Decomposingsocio-economic inequality in catastrophic out-of-pocket health expenditures in Malawi

Abstract
Reducing health inequalities and inequities is one of the key goals that health systems
aspire to achieve as it ensures improvement in health outcomes among all population
groups. Addressing the factors contributing to inequality in catastrophic health expenditures
is important to reducing inequality in the burden of health expenditures. However, there are
limited studies to explain the factors contributing to inequalities in catastrophic health expen
ditures. The study aimed to measure and decompose socio-economic inequality in cata
strophic health into its determinants. Data for the analysis come from the fourth integrated
household survey. Data for 12447 households in Malawi were collected from April 2016 to
April 2017 by the National Statistical Office. The secondary analysis was conducted from
June 2021to October 2021. Catastrophic health expenditure was estimated as a proportion
of households whose out-of-pocket health expenditures as a ratio of non-food consumption
expenditures exceeds 40% threshold level. We estimated the magnitude of socio-economic
inequality using the Erreygers corrected concentration index and used decomposition analy
sis to assess the contribution of inequality in each determinant of catastrophic health expen
diture to the overall socio-economic inequality. The magnitude of the Erreygers corrected
concentration index of catastrophic health expenditure (CI = 0.004) is small and positive
which indicates that inequality is concentrated among the better-off. Inequality in cata
strophic health expenditure is largely due to inequalities in rural residency (127%), socio
economic status (-40%), household size (14%), presence of a child under five years old
(10%) andregion of the household (10%). The findings indicate that socio-economic
inequality in catastrophic health expenditures is concentrated among the better-off in
Malawi. The results imply that policies that aim to reduce inequalities in catastrophic health
expenditures should simultaneously address urban-rural and income inequalities.