Health Insurance Effects on Out-of-pocket Health Expenditure Among the Low-income Groups in Malaysia
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Abstract
Introduction: Health insurance plays a crucial role in healthcare and financial protection. Nonetheless, a considerable portion of Malaysia's low-income population lacks health insurance. This study aimed to investigate the relationship between health insurance and out-of-pocket health expenditure (OOPHE) among the low-income group (B40 households) in Malaysia. Materials and methods: The current study used data from the National Health and Morbidity Surveys (NHMS) conducted in 2015 and consisted of 18,616 B40 respondents. Ordinary least squares (OLS) regression and a two-part model were employed for data analysis purposes. The two-part model encompassed a logit regression in the first part and a generalised linear model (GLM) in the second. Results: Most B40 households are underinsured, with only 13.81% having insurance. The results also found that insured households (0.44, 95% confidence interval [CI]: 0.01%, 0.0.87%), those over 65 years old (1.00, 95% CI: 0.41%, 1.60%), utilisation of inpatient care (2.62, 95% CI: 2.24%, 2.99%), women (0.28, 95% CI: 0.20%, 0.35%), higher education (0.27, 95% CI: 0.13%, 0.42%) and retirees (1.18, 95% CI: -0.01%, 2.37%) significantly spent more on OOPHE. In comparison, private workers (-0.32, 95% CI: -0.50%, -0.14%) and self-employed individuals (-0.27, 95% CI: -0.46%, -0.08%) significantly spent less on OOPHE. Conclusion: The findings confirm that health insurance significantly increases the OOPHE among B40 households. This highlights the necessity of a national health insurance (NHI) program that is managed by the government and provides a comprehensive benefits package. NHI will achieve much better results in controlling healthcare expenditures and reducing the prevalence of catastrophic OOPHE.
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Wagstaff A, Flores G, Smitz MF, Hsu J, Chepynoga K, Eozenou P. Progress on impoverishing health spending in 122 countries: A retrospective observational study. Lancet Glob Health. 2018;6(2):e180–92. DOI: 10.1016/S2214-109X(17)30486-2.
World Health Organization. Global Health Expenditure Database 2019. Geneva: World Health Organization; 2019. [cited 2025 Jan 27]. Available from: https://apps.who.int/nha/database
Ministry of Health Malaysia. Malaysia national health accounts: Health expenditure report 1997-2019. Putrajaya: Malaysia National Health Accounts Section, Planning Division, Ministry of Health Malaysia; 2021. [cited 2025 Jan 27]. Available from: https://www.moh.gov.my
Bank Negara Malaysia. Developments in the medical and health insurance sector. Kuala Lumpur: Bank Negara Malaysia; 2005. [cited 2025 Jan 27]. Available from: https://www.bnm.gov.my
Kefeli Z, Jones G. Moral hazard and the impact of private health insurance on the utilization of health care in Malaysia. Jurnal Ekonomi Malaysia. 2012;46(2):159–75. [cited 2025 Jan 27]. Available from: https://www.ukm.my/jem/article/moral-hazard-and-the-impact-of-private-health-insurance-on-the-utilisation-of-health-care-in-malaysia/
Whitehead M, Dahlgren G, Evans T. Equity and health sector reforms: Can low-income countries escape the medical poverty trap? Lancet. 2001;358(September 8):833–836. doi: https://doi.org/10.1016/S0140-6736(01)05975-X
Aizawa T. The impact of health insurance on out-of-pocket expenditure on delivery in Indonesia. Health Care Women Int. 2019;1–22. doi: https://doi.org/10.1080/07399332.2019.1578778
Nguyen C. The impact of health insurance programs for children: evidence from Vietnam. Health Econ Rev. 2016;6(34):1–15. doi: http://dx.doi.org/10.1186/s13561-016-0111-9
Wang Z, Li X, Chen M, Si L. Social health insurance, healthcare utilization, and costs in middle-aged and elderly community-dwelling adults in China. Int J Equity Health. 2018;17(17):1–13. doi: https://doi.org/10.1186/s12939-018-0733-0
Sepehri A, Sarma S, Simpson W. Does non-profit health insurance reduce financial burden? Evidence from the Vietnam living standards survey panel. Health Econ. 2006;15(6):603–16. doi: https://doi.org/10.1002/hec.1080
Jowett M, Contoyannis P, Vinh ND. The impact of public voluntary health insurance on private health expenditures in Vietnam. Soc Sci Med. 2003;56(2):333–42. doi: https://doi.org/10.1016/S0277-9536(02)00031-X
Ataguba JEO, Goudge J. The impact of health insurance on healthcare utilisation and out-of-pocket payments in South Africa. Geneva Papers on Risk and Insurance: Issues and Practice. 2012; 37:633–54. doi: https://doi.org/10.1057/gpp.2012.35
Economic Planning Unit Malaysia. Rancangan Malaysia Kesebelas Bab 3: Memperkukuh inklusiviti ke arah masyarakat yang saksama. Putrajaya: Economic Planning Unit Malaysia; 2016. [cited 2025 Jan 27]. Available from: https://www.epu.gov.my
Department of Statistics Malaysia. Penemuan utama: Pendapatan, kemiskinan, ketaksamarataan, kerbelanjaan, kemudahan asas 2019. Putrajaya: Department of Statistics Malaysia: 2020. [cited 2025 Jan 27]. Available from: https://www.dosm.gov.my
Noor NM, Mudaris ISM. Health and social protection: Continuing universal health coverage. Khazanah Research Institute. 2021. [cited 2025 Jan 27]. Available from: https://www.krinstitute.org/Discussion_Papers-%40-Health_and_Social_Protection-%3B_Continuing_Universal_Health_Coverage.aspx
Van Dongen, D. Impact of health financing on healthcare quality and affordability in Malaysia: A conceptual review. Malays J Med Biol Res. 2022;9(1):33-40. doi: https://doi.org/10.18034/mjmbr.v9i1.638
Bakar AA. The individual demand for private health insurance in Malaysia[thesis]. Kuala Lumpur: University of Malaya; 2012.
Verma AK., Hassali MA, Saleem F. Health care financing in Malaysia: A way forward. Arch Pharma Pract. 2015; 6(2):93-96. doi: 10.4103/2045‑080X.165136
Isamail N, Said R, Ismail NW, Haron SA. Non-communicable diseases impact low-income households in Malaysia. Malays J Med Sci. 2024;31(1):124–139. doi: https://doi.org/10.21315/mjms2024.31.1.11
Said R, Isamail N, Ismail NW. Determining factors influence out-of-pocket health expenditure among the low-income group in Malaysia. Int J Acad Res Bus Soc Sci. 2020;10(10): 292-311. doi: http://dx.doi.org/10.6007/IJARBSS/v10-i10/7740
Institute of Public Health. National Health & Morbidity Survey 2015. Vol I: Methodology & General Findings. Putrajaya: Ministry of Health Malaysia; 2015. doi: http://www.iku.gov.my/images/IKU/Document/nhmsreport2015vol2.pdf
Ministry of Health Malaysia. National Health and Morbidity Survey 2015. Putrajaya: Ministry of Health Malaysia; 2015.
Ministry of Health Malaysia. National Health and Morbidity Survey 2019. Putrajaya: Ministry of Health Malaysia; 2019.
Mahumud RA, Sarker AR, Sultana M, Islam Z, Khan J, Morton A. Distribution and determinants of out-of-pocket healthcare expenditures in Bangladesh. Journal of Preventive Medicine and Public Health. 2017; 50:91–9. doi: 10.3961/jpmph.16.089
Hamid HA. Pengkelasan isi rumah Malaysia perlu diperhalusi semula. Kuala Lumpur: Khazanah Research Institute; 2020;1–3.
Somkotra T, Lagrada LP. Which households are at risk of catastrophic health spending: Experience in Thailand after universal coverage. Health Aff. 2009;28(3):467–78. doi: https://doi.org/10.1377/hlthaff.28.3.w467
Cawley J, Meyerhoefer C. The medical care costs of obesity: An instrumental variables approach. J Health Econ. 2012;31(1):219–30. doi: http://dx.doi.org/10.1016/j.jhealeco.2011.10.003
Deb P, Norton EC. Modelling health care expenditures and use. Annu Rev Public Health. 2018; 39:489–505. doi: https://doi.org/10.1146/annurev-publhealth-040617-013517
Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual medical spending attributable to obesity: Payer-and service-specific estimates. Health Aff. 2009;28(5). doi: https://doi.org/10.1377/hlthaff.28.5.w822
Matsaganis M, Mitrakos T, Tsakloglou P. Modelling health expenditure at the household level in Greece. European Journal of Health Economics. 2009;10(3):329–36. doi: https://doi.org/10.1007/s10198-008-0137-y
Deb P, Trivedi PK. The structure of demand for health care: Latent class versus two-part models. J Health Econ. 2002;21(4):601–25. doi: https://doi.org/10.1016/S0167-6296(02)00008-5
Manning WG, Basu A, Mullahy J. Generalized modelling approaches to risk adjustment of skewed outcomes data. J Health Econ. 2005;24(3):465–88. doi: https://doi.org/10.1016/j.jhealeco.2004.09.011
Karan A, Yip W, Mahal A. Extending health insurance to the poor in India: An impact evaluation of Rashtriya Swasthya Bima Yojana on out-of-pocket spending for healthcare. Soc Sci Med. 2017;181:83–92. doi: http://dx.doi.org/10.1016/j.socscimed.2017.03.053
National Institutes of Health. National Health and Morbidity Survey 2019: Vol. I: NCDs – Non-Communicable Diseases: Risk Factors and other Health Problems. Putrajaya: Ministry of Health Malaysia; 2020. doi: http://www.iku.gov.my/nhms-2019
Adrion ER, Ryan AM, Seltzer AC, Chen LM, Ayanian JZ, Nallamothu BK. Out-of-pocket spending for hospitalizations among nonelderly adults. JAMA Intern Med. 2016;176(9):1325–32. doi: 10.1001/jamainternmed.2016.3663
Özgen Narcı H, Şahin İ, Yıldırım HH. Financial catastrophe and poverty impacts of out-of-pocket health payments in Turkey. Eur J Health Econ. 2015;16(3):255-270. doi: https://doi.org/10.1007/s10198-014-0570-z
Okedo-Alex IN, Akamike IC, Ezeanosike OB, Uneke CJ. A review of the incidence and determinants of catastrophic health expenditure in Nigeria: Implications for universal health coverage. Int J Health Plann Manage. 2019;34(1):1–18. doi: https://doi.org/10.1002/hpm.2847
Barasa EW, Maina T, Ravishankar N. Assessing the impoverishing effects, and factors associated with the incidence of catastrophic health care payments in Kenya. Int J Equity Health. 2017;16(31):1–14. doi: https://doi.org/10.1186/s12939-017-0526-x
Tan MP, Kamaruzzaman SB, Poi PJH. An analysis of geriatric medicine in Malaysia-riding the wave of political change. Geriatrics (Basel). 2018;3(80):1–9. doi: https://doi.org/10.3390/geriatrics3040080
Poi PJH, Forsyth DR, Chan DKY. Services for older people in Malaysia: Issues and challenges. Age Ageing. 2004;33(5):444–6. doi: 10.1093/ageing/afh182
Kočiš Krůtilová V, Doubková D. The out-of-pocket health burden in the Czech Republic – Should we care? Kontakt. 2018;20:99–107. doi: https://doi.org/10.1016/j.kontakt.2017.10.007
Ferrant G, Pesando LM, Nowacka K. Unpaid care work: The missing link in the analysis of gender gaps in labour outcomes. Paris: OECD Development Centre; 2014.
Li Y, Wu Q, Liu C, Kang Z, Xie X, Yin H, et al. Catastrophic health expenditure and rural household impoverishment in China: What role does the new cooperative health insurance scheme play? PLoS One. 2014;9(4):1–9. doi: https://doi.org/10.1371/journal.pone.0093253
Buigut S, Ettarh R, Amendah DD. Catastrophic health expenditure and its determinants in Kenya slum communities. Int J Equity Health. 2015;14(46):1–12. doi: https://doi.org/10.1186/s12939-015-0168-9