CATA meets IMPOV: a unified approach to measuring financial protection in health

Up to now catastrophic and impoverishing payments have been seen as two alternative approaches to measuring financial protection in health. Building on the previous literature, the authors propose a unified methodology in which impoverishing and catastrophic payments are mutually exclusive outcomes. They achieve this by expressing out-of-pocket payments as a ratio of'discretionary'consumption, defined as the amount by which total consumption (gross of out-of-pocket payments) exceeds the poverty line. This allows the authors to identify both households who are impoverished by out-of-pocket payments (their ratio exceeds one) and households who are pushed even further into poverty by out-of-pocket payments (their ratio is negative); the authors call such payments'immiserizing'. Households experiencing'catastrophic'payments are a subset of those who incur out-of-pocket payments but who are neither impoverished nor immiserized by them. Two alternative definitions of catastrophic payments are offered: those that absorb more than a pre-specified fraction of discretionary consumption; and those that leave a household's nonmedical consumption (total consumption net of out-of-pocket spending) below a pre-specified multiple of the poverty line. The authors also offer a simple financial protection index that reflects the percentages of households incurring immiserizing, impoverishing, catastrophic, non-catastrophic, and zero out-of-pocket payments. They illustrate their unified approach with data from the World Health Survey, using international poverty lines and a catastrophic payment threshold of 40 percent.