HEALTH INSURANCE, CATASTROPHIC MEDICAL SPENDING, AND DIABETES TREATMENT IN DEVELOPING COUNTRIES

Purpose: People obtain health insurance to protect themselves from the high costs of medical care and particularly from catastrophic medical spending.  Numerous developing countries provide health insurance schemes, though insurance is often incomplete, necessitating out-of-pocket expenses for major illnesses. The global increase in diabetes has also increased the need for potentially unaffordable medical care. This study quantified the out-of-pocket medical spending associated with diabetes in developing countries and assessed whether health insurance was associated with less catastrophic medical spending and increased availability of diabetes medications.

Method: Using 2002-3 World Health Survey data (n=124,484 individuals from 35 low- and middle-income countries), we estimated the relationship between diabetes and out-of-pocket medical expenditures, expressed in 2003 international dollars, with quantile regressions that conditioned on age, sex, income, urban location, smoking, educational attainment, and health insurance. Similarly, we estimated the relationship between diabetes, catastrophic medical spending, health insurance, and possessing diabetes medications using logistic regressions. All analyses included country fixed effects and robust standard errors clustered by country.

Result: Diabetes is associated with differentially higher out-of-pocket medical spending, particularly among individuals with high levels of out-of-pocket spending (excess spending of $3/year [95% CI: $2-$4] at the 50th percentile of out-of-pocket spending rising to $159/year [95% CI: $133-$184] at the 95th percentile). While having diabetes is associated with catastrophic spending (OR 1.38 [95% CI: 1.06-1.80]), health insurance is not significantly associated with reductions in catastrophic spending among diabetics (OR 1.07, p=0.84]) or non-diabetics (OR 1.06 p=0.28). Among diabetics, insurance is not significantly associated with increased diabetes medication possession (OR 1.17 [95% CI: 0.75-1.84]).

Conclusion: Individuals with diabetes in low- and middle-income countries have higher out-of-pocket medical expenditures and a greater risk of catastrophic medical spending. In these settings, current health insurance schemes do not provide sufficient protection against costly medical care or sufficient subsidies to ensure that diabetes medication are obtained. To improve outcomes and avert the costs of diabetes in developing countries, policies that combine primary prevention, improved health insurance mechanisms, and accessible delivery of healthcare delivery are likely required.