Variation in financial protection and its association with health expenditure indicators: an analysis of low- and middle-income countries

Background: An insight into variation in financial protection among countries and the underpinning factors associated with the variations observed will help to inform public health policy and practice. Method: Secondary datasets from Global Health Expenditure Database and World Bank Development Indicators collected between 2000 and 2016 were used. Financial protection was measured in 75 low- and middle-income countries (LMICs) using the sustainable development goals framework. Funnel plot charts were used to explore the variation, and regression models were used to measure associations. Result: Fifty-three (67%) countries were within the 99% control limits indicating common-cause variation; 11 countries were above the upper control limit and 15 countries were below the lower control limit. In the fully adjusted model, country, spending on health relative to their economy had the strongest association with the variation in catastrophic spending. Every 1% increase in health spending relative to gross domestic product (GDP) was found to be associated with a reduction of 0.13% in the number of people that incurred catastrophic health spending. Conclusion: There is substantial variation in financial protection, as measured by the number of people that incurred catastrophic health spending, in LMICs; a proportion of this could be explained by the difference in GDP and external health expenditure.