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Publication date: 
March 4, 2009

March 4, 2009 - For many families in the developing world, out-of-pocket health spending is a huge financial burden, but measuring the extent of that burden is being hampered by inconsistent survey methods, according to a new study "Limitations of methods for measuring out-of-pocket and catastrophic private health expenditures," recently published in the Bulletin of the World Health Organization by lead author Chunling Lu of Harvard Medical School and senior author Dr. Christopher Murray of the Institute for Health Metrics and Evaluation at University of Washington.

Out-of-pocket payments by households are estimated to account for 23% of total global health expenditure and 45% of health expenditure in the developing world. However, a team of researchers, including Lu and Murray, found major limitations in the surveys that helped produce these estimates while investigating the results from two of the most commonly used surveys that capture health expenditure data: the World Bank’s Living Standards Measurement Surveys and the WHO’s World Health Surveys.

The findings indicate that estimates are extremely sensitive to survey design. There are significant technical challenges with the existing tools, including a lack of standardization in the wording, framing, recall periods, and number of questions. In many countries, when fewer questions were asked, the average estimate for health spending was lower than for countries where additional items were included. Questions with a shorter recall period, for example four weeks, yielded a larger estimate of private health spending than questions with a longer recall period such as 12 months. Cultural and contextual factors may also be influential. Researchers noted that the same survey can generate vastly different results when administered to different populations.

“Reliable information on household out-of-pocket expenditures is a critical component of health policy assessment, implementation of interventions, and evaluation of program performance,” says Dr. Murray. “The existing survey methods are impeding the research community’s ability to inform effective policy decisions or guide resource allocation.”

The problem of poor measurement is magnified given the large share of health expenditure from out-of-pocket sources in nearly all developing countries.