DESK REVIEWS | 03.02.03. Out-of-pocket expenses

DESK REVIEW | 03.02.03. Out-of-pocket expenses

Around 22% of the population aged 60 and over in Brazil have a private healthcare insurance  (ANS, 2013). However, we do not know how many of these individuals have access to LTC in this group. Data from the Institute for Applied Economic Research (IPEA) showed that 64% of the long-term care homes were private in Brazil, but we do not know how much of the costs are paid for by the individuals/families or health insurances (Camarano, 2017).


ANS. (2013). Caderno de informação da saúde suplementar. Beneficiários, operadoras e planos.

Camarano, A. A. (2017). Cuidados para a população idosa: Demandas e perspectivas. 

Information specific to out-of-pocket expenditures on long-term care services is not available.

No data found (27 February 2020) on the proportion of population incurring out of pocket expenditures, or the amount. However, the LTC guideline for Puskesmas explained that most components of LTC services are still not covered under the national health insurance or other insurances, and therefore might be covered by donations or out-of-pocket expenses (Kementerian Kesehatan RI Direktorat Jenderal Kesehatan Masyarakat, 2018).


Kementerian Kesehatan RI Direktorat Jenderal Kesehatan Masyarakat. (2018). Pedoman untuk Puskesmas dalam Perawatan Jangka Panjang bagi Lanjut Usia. Kementerian Kesehatan RI.

There is no data on the population that incurs out-of-pocket expenditure when purchasing long-term care services. Although the cost of residential homes is not included on the websites, only a few people can afford to pay for the high costs as indicated by the 2016 NGEC audit (National Gender and Equality Commission, 2016).

Studies on OOP spending in both public and private sector for the general population in 2005/2006, reveal that more than 50% of individuals spend their own resources in the public health sector (Barnes et al., 2010). While the percentage of households incurring OOP has been decreasing since 2003, 7.1% of households were still experiencing catastrophic health expenditures in 2018 (Salari et al., 2019). Measures such as Universal Health Coverage starting with four pilot counties may enhance access to care in the coming years.


Barnes, J., O’Hanlon, B., Feeley, F., McKeon, K., Gitonga, N., & Decker, C. (2010). Private Health Sector Assessment in Kenya. 193(1). Washington, D.C.

National Gender and Equality Commission. (2016). Audit of Residential Institutions of Older Members of Society in Selected Counties of Kenya. Nairobi, Kenya.

Salari, P., Di Giorgio, L., Ilinca, S., & Chuma, J. (2019). The catastrophic and impoverishing effects of out-of-pocket healthcare payments in Kenya, 2018. BMJ Global Health, 4(6).


No data is available at national level regarding the purchase of long-term care services or the number of people incurring in catastrophic levels of out-of-pocket LTC expenditures within the private market (profit or non-profit). However, some information on unpaid care work and its value is available.

As part of Mexico’s National Accounts, the National Statistics Institute, INEGI generates different Satellite Accounts[1] in order to cover activities that are not part of the core economy but they are linked to it in a highly relevant way. To date, many countries have a parallel system of Satellite Accounts, being environmental accounts, tourism, unpaid household (domestic) work satellite accounts, and satellite accounts on non-profit institutions and voluntary work are some of the most widely estimated.

Mexico currently estimates satellite accounts for unpaid household work, for unpaid health and personal care, a tourism satellite account, among others (INEGI, 2018b). Unpaid health and personal care is estimated on a yearly basis and published as the National Satellite Health Accounts of the Health Sector (Cuenta Satelite del Sector Salud en Mexico, CSSSM), with data from the National Time Use Survey. Data for 2017 (base year 2013) reports that GDP of the health sector is 5.6% of the national GDP. Of this 5.6%, 1.4% represents unpaid health and personal care (performed within the household). Within the health sector GDP, 72.3% corresponds to the economic activities of the sector and 27.7% to unpaid health and personal care work.

In order to take into account the dimension of the role of unpaid personal and health unpaid work performed within the household, it is important to note that the monetary value of household’s contribution to personal health care of other household members (27.7%) represents more than half of what is generated by public sector establishments (39.5%). This is also larger than the contribution of primary care (ambulatory) medical services (17.0%) and is similar to the one generated by all hospital services (20.7%) (INEGI, 2018b).

Figures of unpaid work in health refer to care for people of all ages. However, changes in the population structure due to the aging process are visible. Since among the population reporting motor, cognitive or sensory limitations in the country, 26% of them refers to old age as being the cause of their limitations, it can be expected that a significant percentage of unpaid care is dedicated to care for the elderly.

Results from the 10/66 research group’s INDEP study (The Economic and Social Effects of Care Dependence in Later Life) show that significant health care costs for households with care additionally presented higher likelihood of catastrophic healthcare spending (Guerchet et al., 2018).

[1]According to the European Union, satellite accounts provide a framework linked to the central accounts and which enables attention to be focussed on a certain field or aspect of economic and social life in the context of national accounts; common examples are satellite accounts for the environment, or tourism, or unpaid household work (European system of national and regional accounts (ESA 2010).


Guerchet, M. M., Guerra, M., Huang, Y., Lloyd-Sherlock, P., Sosa, A. L., Uwakwe, R., Acosta, I., Ezeah, P., Gallardo, S., Liu, Z., Mayston, R., de Oca, V. M., Wang, H., & Prince, M. J. (2018). A cohort study of the effects of older adult care dependence upon household economic functioning, in Peru, Mexico and China. PLoS ONE, 13(4).

INEGI. (2018b). INEGI. Datos.