p>Por otra parte, en aquellos países en los que existe un reembolso retrospectivo, por ejemplo, a través de un esquema de seguro de salud contributivo, el monto reportado por un hogar sobre los gastos de salud podría ser total o parcialmente reembolsado en algún momento posterior, tal vez fuera del período de recolección de datos de la encuesta a hogares.</p> <p>Evidentemente, es necesario trabajar más para garantizar que los instrumentos de las encuestas recopilen información sobre las fuentes de financiación utilizadas por el hogar para pagar la atención sanitaria, o que los instrumentos de las encuestas a hogares especifiquen siempre que los gastos sanitarios deben ser netos de cualquier reembolso.</p> <p>En segundo lugar, en la definición actual del indicador 3.8.2 los grandes gastos en salud pueden identificarse comparando cuánto gastan los hogares en salud con los ingresos del hogar o con el gasto total del hogar. El gasto es la medida recomendada de los recursos de los hogares (véase la sección de conceptos), pero los trabajos empíricos recientes han demostrado que, si bien las estadísticas del indicador 3.8.2 a nivel de país son bastante robustas a dicha elección, su desagregación por grupo de ingresos es bastante sensible a la misma. Las medidas basadas en los ingresos muestran una mayor concentración de la proporción de la población con grandes gastos familiares en salud entre los pobres que las medidas basadas en los gastos (véase el capítulo 2 del informe de la OMS y el Banco Mundial de 2017 sobre el seguimiento de la cobertura sanitaria universal, así como Wagstaff et al 2018).</p> <p>En tercer lugar, el indicador 3.8.2. se basa en un único punto de corte para identificar lo que constituye un ‘gran gasto sanitario como proporción del gasto o los ingresos totales del hogar’. Las personas que se encuentran justo por debajo de dicho umbral no se tienen en cuenta, lo que siempre es un problema con las medidas basadas en puntos de corte. Esto se evita simplemente trazando la función de distribución acumulativa del coeficiente de gasto sanitario detrás de 3.8.2. Al hacerlo, es posible identificar, para cualquier umbral, la proporción de la población que dedica alguna parte del presupuesto de su hogar a la salud.</p> <p>En cuarto lugar, el indicador 3.8.2. se basa en medidas de gasto ex-post en atención sanitaria. Los bajos niveles de gasto podrían deberse a errores de medición debidos tanto a errores ajenos al muestreo, como un periodo de recuerdo muy corto que no permite recopilar información sobre la atención sanitaria que requiere una estancia de una noche; o a errores de muestreo, como un exceso de muestreo de zonas con una carga de enfermedad especialmente baja. La ausencia de gasto también podría deberse a que la gente no puede gastar nada en salud, lo que, al menos para los servicios que se incluyen en 3.8.1, debería dar lugar a niveles bajos de cobertura.</p> <p>Hay otros indicadores utilizados para medir las dificultades económicas. La OMS utiliza un marco que incluye, además del indicador 3.8.2, una definición de gran gasto sanitario en relación con el gasto no destinado a la subsistencia<sup><a href="#footnote-11" id="footnote-ref-11">[11]</a></sup> <sup><a href="#footnote-12" id="footnote-ref-12">[12]</a></sup><sup><a href="#footnote-13" id="footnote-ref-13">[13]</a></sup>.</p><div class="footnotes"><div><sup class="footnote-number" id="footnote-10">10</sup>.<p> <a href="http://unstats.un.org/sdgs/metadata/files/Metadata-01-01-01a.pdf">http://unstats.un.org/sdgs/metadata/files/Metadata-01-01-01a.pdf</a><a href="#footnote-ref-10">↑</a>.</p></div><div><sup class="footnote-number" id="footnote-11">11</sup>.<p>Capítulo 2 en “Seguimiento de la cobertura sanitaria universal: informe de seguimiento mundial 2017”, Organización Mundial de la Salud y Banco Internacional de Reconstrucción y Fomento/Banco Mundial; 2017; <a href="http://www.who.int/healthinfo/indicators/2015/en/">http://www.who.int/healthinfo/indicators/2015/en/</a> ; <a href="#footnote-ref-11">↑</a>.</p></div><div><sup class="footnote-number" id="footnote-12">12</sup>.<p>Xu, K., Evans, D. B., Carrin, G., Aguilar-Rivera, A. M., Musgrove, P., y Evans, T. (2007), “Protecting Households From Catastrophic Health Spending,”<em>Health Affairs</em>, 26, 972–983. Xu, L., Evans, D., Kawabata, K., Zeramdini, R., Klavus, J., y Murray, C. (2003), “Households Catastrophic Health Expenditure: A Multi-Country Analysis,” <em>The Lancet</em>, 326, 111–117. <a href="#footnote-ref-12">↑</a>.</p></div><div><sup class="footnote-number" id="footnote-13">13</sup>.<p><a href="http://www.euro.who.int/en/health-topics/Health-systems/health-systems-financing/publications/clusters/universal-health-coverage-financial-protection">http://www.euro.who.int/en/health-topics/Health-systems/health-systems-financing/publications/clusters/universal-health-coverage-financial-protection</a>;<a href="http://applications.emro.who.int/dsaf/EMROPUB_2016_EN_19169.pdf?ua=1">http://applications.emro.who.int/dsaf/EMROPUB_2016_EN_19169.pdf?ua=1</a> ; <a href="http://apps.searo.who.int/uhc">http://apps.searo.who.int/uhc</a><a href="http://www.paho.org/hq/index.php?option=com_content&view=article&id=11065%3A2015-universal-health-coverage-latin-america-caribbean&catid=3316%3Apublications&Itemid=3562&lang=en">http://www.paho.org/hq/index.php?option=com_content&view=article&id=11065%3A2015-universal-health-coverage-latin-america-caribbean&catid=3316%3Apublications&Itemid=3562&lang=en</a> <a href="#footnote-ref-13">↑</a>.</p></div></div> |
|
None
Source string changed |
<p>It is feasible to monitor indicator 3.8.2 on a regular basis using the same household survey data that is used to monitor SDG target 1.1 and 1.2 on poverty<sup><sup><a href="#footnote-
<p>First, indicator 3.8.2 attempts to identify financial hardship that individuals face when using their income, savings or taking loans to pay for health care. However, most household surveys fail to identify the source of funding used by a household who is reporting health expenditure. In countries where there is no retrospective reimbursement of household spending on health this is not a problem. If a household does report any expenditure on health, it would be because it is not going to be reimbursed by any third-party payer. It is therefore consistent with the definition given for direct health care payments (the numerator). </p> <p>For those countries on the other hand where there is retrospective reimbursement – for example, via a contributory health insurance scheme - the amount reported by a household on health expenditures might be totally or partially reimbursed at some later point, perhaps outside the recall period of the household survey. </p> <p>Clearly, more work is needed to ensure that survey instruments gather information on the sources of funding used by the household to pay for health care, or the household survey instrument always specifies that health expenditures should be net of any reimbursement. </p> <p>Second, in the current definition of indicator 3.8.2 large health expenditures can be identified by comparing how much household spend on health to either household income or total household expenditure. Expenditure is the recommended measure of household’s resources (see concept section) but recent empirical work has demonstrated that while statistics on 3.8.2 at country level are fairly robust to such choice, their disaggregation by income group is pretty sensitive to it. Income based measures show a greater concentration of the proportion of the population with large household expenditure on health among the poor than expenditure based measures (see chapter 2 in the WHO and World Bank 2017 report on tracking universal health coverage as well as Wagstaff et al 2018) .</p> <p>Third, indicator 3.8.2. relies on a single cut-off point to identify what constitutes ‘large health expenditure as a share of total household expenditure or income’. People just below such threshold are not taken into account, which is always the problem with measures based on cut-offs. This is simply avoided by plotting the cumulative distribution function of the health expenditure ratio behind 3.8.2. By doing so, it is possible to identify for any threshold the proportion of the population that is devoting any share of its household’s budget to health. </p> <p>Fourth, indicator 3.8.2. is based on measures of ex-post spending on health care. Low levels of spending could be driven by measurement errors due to both non-sampling errors such as a very short recall period that does not allow the collection of information on health care requiring an overnight stay; or sampling errors such as over-sample of areas with a particularly low burden of disease. No spending could also be due to people not being able to spend anything on health which, at least for the services that are included in 3.8.1, should result in low levels of coverage. </p> <p>There are other indicators used to measure financial hardship. WHO uses a framework which includes , in addition to indicator 3.8.2, a definition of large health expenditure in relation to non-subsistence spending<sup><sup><a href="#footnote-12" id="footnote-ref-12">[11]</a></sup>,<sup><a href="#footnote-13" id="footnote-ref-13">[12]</a></sup>,<sup><a href="#footnote-14" id="footnote-ref-14">[13]</a></sup>,</sup>.</p><div class="footnotes"><div><sup class="footnote-number" id="footnote-11">10</sup><p> <a href="http://unstats.un.org/sdgs/metadata/files/Metadata-01-01-01a.pdf">http://unstats.un.org/sdgs/metadata/files/Metadata-01-01-01a.pdf</a> <a href="#footnote-ref-11">↑</a></p></div><div><sup class="footnote-number" id="footnote-12">11</sup><p> Chapter 2 in “Tracking universal health coverage: 2017 global monitoring report”, World Health Organization and International Bank for Reconstruction and Development/ The World Bank; 2017; <a href="http://www.who.int/healthinfo/indicators/2015/en/">http://www.who.int/healthinfo/indicators/2015/en/</a> ; <a href="#footnote-ref-12">↑</a></p></div><div><sup class="footnote-number" id="footnote-13">12</sup><p>Xu, K., Evans, D. B., Carrin, G., Aguilar-Rivera, A. M., Musgrove, P., and Evans, T. (2007), “Protecting Households From Catastrophic Health Spending,” <em>Health Affairs</em>, 26, 972–983. Xu, L., Evans, D., Kawabata, K., Zeramdini, R., Klavus, J., and Murray, C. (2003), “Households Catastrophic Health Expenditure: A Multi-Country Analysis,” <em>The Lancet</em>, 326, 111–117. <a href="#footnote-ref-13">↑</a></p></div><div><sup class="footnote-number" id="footnote-14">13</sup><p> <a href="http://www.euro.who.int/en/health-topics/Health-systems/health-systems-financing/publications/clusters/universal-health-coverage-financial-protection">http://www.euro.who.int/en/health-topics/Health-systems/health-systems-financing/publications/clusters/universal-health-coverage-financial-protection</a>;<a href="http://applications.emro.who.int/dsaf/EMROPUB_2016_EN_19169.pdf?ua=1">http://applications.emro.who.int/dsaf/EMROPUB_2016_EN_19169.pdf?ua=1</a> ; <a href="http://apps.searo.who.int/uhc">http://apps.searo.who.int/uhc</a><a href="http://www.paho.org/hq/index.php?option=com_content&view=article&id=11065%3A2015-universal-health-coverage-latin-america-caribbean&catid=3316%3Apublications&Itemid=3562&lang=en">http://www.paho.org/hq/index.php?option=com_content&view=article&id=11065%3A2015-universal-health-coverage-latin-america-caribbean&catid=3316%3Apublications&Itemid=3562&lang=en</a> <a href="#footnote-ref-14 <p>First, challenges to track out-of-pocket health spending (numerator): indicator 3.8.2 attempts to identify financial hardship that individuals face when using their income, savings or taking loans to pay for health care. However, most household surveys fail to identify the source of funding used by a household who is reporting health expenditure. In countries where there is no retrospective reimbursement of household spending on health this is not a problem. If a household does report any expenditure on health, it would be because it is not going to be reimbursed by any third-party payer. It is therefore consistent with the definition given for direct health care payments (the numerator). </p> <p>For those countries on the other hand where there is retrospective reimbursement – for example, via a contributory health insurance scheme - the amount reported by a household on health expenditures might be totally or partially reimbursed at some later point, perhaps outside the recall period of the household survey. </p> <p>Clearly, more work is needed to ensure that survey instruments gather information on the sources of funding used by the household to pay for health care, or the household survey instrument always specifies that health expenditures should be net of any reimbursement. Survey instrument and sample design should also be carefully reviewed to minimize measurement errors due to both non-sampling errors such as a very short or very long recall periods precluding proper data collection of all health care components (overnight stay, medicines, etc..); or sampling errors such as over-sample of areas with a particularly low burden of disease.</p> <p>Second, sensitivity of the indicator to the choice of the welfare metric for disaggregation (consumption or income in the denominator): in the current definition of indicator 3.8.2 large health expenditures can be identified by comparing how much household spend on health to either household income or total household expenditure. Expenditure is the recommended measure of household’s resources (see concept section) but recent empirical work has demonstrated that while statistics on 3.8.2 at country level are fairly robust to such choice, their disaggregation by income group is pretty sensitive to it. Income based measures show a greater concentration of the proportion of the population with large household expenditure on health among the poor than expenditure based measures (see chapter 2 in the WHO and World Bank 2017 report on tracking universal health coverage as well as Wagstaff et al 2018) .</p> <p>Third, cut-off values to identify large health expenditures: indicator 3.8.2. relies on a single cut-off point to identify what constitutes ‘large health expenditure as a share of total household expenditure or income’. People just below such threshold are not taken into account, which is always the problem with measures based on cut-offs. This is simply avoided by plotting the cumulative distribution function of the health expenditure ratio behind 3.8.2. By doing so, it is possible to identify for any threshold the proportion of the population that is devoting any share of its household’s budget to health. </p> <p>Fourth, there are other indicators used to measure financial hardship, all based on the same data sources: The current definition of SDG indicator 3.8.2 is based on methodologies dating back to the 1990s developed in collaboration with academics at the World Bank and the World Health Organization and corresponds to an indicator of the incidence of catastrophic health spending using a budget share approach (see references). In addition to indicator 3.8.2, WHO also defines large health expenditure in relation to non-subsistence spending<sup><sup><a href="#footnote-7" id="footnote-ref-7">[6]</a></sup>,<sup><a href="#footnote-8" id="footnote-ref-8">[7]</a></sup>,<sup><a href="#footnote-9" id="footnote-ref-9">[8]</a></sup>,</sup> and both WHO and the World Bank use indicators of impoverishing health spending to assess to what extent OOP health spending deters efforts to “End poverty in all its form everywhere” (SDG 1). </p> <p>Fifth, indicator 3.8.2. needs to be tracked jointly with SDG indicator 3.8.1 as well as indicators of barriers to access: Two indicators have been chosen to monitor target 3.8 on Universal Health Coverage within the SDG framework. Indicator 3.8.1 is for the health service coverage dimension of UHC and Indicator 3.8.2 to track the financial protection dimensions. These two indicators should be always monitored jointly. Indeed, some of the people seeking care face barriers to access related to financial constraints, acceptability issues, unavailability of services, or accessibility. Those unable to overcome such barriers (financial and non-financial ones) will not report any spending on health which will tend to reduce SDG 3.8.2 rates. When this happens, SDG 3.8.1 levels should also be low as the tracer indicators of service coverage should reflect that large fractions of the population are unable to get the services they needed. But specific indicators on barriers to access ought to be tracked to understand which type of barriers is precluding access to needed services. </p><div class="footnotes"><div><sup class="footnote-number" id="footnote-6">5</sup><p> <a href="http://unstats.un.org/sdgs/metadata/files/Metadata-01-01-01a.pdf">http://unstats.un.org/sdgs/metadata/files/Metadata-01-01-01a.pdf</a> <a href="#footnote-ref-6">↑</a></p></div><div><sup class="footnote-number" id="footnote-7">6</sup><p> Chapter 2 in “Tracking universal health coverage: 2017 global monitoring report”, World Health Organization and International Bank for Reconstruction and Development/ The World Bank; 2017; <a href="http://www.who.int/healthinfo/indicators/2015/en/">http://www.who.int/healthinfo/indicators/2015/en/</a> ; <a href="#footnote-ref-7">↑</a></p></div><div><sup class="footnote-number" id="footnote-8">7</sup><p>Xu, K., Evans, D. B., Carrin, G., Aguilar-Rivera, A. M., Musgrove, P., and Evans, T. (2007), “Protecting Households From Catastrophic Health Spending,” <em>Health Affairs</em>, 26, 972–983. Xu, K., Evans, D., Kawabata, K., Zeramdini, R., Klavus, J., and Murray, C. (2003), “Households Catastrophic Health Expenditure: A Multi-Country Analysis,” <em>The Lancet</em>, 326, 111–117. <a href="#footnote-ref-8">↑</a></p></div><div><sup class="footnote-number" id="footnote-9">8</sup><p> <a href="http://www.euro.who.int/en/health-topics/Health-systems/health-systems-financing/publications/clusters/universal-health-coverage-financial-protection">http://www.euro.who.int/en/health-topics/Health-systems/health-systems-financing/publications/clusters/universal-health-coverage-financial-protection</a>;<a href="http://applications.emro.who.int/dsaf/EMROPUB_2016_EN_19169.pdf?ua=1">http://applications.emro.who.int/dsaf/EMROPUB_2016_EN_19169.pdf?ua=1</a> ; <a href="http://apps.searo.who.int/uhc">http://apps.searo.who.int/uhc</a><a href="http://www.paho.org/hq/index.php?option=com_content&view=article&id=11065%3A2015-universal-health-coverage-latin-america-caribbean&catid=3316%3Apublications&Itemid=3562&lang=en">http://www.paho.org/hq/index.php?option=com_content&view=article&id=11065%3A2015-universal-health-coverage-latin-america-caribbean&catid=3316%3Apublications&Itemid=3562&lang=en</a> <a href="#footnote-ref-9">↑</a></p></div></div> |
|
None
String updated in the repository |
<p>It is feasible to monitor indicator 3.8.2 on a regular basis using the same household survey data that is used to monitor SDG target 1.1 and 1.2 on poverty<sup><sup><a href="#footnote-11" id="footnote-ref-11">[10]</a></sup></sup>. These surveys are also regularly conducted for other purposes such as calculating weights for the Consumer Price Index. These surveys are conducted typically by NSOs. Thus, monitoring the proportion of the population with large household expenditures on health as a share of total household consumption or income does not add any additional data collection burden so long as the health expenditure component of the household non-food consumption data can be identified. While this is an advantage, indicator 3.8.2 suffers from the same challenges of timeliness, frequency, data quality and comparability of surveys than SDG indicator 1.1.1. However, indicator 3.8.2 has its own conceptual and empirical limitations.</p>
<p>First, indicator 3.8.2 attempts to identify financial hardship that individuals face when using their income, savings or taking loans to pay for health care. However, most household surveys fail to identify the source of funding used by a household who is reporting health expenditure. In countries where there is no retrospective reimbursement of household spending on health this is not a problem. If a household does report any expenditure on health, it would be because it is not going to be reimbursed by any third-party payer. It is therefore consistent with the definition given for direct health care payments (the numerator). </p> <p>For those countries on the other hand where there is retrospective reimbursement – for example, via a contributory health insurance scheme - the amount reported by a household on health expenditures might be totally or partially reimbursed at some later point, perhaps outside the recall period of the household survey. </p> <p>Clearly, more work is needed to ensure that survey instruments gather information on the sources of funding used by the household to pay for health care, or the household survey instrument always specifies that health expenditures should be net of any reimbursement. </p> <p>Second, in the current definition of indicator 3.8.2 large health expenditures can be identified by comparing how much household spend on health to either household income or total household expenditure. Expenditure is the recommended measure of household’s resources (see concept section) but recent empirical work has demonstrated that while statistics on 3.8.2 at country level are fairly robust to such choice, their disaggregation by income group is pretty sensitive to it. Income based measures show a greater concentration of the proportion of the population with large household expenditure on health among the poor than expenditure based measures (see chapter 2 in the WHO and World Bank 2017 report on tracking universal health coverage as well as Wagstaff et al 2018) .</p> <p>Third, indicator 3.8.2. relies on a single cut-off point to identify what constitutes ‘large health expenditure as a share of total household expenditure or income’. People just below such threshold are not taken into account, which is always the problem with measures based on cut-offs. This is simply avoided by plotting the cumulative distribution function of the health expenditure ratio behind 3.8.2. By doing so, it is possible to identify for any threshold the proportion of the population that is devoting any share of its household’s budget to health. </p> <p>Fourth, indicator 3.8.2. is based on measures of ex-post spending on health care. Low levels of spending could be driven by measurement errors due to both non-sampling errors such as a very short recall period that does not allow the collection of information on health care requiring an overnight stay; or sampling errors such as over-sample of areas with a particularly low burden of disease. No spending could also be due to people not being able to spend anything on health which, at least for the services that are included in 3.8.1, should result in low levels of coverage. </p> <p>There are other indicators used to measure financial hardship. WHO uses a framework which includes , in addition to indicator 3.8.2, a definition of large health expenditure in relation to non-subsistence spending<sup><sup><a href="#footnote-12" id="footnote-ref-12">[11]</a></sup>,<sup><a href="#footnote-13" id="footnote-ref-13">[12]</a></sup>,<sup><a href="#footnote-14" id="footnote-ref-14">[13]</a></sup>,</sup>.</p><div class="footnotes"><div><sup class="footnote-number" id="footnote-11">10</sup><p> <a href="http://unstats.un.org/sdgs/metadata/files/Metadata-01-01-01a.pdf">http://unstats.un.org/sdgs/metadata/files/Metadata-01-01-01a.pdf</a> <a href="#footnote-ref-11">↑</a></p></div><div><sup class="footnote-number" id="footnote-12">11</sup><p> Chapter 2 in “Tracking universal health coverage: 2017 global monitoring report”, World Health Organization and International Bank for Reconstruction and Development/ The World Bank; 2017; <a href="http://www.who.int/healthinfo/indicators/2015/en/">http://www.who.int/healthinfo/indicators/2015/en/</a> ; <a href="#footnote-ref-12">↑</a></p></div><div><sup class="footnote-number" id="footnote-13">12</sup><p>Xu, K., Evans, D. B., Carrin, G., Aguilar-Rivera, A. M., Musgrove, P., and Evans, T. (2007), “Protecting Households From Catastrophic Health Spending,” <em>Health Affairs</em>, 26, 972–983. Xu, L., Evans, D., Kawabata, K., Zeramdini, R., Klavus, J., and Murray, C. (2003), “Households Catastrophic Health Expenditure: A Multi-Country Analysis,” <em>The Lancet</em>, 326, 111–117. <a href="#footnote-ref-13">↑</a></p></div><div><sup class="footnote-number" id="footnote-14">13</sup><p> <a href="http://www.euro.who.int/en/health-topics/Health-systems/health-systems-financing/publications/clusters/universal-health-coverage-financial-protection">http://www.euro.who.int/en/health-topics/Health-systems/health-systems-financing/publications/clusters/universal-health-coverage-financial-protection</a>;<a href="http://applications.emro.who.int/dsaf/EMROPUB_2016_EN_19169.pdf?ua=1">http://applications.emro.who.int/dsaf/EMROPUB_2016_EN_19169.pdf?ua=1</a> ; <a href="http://apps.searo.who.int/uhc">http://apps.searo.who.int/uhc</a><a href="http://www.paho.org/hq/index.php?option=com_content&view=article&id=11065%3A2015-universal-health-coverage-latin-america-caribbean&catid=3316%3Apublications&Itemid=3562&lang=en">http://www.paho.org/hq/index.php?option=com_content&view=article&id=11065%3A2015-universal-health-coverage-latin-america-caribbean&catid=3316%3Apublications&Itemid=3562&lang=en</a> <a href="#footnote-ref-14">↑</a></p></div></div>
<h2>Comentarios y limitaciones:</h2>
<p>Es posible realizar un seguimiento periódico del indicador 3.8.2 utilizando los mismos datos de las encuestas a hogares que se utilizan para el seguimiento de las metas 1.1 y 1.2 de los ODS sobre la pobreza<sup><a href="#footnote-10" id="footnote-ref-10">[10]</a></sup>. Estas encuestas también se realizan periódicamente para otros fines, como el cálculo de las ponderaciones para el Índice de Precios al Consumo. Estas encuestas suelen ser realizadas por las ONEs. Por lo tanto, el monitoreo de la proporción de la población con grandes gastos del hogar en salud como proporción del consumo o ingreso total del hogar no agrega ninguna carga adicional de recolección de datos, siempre y cuando se pueda identificar el componente de gasto en salud de los datos de consumo no alimentario del hogar. Si bien esto es una ventaja, el indicador 3.8.2 sufre los mismos problemas de puntualidad, frecuencia, calidad de los datos y comparabilidad de las encuestas que el indicador 1.1.1 de los ODS. Sin embargo, el indicador 3.8.2 tiene sus propias limitaciones conceptuales y empíricas.</p> <p>En primer lugar, el indicador 3.8.2 trata de identificar las dificultades financieras a las que se enfrentan los individuos cuando utilizan sus ingresos, ahorros o toman préstamos para pagar la atención sanitaria. Sin embargo, la mayoría de las encuestas a hogares no identifican la fuente de financiación utilizada por un hogar que declara gastos de salud. En los países en los que no existe un reembolso retrospectivo del gasto de los hogares en salud, esto no es un problema. Si un hogar notifica algún gasto en salud, será porque no va a ser reembolsado por ningún tercero. Por lo tanto, es coherente con la definición dada para los pagos directos de asistencia sanitaria (el numerador).</p> <p>Por otra parte, en aquellos países en los que existe un reembolso retrospectivo, por ejemplo, a través de un esquema de seguro de salud contributivo, el monto reportado por un hogar sobre los gastos de salud podría ser total o parcialmente reembolsado en algún momento posterior, tal vez fuera del período de recolección de datos de la encuesta a hogares.</p> <p>Evidentemente, es necesario trabajar más para garantizar que los instrumentos de las encuestas recopilen información sobre las fuentes de financiación utilizadas por el hogar para pagar la atención sanitaria, o que los instrumentos de las encuestas a hogares especifiquen siempre que los gastos sanitarios deben ser netos de cualquier reembolso.</p> <p>En segundo lugar, en la definición actual del indicador 3.8.2 los grandes gastos en salud pueden identificarse comparando cuánto gastan los hogares en salud con los ingresos del hogar o con el gasto total del hogar. El gasto es la medida recomendada de los recursos de los hogares (véase la sección de conceptos), pero los trabajos empíricos recientes han demostrado que, si bien las estadísticas del indicador 3.8.2 a nivel de país son bastante robustas a dicha elección, su desagregación por grupo de ingresos es bastante sensible a la misma. Las medidas basadas en los ingresos muestran una mayor concentración de la proporción de la población con grandes gastos familiares en salud entre los pobres que las medidas basadas en los gastos (véase el capítulo 2 del informe de la OMS y el Banco Mundial de 2017 sobre el seguimiento de la cobertura sanitaria universal, así como Wagstaff et al 2018).</p> <p>En tercer lugar, el indicador 3.8.2. se basa en un único punto de corte para identificar lo que constituye un ‘gran gasto sanitario como proporción del gasto o los ingresos totales del hogar’. Las personas que se encuentran justo por debajo de dicho umbral no se tienen en cuenta, lo que siempre es un problema con las medidas basadas en puntos de corte. Esto se evita simplemente trazando la función de distribución acumulativa del coeficiente de gasto sanitario detrás de 3.8.2. Al hacerlo, es posible identificar, para cualquier umbral, la proporción de la población que dedica alguna parte del presupuesto de su hogar a la salud.</p> <p>En cuarto lugar, el indicador 3.8.2. se basa en medidas de gasto ex-post en atención sanitaria. Los bajos niveles de gasto podrían deberse a errores de medición debidos tanto a errores ajenos al muestreo, como un periodo de recuerdo muy corto que no permite recopilar información sobre la atención sanitaria que requiere una estancia de una noche; o a errores de muestreo, como un exceso de muestreo de zonas con una carga de enfermedad especialmente baja. La ausencia de gasto también podría deberse a que la gente no puede gastar nada en salud, lo que, al menos para los servicios que se incluyen en 3.8.1, debería dar lugar a niveles bajos de cobertura.</p> <p>Hay otros indicadores utilizados para medir las dificultades económicas. La OMS utiliza un marco que incluye, además del indicador 3.8.2, una definición de gran gasto sanitario en relación con el gasto no destinado a la subsistencia<sup><a href="#footnote-11" id="footnote-ref-11">[11]</a></sup> <sup><a href="#footnote-12" id="footnote-ref-12">[12]</a></sup><sup><a href="#footnote-13" id="footnote-ref-13">[13]</a></sup>.</p><div class="footnotes"><div><sup class="footnote-number" id="footnote-10">10</sup>.<p> <a href="http://unstats.un.org/sdgs/metadata/files/Metadata-01-01-01a.pdf">http://unstats.un.org/sdgs/metadata/files/Metadata-01-01-01a.pdf</a><a href="#footnote-ref-10">↑</a>.</p></div><div><sup class="footnote-number" id="footnote-11">11</sup>.<p>Capítulo 2 en “Seguimiento de la cobertura sanitaria universal: informe de seguimiento mundial 2017”, Organización Mundial de la Salud y Banco Internacional de Reconstrucción y Fomento/Banco Mundial; 2017; <a href="http://www.who.int/healthinfo/indicators/2015/en/">http://www.who.int/healthinfo/indicators/2015/en/</a> ; <a href="#footnote-ref-11">↑</a>.</p></div><div><sup class="footnote-number" id="footnote-12">12</sup>.<p>Xu, K., Evans, D. B., Carrin, G., Aguilar-Rivera, A. M., Musgrove, P., y Evans, T. (2007), “Protecting Households From Catastrophic Health Spending,”<em>Health Affairs</em>, 26, 972–983. Xu, L., Evans, D., Kawabata, K., Zeramdini, R., Klavus, J., y Murray, C. (2003), “Households Catastrophic Health Expenditure: A Multi-Country Analysis,” <em>The Lancet</em>, 326, 111–117. <a href="#footnote-ref-12">↑</a>.</p></div><div><sup class="footnote-number" id="footnote-13">13</sup>.<p><a href="http://www.euro.who.int/en/health-topics/Health-systems/health-systems-financing/publications/clusters/universal-health-coverage-financial-protection">http://www.euro.who.int/en/health-topics/Health-systems/health-systems-financing/publications/clusters/universal-health-coverage-financial-protection</a>;<a href="http://applications.emro.who.int/dsaf/EMROPUB_2016_EN_19169.pdf?ua=1">http://applications.emro.who.int/dsaf/EMROPUB_2016_EN_19169.pdf?ua=1</a> ; <a href="http://apps.searo.who.int/uhc">http://apps.searo.who.int/uhc</a><a href="http://www.paho.org/hq/index.php?option=com_content&view=article&id=11065%3A2015-universal-health-coverage-latin-america-caribbean&catid=3316%3Apublications&Itemid=3562&lang=en">http://www.paho.org/hq/index.php?option=com_content&view=article&id=11065%3A2015-universal-health-coverage-latin-america-caribbean&catid=3316%3Apublications&Itemid=3562&lang=en</a> <a href="#footnote-ref-13">↑</a>.</p></div></div> |
<p>First, challenges to track out-of-pocket health spending (numerator): indicator 3.8.2 attempts to identify financial hardship that individuals face when using their income, savings or taking loans to pay for health care. However, most household surveys fail to identify the source of funding used by a household that is reporting health expenditure. In countries where there is no retrospective reimbursement of household spending on health, this is not a problem. If a household does report any expenditure on health, it would be because it will not be reimbursed by any third-party payer. It is, therefore, consistent with the definition given for direct health care payments (the numerator). For those countries, on the other hand, where there is retrospective reimbursement – for example, via a contributory health insurance scheme - the amount reported by a household on health expenditures might be totally or partially reimbursed at some later point, perhaps outside the recall period of the household survey. </p>
<p>Clearly, more work is needed to ensure that survey instruments gather information on the sources of funding used by the household to pay for health care or that the household survey instrument always specifies that health expenditures should be net of any reimbursement. The survey instrument and sample design should also be carefully reviewed to minimize measurement errors due to both non-sampling errors such as very short or very long recall periods precluding proper data collection of all health care components (overnight stay, medicines, etc.); or sampling errors such as over-sample of areas with a particularly low burden of disease.</p>
<p>Second, the sensitivity of the indicator to the choice of the welfare metric for disaggregation (consumption or income in the denominator): in the current definition of indicator 3.8.2, large health expenditures can be identified by comparing how much household spend on health to either household income or total household expenditure. Expenditure is the recommended measure of a household’s resources (see concept section), but recent empirical work has demonstrated that while statistics on 3.8.2 at the country level are fairly robust to such choice, their disaggregation by income group is pretty sensitive to it. Income-based measures show a greater concentration of the proportion of the population with large household expenditure on health among the poor than expenditure-based measures (see Chapter 2 in the WHO and World Bank 2017 report on tracking universal health coverage as well as Wagstaff et al. 2018).</p>
<p>Third, cut-off values to identify large health expenditures: indicator 3.8.2. relies on a single cut-off point to identify what constitutes ‘large health expenditure as a share of total household expenditure or income’. People just below such threshold are not taken into account, which is always the problem with measures based on cut-offs. This is simply avoided by plotting the cumulative distribution function of the health expenditure ratio behind 3.8.2. By doing so, it is possible to identify for any threshold the proportion of the population that is devoting any share of its household’s budget to health. </p>
<p>Fourth, there are other indicators used to measure financial hardship, all based on the same data sources. The current definition of SDG indicator 3.8.2 is based on methodologies dating back to the 1990s developed in collaboration with academics at the World Bank and the World Health Organization. It corresponds to an indicator of the incidence of catastrophic health spending using a budget share approach (see references). In addition to SDG indicator 3.8.2, WHO also defines large health expenditure in relation to non-subsistence spending<sup><sup><a href="#footnote-8" id="footnote-ref-8">[7]</a></sup>,<sup><a href="#footnote-9" id="footnote-ref-9">[8]</a></sup>,<sup><a href="#footnote-10" id="footnote-ref-10">[9]</a></sup>,</sup> and both WHO and the World Bank use indicators of impoverishing health spending to assess to what extent OOP health spending deters efforts to “End poverty in all its form everywhere” (SDG 1). </p>
<p>Fifth, SDG indicator 3.8.2. needs to be tracked jointly with SDG indicator 3.8.1, as well as indicators of barriers to access. Two indicators have been chosen to monitor target 3.8 on Universal Health Coverage within the SDG framework. SDG indicator 3.8.1 is for the health service coverage dimension of universal health coverage (UHC), and SDG indicator 3.8.2 tracks the financial protection dimensions. These two indicators should always be monitored jointly. Indeed, some of the people seeking care face barriers to access related to financial constraints, acceptability issues, unavailability of services, or accessibility. Those unable to overcome such barriers (financial and non-financial ones) will not report any spending on health, which will tend to reduce SDG indicator 3.8.2 rates. When this happens, SDG indicator 3.8.1 levels should also be low as the tracer indicators of service coverage should reflect that large fractions of the population are unable to get the services they need. But specific indicators on barriers to access ought to be tracked to understand which type of barriers is precluding access to needed services. </p><div class="footnotes"><div><sup class="footnote-number" id="footnote-7">6</sup><p> <a href="http://unstats.un.org/sdgs/metadata/files/Metadata-01-01-01a.pdf">http://unstats.un.org/sdgs/metadata/files/Metadata-01-01-01a.pdf</a> <a href="#footnote-ref-7">↑</a></p></div><div><sup class="footnote-number" id="footnote-8">7</sup><p> Chapter 2 in “Tracking universal health coverage: 2017 global monitoring report”, World Health Organization and International Bank for Reconstruction and Development/ The World Bank; 2017; <a href="http://www.who.int/healthinfo/indicators/2015/en/">http://www.who.int/healthinfo/indicators/2015/en/</a> ; <a href="#footnote-ref-8">↑</a></p></div><div><sup class="footnote-number" id="footnote-9">8</sup><p>Xu, K., Evans, D. B., Carrin, G., Aguilar-Rivera, A. M., Musgrove, P., and Evans, T. (2007), “Protecting Households From Catastrophic Health Spending,” <em>Health Affairs</em>, 26, 972–983. Xu, K., Evans, D., Kawabata, K., Zeramdini, R., Klavus, J., and Murray, C. (2003), “Households Catastrophic Health Expenditure: A Multi-Country Analysis,” <em>The Lancet</em>, 326, 111–117. <a href="#footnote-ref-9">↑</a></p></div><div><sup class="footnote-number" id="footnote-10">9</sup><p> <a href="http://www.euro.who.int/en/health-topics/Health-systems/health-systems-financing/publications/clusters/universal-health-coverage-financial-protection">http://www.euro.who.int/en/health-topics/Health-systems/health-systems-financing/publications/clusters/universal-health-coverage-financial-protection</a>;<a href="http://applications.emro.who.int/dsaf/EMROPUB_2016_EN_19169.pdf?ua=1">http://applications.emro.who.int/dsaf/EMROPUB_2016_EN_19169.pdf?ua=1</a> ; <a href="http://apps.searo.who.int/uhc">http://apps.searo.who.int/uhc</a><a href="http://www.paho.org/hq/index.php?option=com_content&view=article&id=11065%3A2015-universal-health-coverage-latin-america-caribbean&catid=3316%3Apublications&Itemid=3562&lang=en">http://www.paho.org/hq/index.php?option=com_content&view=article&id=11065%3A2015-universal-health-coverage-latin-america-caribbean&catid=3316%3Apublications&Itemid=3562&lang=en</a> <a href="#footnote-ref-10">↑</a></p></div></div>
<p>Es posible realizar un seguimiento periódico del indicador 3.8.2 utilizando los mismos datos de las encuestas a hogares que se utilizan para el seguimiento de las metas 1.1 y 1.2 de los ODS sobre la pobreza<sup><a href="#footnote-10" id="footnote-ref-10">[10]</a></sup>. Estas encuestas también se realizan periódicamente para otros fines, como el cálculo de las ponderaciones para el Índice de Precios al Consumo. Estas encuestas suelen ser realizadas por las ONEs. Por lo tanto, el monitoreo de la proporción de la población con grandes gastos del hogar en salud como proporción del consumo o ingreso total del hogar no agrega ninguna carga adicional de recolección de datos, siempre y cuando se pueda identificar el componente de gasto en salud de los datos de consumo no alimentario del hogar. Si bien esto es una ventaja, el indicador 3.8.2 sufre los mismos problemas de puntualidad, frecuencia, calidad de los datos y comparabilidad de las encuestas que el indicador 1.1.1 de los ODS. Sin embargo, el indicador 3.8.2 tiene sus propias limitaciones conceptuales y empíricas.</p>
<p>En primer lugar, el indicador 3.8.2 trata de identificar las dificultades financieras a las que se enfrentan los individuos cuando utilizan sus ingresos, ahorros o toman préstamos para pagar la atención sanitaria. Sin embargo, la mayoría de las encuestas a hogares no identifican la fuente de financiación utilizada por un hogar que declara gastos de salud. En los países en los que no existe un reembolso retrospectivo del gasto de los hogares en salud, esto no es un problema. Si un hogar notifica algún gasto en salud, será porque no va a ser reembolsado por ningún tercero. Por lo tanto, es coherente con la definición dada para los pagos directos de asistencia sanitaria (el numerador).</p>
<p>Por otra parte, en aquellos países en los que existe un reembolso retrospectivo, por ejemplo, a través de un esquema de seguro de salud contributivo, el monto reportado por un hogar sobre los gastos de salud podría ser total o parcialmente reembolsado en algún momento posterior, tal vez fuera del período de recolección de datos de la encuesta a hogares.</p>
<p>Evidentemente, es necesario trabajar más para garantizar que los instrumentos de las encuestas recopilen información sobre las fuentes de financiación utilizadas por el hogar para pagar la atención sanitaria, o que los instrumentos de las encuestas a hogares especifiquen siempre que los gastos sanitarios deben ser netos de cualquier reembolso.</p>
<p>En segundo lugar, en la definición actual del indicador 3.8.2 los grandes gastos en salud pueden identificarse comparando cuánto gastan los hogares en salud con los ingresos del hogar o con el gasto total del hogar. El gasto es la medida recomendada de los recursos de los hogares (véase la sección de conceptos), pero los trabajos empíricos recientes han demostrado que, si bien las estadísticas del indicador 3.8.2 a nivel de país son bastante robustas a dicha elección, su desagregación por grupo de ingresos es bastante sensible a la misma. Las medidas basadas en los ingresos muestran una mayor concentración de la proporción de la población con grandes gastos familiares en salud entre los pobres que las medidas basadas en los gastos (véase el capítulo 2 del informe de la OMS y el Banco Mundial de 2017 sobre el seguimiento de la cobertura sanitaria universal, así como Wagstaff et al 2018).</p>
<p>En tercer lugar, el indicador 3.8.2. se basa en un único punto de corte para identificar lo que constituye un ‘gran gasto sanitario como proporción del gasto o los ingresos totales del hogar’. Las personas que se encuentran justo por debajo de dicho umbral no se tienen en cuenta, lo que siempre es un problema con las medidas basadas en puntos de corte. Esto se evita simplemente trazando la función de distribución acumulativa del coeficiente de gasto sanitario detrás de 3.8.2. Al hacerlo, es posible identificar, para cualquier umbral, la proporción de la población que dedica alguna parte del presupuesto de su hogar a la salud.</p>
<p>En cuarto lugar, el indicador 3.8.2. se basa en medidas de gasto ex-post en atención sanitaria. Los bajos niveles de gasto podrían deberse a errores de medición debidos tanto a errores ajenos al muestreo, como un periodo de recuerdo muy corto que no permite recopilar información sobre la atención sanitaria que requiere una estancia de una noche; o a errores de muestreo, como un exceso de muestreo de zonas con una carga de enfermedad especialmente baja. La ausencia de gasto también podría deberse a que la gente no puede gastar nada en salud, lo que, al menos para los servicios que se incluyen en 3.8.1, debería dar lugar a niveles bajos de cobertura.</p>
<p>Hay otros indicadores utilizados para medir las dificultades económicas. La OMS utiliza un marco que incluye, además del indicador 3.8.2, una definición de gran gasto sanitario en relación con el gasto no destinado a la subsistencia<sup><a href="#footnote-11" id="footnote-ref-11">[11]</a></sup> <sup><a href="#footnote-12" id="footnote-ref-12">[12]</a></sup><sup><a href="#footnote-13" id="footnote-ref-13">[13]</a></sup>.</p><div class="footnotes"><div><sup class="footnote-number" id="footnote-10">10</sup>.<p> <a href="http://unstats.un.org/sdgs/metadata/files/Metadata-01-01-01a.pdf">http://unstats.un.org/sdgs/metadata/files/Metadata-01-01-01a.pdf</a><a href="#footnote-ref-10">↑</a>.</p></div><div><sup class="footnote-number" id="footnote-11">11</sup>.<p>Capítulo 2 en “Seguimiento de la cobertura sanitaria universal: informe de seguimiento mundial 2017”, Organización Mundial de la Salud y Banco Internacional de Reconstrucción y Fomento/Banco Mundial; 2017; <a href="http://www.who.int/healthinfo/indicators/2015/en/">http://www.who.int/healthinfo/indicators/2015/en/</a> ; <a href="#footnote-ref-11">↑</a>.</p></div><div><sup class="footnote-number" id="footnote-12">12</sup>.<p>Xu, K., Evans, D. B., Carrin, G., Aguilar-Rivera, A. M., Musgrove, P., y Evans, T. (2007), “Protecting Households From Catastrophic Health Spending,”<em>Health Affairs</em>, 26, 972–983. Xu, L., Evans, D., Kawabata, K., Zeramdini, R., Klavus, J., y Murray, C. (2003), “Households Catastrophic Health Expenditure: A Multi-Country Analysis,” <em>The Lancet</em>, 326, 111–117. <a href="#footnote-ref-12">↑</a>.</p></div><div><sup class="footnote-number" id="footnote-13">13</sup>.<p><a href="http://www.euro.who.int/en/health-topics/Health-systems/health-systems-financing/publications/clusters/universal-health-coverage-financial-protection">http://www.euro.who.int/en/health-topics/Health-systems/health-systems-financing/publications/clusters/universal-health-coverage-financial-protection</a>;<a href="http://applications.emro.who.int/dsaf/EMROPUB_2016_EN_19169.pdf?ua=1">http://applications.emro.who.int/dsaf/EMROPUB_2016_EN_19169.pdf?ua=1</a> ; <a href="http://apps.searo.who.int/uhc">http://apps.searo.who.int/uhc</a><a href="http://www.paho.org/hq/index.php?option=com_content&view=article&id=11065%3A2015-universal-health-coverage-latin-america-caribbean&catid=3316%3Apublications&Itemid=3562&lang=en">http://www.paho.org/hq/index.php?option=com_content&view=article&id=11065%3A2015-universal-health-coverage-latin-america-caribbean&catid=3316%3Apublications&Itemid=3562&lang=en</a> <a href="#footnote-ref-13">↑</a>.</p></div></div>