Many low middle income countries try over the years to find betterways of financing their health systems. Common among many of these systems is inabilityto mobilize sufficient resources to provide the desired level of health carefor the citizens 9– 13.Globally,150 million people suffer catastrophic expenditure each year and 100 millionare pushed into impoverishment because of the expenses of health services 9–13.

This indicates a lack of financial risk protection in low-incomecountries. The global healthcare expenditure has risen from 3% of world GPD in1948 to 7% in 1997 and recently to 9% in 2010, yet millions are pushed intofurther poverty due to paying directly for health care services. So financinghealth care is not only an issue of spending more money for health care; it isalso an issue of who is required to pay, when they pay and how the money isspent 9– 13.          2.1  Health insurance status in JordanOver seventy-five percent of Jordanians are covered with some formof health insurance (civil, military, UNRWA, and private). Those who are notcovered do not necessarily lack access to health care.

Any individual canutilize Ministry of Health (MOH) services and pay subsidized charges (15-20% ofcost). Therefore, MOH provides a safety net for Jordanians who need health careand have no insurance 14.The Civil Insurance Program CIP run by MOH is thelargest health insurance provider as it covers 34 percent of the population,mainly all government employees and their dependents, the poor, the disabled,children below six years of age, senior citizens over sixty years of age,pregnant women, and blood donors. Jordanians below the poverty line areeligible for CIP’s insurance 14. Military insurance MI covers 27 percent ofthe population, mainly military personnel, and their dependents.

UNRWA coverseligible Palestinian refugees in Jordan (9 percent of the population) with freeprimary health care and contributes to the cost of inpatient health services14. Private health insurance covers 8 percent of the population and it isadministered either by private insurance companies or by self-insured systems.Insured population pays fixed premiums in addition to co-payments wheneverservices are used 14.

Somestudies have, surprisingly, found a positive relationship between insurance andprevalence of catastrophic health expenditures. In Zambia, health insurance didnot provide financial protection against the risk of catastrophic expenditures,rather it increased the risk 15. Cavagnero, et al. found no evidence that householdswith social health insurance coverage are protected against catastrophic healthexpenditures. They concluded that the issue is not so much the presence ofhealth insurance coverage but the depth of the coverage in terms of benefitspackage 16.         2.

2 Healthcarefinancing systemCountries have to provide sufficient resources in order to affordthe primary health care for the population, pay for that health care, andfinancially protect the population from the poverty related to the catastrophicexpenditure 17. Developing countries, those with low income in particular, facemany difficulties in providing sufficient resources to equally satisfy primary healthcare, while middle–income countries pay more attention on providing overall coverageto their populations 17.The process of health financing aims to provide funding to the healthcare sector and to motivate the providers to produce assistance. The successfulhealth financing process leads to lower rate of inability to pay for healthservices, and thus lower rate of poverty due to OOP health payments 9.In addition to the contribution of the private sector,the role of government in financing health services is still the key one. Theeffect of governmental financing in protecting households from catastrophichealth expenditure was observed in a study by Xu et al. 19 in which anegative correlation was found between the rate of catastrophic expenditure andthe proportion of governmental contribution in health financing in 89countries.

Two main approaches are usually adopted by countries to financehealth sector: General Taxation (GT) and Social Health Insurance (SHI). With GT, governments depends on taxesin health financing to provide their population with health services for freeor at very low costs. Unfortunately, low and middle-income countries faceproblems in applying this approach because the high extent of poverty makestaxes insufficient to meet the needs of the health sector 20. In SHI approach aself-directed organization saves individuals’ prepayments on which it dependsto later finance their health needs if they get ill.National Health Accounts have shown in 2013that the government contributes to about 61.47 percent of the total healthfinancial funding, about 34.78 percent are provided by private agencies, andthe remaining 3.75 percent comes from international sources 6.

Thegovernmental contribution occurs as taxes-based allocations from the Ministryof Finance (MOF) to the RMS, MOH. The private funding consists of payments bypeople for private commercial insurance, expenditures by self-insured companieson health care services for their employees, and OOP payments for health careand for medications at pharmacies 6.                2.3.Catastrophic Health Expenditure and Impoverishment: 2.3.1. Definition and measurement of catastrophic healthexpenditures:Health expenditures becomecatastrophic when households are forced to decrease their basic consumption,sell properties, and borrow, in order to cover healthcare costs to an extentthat their living standards are disrupted 3.

Two methods are usually employed toevaluate whether the health expenditure is catastrophic or not: Van Doorslaeret al. 21 method and Xu 3 method. Both methods share the idea thatout-of-pocket payments (OPP) for health care should exceed a certain level inorder to be considered catastrophic. Van Doorslaer et al. reported that OPP forhealth care is considered to be catastrophic if the ratio between OPP and thetotal expenditure exceeds a pre-specified fraction, usually 10 percent of totalexpenditure. On the other hand, Xu considered OOP expenditures on healthservices catastrophic if it exceeds 40% of the capacity to pay. The household’scapacity to pay is defined as the remaining income after basic necessary needs(payments on food) have been paid for.  2.

3.2. Prevalence of catastrophic health expenditure: According to WHO it is estimated that every year, around 44 millionhouseholds, or more than 150 million individuals, face catastrophic expenditureworldwide, and approximately 25 million households or more than 100 millionindividuals are pushed into poverty due to the health care payments 18.

On a global scale, the percentage of households that facedcatastrophic expenditure from out-of-pocket health payments varied widely amongcountries, from less than 0·01% in the Czech Republic and Slovakia to 10·5% inVietnam 2, 22, 23. In general, lower rates of catastrophic health expenditurewere reported by the studies on the developed countries compared to those conductedon the developing countries. In the Arab world, a little amount of data have been found on catastropheand poverty levels resulting from health OOP payments. A study by Elgazzar etal. 5 examined the types of out-of-pocket payments in six countries in theMiddle East and North Africa explained the effects of that OOP expenditure on thestandards of living of the population. The study indicated that the examinedhouseholds paid an average of 6% of their total expenditure on health.

Most ofthose out-of-pocket payments were spent on medications, doctor visits, anddiagnostic services. The study also found that 7% to 13% of the householdsfaced out-of-pocket payments equal to or higher than 10 percent of the total householdpayments.The contribution of OOP payments to the total health expenditurewas found high many Arab countries. Egypt’s National Health Accounts for 200825 indicated that OOP payments accounted for 60 percent of total healthexpenses. In Palestine, 43.1 percent of the total health expenditure were OOPin 2011 26, and in Jordan the percentage was 42.

3 percent in 2008 27. When we come to the numeric data on catastrophic healthexpenditure, some numbers were found. Proportions of households withcatastrophic health payments in Lebanon and Yemen were reported at 5.17% and1.665, respectively 2. Rashad et al. 28 examined the catastrophic healthexpenditure and the related poverty in Egypt. Results have shown that 6% of thehouseholds faced financial catastrophe from health payments.

A study oncatastrophic health expenditure Palestine between 1998 and 2007 29. Foundthat the incidence of catastrophic health payments was relatively low; only 1%of the examined households spent more than 40% of their capacity to pay (totalhousehold expenditures after necessary needs, such as food, have been paid for)in 1998. However, the percentage nearly doubled in 2007 and the percentage ofhouseholds who fell into deep poverty increased from 11.8% in 1998 to 12.

5% in2006. 2.3.3. Factors related to catastrophic health expenditures:Several studies were conducted to assess the factors generallyrelated to catastrophic expenditures such as poverty, aging, chronic illnesses,low levels of insurance coverage, financing system, rural/urban differences,socio-economic status, types of illness, demographic composition of thehousehold, and the characteristics of household head such as age, sex, andeducation 30-34. They found that gender, education and working status of thehousehold head are the key variables in explaining catastrophic healthexpenditures. Being employed and having a higher level of education could beassociated with more opportunities to cope with the financial burden such asborrowing money or selling assets.

The influence of health insurance on the incidence of catastrophichealth expenditures had shown a limitation in decreasing or eliminatingcatastrophic health expenditures; even with health insurance, poor householdswere still at significant risk of catastrophic expenditure 35.A study was conducted in Serbia by Arsenijevic et al. 36 toevaluate the catastrophic health expenditure as well as the related poverty inSerbia. The sample consisted of 5557 households with 17,375 participants. Theresults have shown that out-of-pocket payments have a catastrophic effect onpoor households in Serbia. They also have shown higher rates of catastrophichealth expenditure in rural areas, in larger households, and among chronicallysick household members.In another study, Van Minh et al. 37 examined the catastrophicexpenditure and impoverishment problems in Vietnam between 2002 and 2010.

Theyfound that catastrophic and poverty impacts of out-of-pocket payments were morecommon among the households who had more elderly people and those located inrural areas.Anbari Z. et al.

38 conducted a cross-sectional study in Iran toexamine financial expenditure on inpatient and outpatient health care servicesand to assess the predictors of catastrophic costs for inpatient health care inone of the central provinces of Iran. The Iranian data consisted of 760households. Hospitalizations due to inpatient care needs, household membersaged 40-59 years old, especially with chronic diseases and poor status of thehousehold were the highest predictors of facing catastrophic costs and reportedthat 42.6% of hospitalized participants encountered catastrophic expenditure.Suet al. 39 quantified the extent of household catastrophic health expenditureand examined the related predicting factors in Burkina Faso.  They reported the economic status of thehousehold as a key determinant of catastrophic health expenditures.

InGeorgia, Gotsadze et al. 34 reported that households in the richest quintilewere four times less likely to face catastrophic expenditure when compared withthe poorest quintile. Chronicillness is an important factor to predict catastrophic health expenditure 33.Household members with chronic diseases are more likely to use health services,and therefore, have a higher probability of experiencing catastrophicexpenditure. 2.

3.4. Economic consequences and Strategies to deal withcatastrophic health expenditure: Health care costs can cause financial problems directly throughpayments on the healthcare, and indirectly because of losing income as a resultof the inability to work.

Some households may use savings, borrowing or sellingassets to cope with health shocks. Other households with limited options mayget forced to cut their spending on essential goods to cover their healthcosts.Households need to develop strategies to cope with the expenses ofdisease treatment. The aim of these strategies is to maintain the financialviability of the household.

Some strategies are based on mobilizing funds to facedirect costs such as borrowing or selling assets. The ability of households todeal with health shocks depends on their assets portfolio, in addition to thetype, severity, duration of disease and the family members affected 35.Xu examined the strategies adopted by households in 15 Africancountries to deal with health problems 40. They also investigated whetherhouseholds coping strategies vary significantly between financing outpatientservices, inpatient services, and routine care. Low government health spendingand lack of health insurance are key characteristics of these countries.

Theaverage public health spending in these countries is nearly 40% of total healthspending. The results indicated that in 12 countries high inpatient spending increasedthe probability of borrowing or selling assets. Moreover, urban households wereless likely to use coping strategies than rural households. The study reportedthat in 11 countries households headed by males were less likely to borrow orsell assets. The study also reported that households headed by old members(above 60 years) were more likely to borrow or sell assets.