Decomposing socio-economic inequality in catastrophic out-of-pocket health expenditures in Malawi

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 expenditures. The study aimed to measure and decompose socio-economic inequality in catastrophic 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 2021 to 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 analysis to assess the contribution of inequality in each determinant of catastrophic health expenditure 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 catastrophic 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%) and region 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.