The description of the sample statistics is contained in Table 2. On average, household size was five, 65 percent of households were in rural areas, and approximately 55 percent of household heads were married. Forty-two percent of households belonged to the lowest consumption expenditure quantile in 2012, 33 percent in 2013 and approximately 24 percent of households in 2014 to 2018. Six percent of households belonged to the highest consumption expenditure quantile in 2012, 10 percent in 2013, and approximately 18 percent in 2014 to 2018. Monthly food consumption expenditure was around 4000 Soms (US $59) between 2012 and 2014 and 6000 Soms (US $87) between 2015 and 2018.
Table 2
Sample characteristics (percentages unless otherwise specified)
| 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 |
Age group | | | | | | | |
≤ 10 | 17 | 19 | 25 | 20 | 20 | 20 | 20 |
11–20 | 19 | 17 | 18 | 16 | 15 | 15 | 15 |
31–40 | 11 | 11 | 12 | 11 | 11 | 11 | 11 |
41–50 | 14 | 13 | 12 | 13 | 13 | 12 | 12 |
51–60 | 14 | 13 | 11 | 12 | 14 | 15 | 15 |
> 60 | 12 | 12 | 8 | 12 | 12 | 13 | 12 |
Female | 53 | 52 | 52 | 53 | 52 | 54 | 54 |
Rural | 64 | 67 | 64 | 67 | 72 | 64 | 63 |
Household size (mean) | 5 | 5 | 5 | 5 | 5 | 5 | 5 |
Marital status | | | | | | | |
Married | 49 | 54 | 61 | 55 | 54 | 55 | 54 |
Divorced/Separated | 5 | 5 | 5 | 5 | 5 | 5 | 5 |
Widow | 7 | 6 | 6 | 6 | 6 | 10 | 9 |
Single | 20 | 17 | 17 | 16 | 16 | 18 | 16 |
Consumption expenditure quantile | | | | | | |
Q1 (Lowest) | 42 | 33 | 18 | 23 | 24 | 25 | 23 |
Q2 | 23 | 24 | 20 | 19 | 21 | 22 | 19 |
Q3 | 13 | 14 | 19 | 18 | 19 | 18 | 20 |
Q4 | 13 | 18 | 18 | 18 | 20 | 18 | 20 |
Q5 (Highest) | 6 | 10 | 22 | 22 | 16 | 16 | 18 |
Household non-food expenditure | | | | | | |
Monthly average (Soms)* [median] | 4467 [3369] | 4674 [3542] | 6395 [5305] | 4644 [3320] | 4735 [3458] | 4567 [2939] | 3984 [2410] |
Utilities | 35 | 23 | 20 | 37 | 36 | 40 | 31 |
Fuel | 65 | 66 | 62 | 79 | 73 | 81 | 81 |
*households could pay for utilities, rent, and/or fuel in a month |
Table 3 provides information on healthcare costs and components. On average, 40 percent of households reported a member seeking healthcare in the past month and health seeking was lowest in 2016 at 33 percent. For those that sought care, healthcare costs averaged around 1817 Soms (US $26) with highest cost recorded in 2018 (2311 Soms [US $33]). Self-treatment was the most frequent type of healthcare sought by households (78 percent), 18 percent sought outpatient care, and about 8 percent sought inpatient care. In actual spending, out- of- pocket payments remained the same at about 1862 Soms (US $27) between 2012 and 2014 and increased by about 426 Soms (US $6) by 2018. On average, outpatient costs increased from 480 Soms (US $7) to 633 Soms (US $9), inpatient costs increased from 519 Soms (US $7.5) to 940 Soms (US $13.6), and self-treatment costs increased from 257 Soms (US $3.7) to 737 Soms (US $10.7) between 2012 and 2018.
Table 3
Healthcare cost in the past month (percentages unless otherwise specified)
| 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 |
Sought care | 41 | 45 | 41 | 40 | 33 | 45 | 49 |
Outpatient care (% sought care) | 16 | 15 | 17 | 19 | 20 | 23 | 18 |
Inpatient care (% of sought care) | 6 | 7 | 10 | 9 | 8 | 8 | 7 |
Self-treatment (% of sought care) | 81 | 82 | 79 | 76 | 76 | 73 | 79 |
Avg healthcare expenditure per last month (Soms) [median]* | 1885 [220] | 1281 [310] | 1821 [397] | 2136 [400] | 1795 [313] | 2096 [425] | 2311 [589] |
Outpatient cost (Soms) | 480 | 448 | 583 | 626 | 630 | 785 | 633 |
Inpatient cost (Soms) | 519 | 549 | 928 | 1147 | 815 | 880 | 940 |
Self-treatment costs (Soms) | 257 | 283 | 308 | 362 | 349 | 430 | 737 |
*Household could seek healthcare from multiple sources |
[Table 2 here]
[Table 3 here]
Trends in out- of- pocket health expenditure
For households which sought inpatient care, the cost of medication was the highest driver of OOPPs (37 percent), hospitalisation costs were 19 percent, and other costs including medical supplies and payment of physicians contributed 35 percent (Fig. 1). Household which sought inpatient care incurred a substantial cost through payments for gifts and kinds to healthcare providers as this represented 9 percent of total inpatient OOPPs. While the share of inpatient OOPPs attributed to medication costs declined over the years, the share of hospitalisation costs has increased. Medication costs as a share of inpatient OOPPs was about 39 percent between 2012 and 2015, increased to 47 percent in 2016 and declined to 29 percent and 34 percent in 2017 and 2018 respectively. Hospitalisation costs declined from 18 percent in 2012 to about 16 percent in 2013 and 2014 and increased to about 21 percent in 2017 and 2018. Payments for gifts and kinds as a share of inpatient OOPPs increased from 6 percent in 2012 to 11 percent in 2013, declined to about 8 percent in 2014 to 2016, and then increased to 13 percent and 10 percent in 2017 and 2018.
For households which incurred outpatient OOPPs, health expenditure initially declined from 56 percent in 2012 to 49 percent in 2013. Thereafter, there was a steady increase in medications costs as the dominant diver of outpatients OOPPs to about 58 percent in 2018 ((Fig. 2). Payments as gifts and kinds as a share of outpatients OOPPs have marginally declined from 4 percent in 2012 to 3 percent in 2015 and 2 percent in 2018. Other OOPPs, including payments for diagnostic services and medical supply as a share of outpatient OOPPs have remained the same over the years at about 40 percent. Half of households which incurred OOPPs for self-treatment spent their OOPPs on medications over the years.
[Figure 1 here]
Trends in catastrophic health expenditure
Figure 2 illustrates catastrophic health expenditure at the three thresholds. The share of households which incurred catastrophic out- of- pocket expenditure at 10 percent of household consumption expenditure (Cata10) was 17 percent and there has been an upward trend in Cata10 over the years. The incidence of Cata10 increased by about 8 percentage-point from 13 percent in 2012 to 21 percent in 2018. A similar trend was observed when the incidence of catastrophic health expenditure was examined as 25 percent of household consumption expenditure. The share of households which incurred Cata25 was 7 percent and this increased from 6 percent in 2012 to 9 percent in 2018.
Examining the share of households that suffered catastrophic health expenditure at 40 percent of total household non-food consumption expenditure, the incidence of catastrophic health expenditure was 26 percent and incidence increased by about 14 percentage-points; from 19 percent in 2012 to about 33 percent in 2018.
[Figure 2 here]
Although more rural households incurred catastrophic health expenditure at Cata10, Cata25, and Cata40 (Fig. 3) by about 4 percentage-points, catastrophic health expenditure increased in urban and rural areas over the years. The incidence of Cata10 increased from 12 percent in urbans areas (15 percent in rural) in 2012 to 20 percent (21 percent in rural) in 2018. The incidence of Cata25 increased from 4 percent in urban areas (7 percent in rural) in 2012 to 7 percent (10 percent in rural) in 2018. The incidence of Cata40 increased from 17 percent in urban areas (22 percent in rural) in 2012 to 34 percent (33 percent in rural) in 2018. This suggests that while more rural households incurred catastrophic health expenditure at 40 percent of total non-food consumption expenditure, there was a more rapid increase in Cata40 in urban areas relative to rural areas.
[Figure 3 here]
While households who belonged to the highest consumption expenditure quantile incurred a higher catastrophic expenditure relative to those who belonged to the lowest quantile across the three thresholds, over the years, the incidence of catastrophic expenditure increased more rapidly for households who belonged to the lowest quantile (Fig. 3). In 2012, equal proportion of households who belonged to the lowest and highest consumption quantile incurred Cata10 (13 percent) and by 2018, the incidence has increased to 23 percent for the lowest quantile households and 22 percent for the highest. In 2012, equal proportion of households who belonged to the lowest and highest total consumption expenditure quantiles incurred Cata25 (6 percent) and by 2018, the incidence increased to 10 percent of households who belonged to the lowest quantile and 8 percent for those who belonged to the highest quantile). Similarly, the incidence of Cata40 was higher among households who belonged to the highest consumption expenditure quantile in 2012 by about 5 percentage-points, by 2018, equal proportion of households who belonged to the lowest and highest consumption expenditure quantile incurred catastrophic health expenditure at Cata40 (34 percent). (Fig. 4). These findings suggest that catastrophic health expenditure at different thresholds have increased over the years albeit in varying magnitude with households who belonged to the lowest quantiles experiencing more growth.
[Figure 4 here]
The incidence of catastrophic health expenditure was most concentrated among households in Naryn, Chui, Batken, and Osh regions while Bishkek, Jalal-Abad, and Talas regions recorded the least incidence at the three thresholds (Fig. 5). Chui region recorded a 4 percentage-point increase in the incidence of Cata10 from 2013 to 2017, Osh recorded a 22 percent-point increase while Naryn region recorded a 2 percent-point increase in Cata10. This suggests that Cata10 has remained high in Naryn but have recorded the most exponential increase Osh region. In Naryn region, the incidence of Cata25 decreased marginally from 26 percent in 2013 to 24 percent by 2017, and Cata40 increased from 42 percent in 2013 to 51 percent by 2017. In Bishkek, the incidence of Cata10 and Cata25 remained at about 10 percent and 3 percent between 2013 and 2017 respectively while the incidence of Cata40 increased from 15 percent in 2013 to 22 percent by 2017. Between 2013 and 2017, Talas region recorded a 3 percentage-point increase in the incidence of Cata10, Cata25 remained the same at about 3 percent, and the incidence of Cata40 increased by 16 percentage-point.
[Figure 5 here]
Predictors of catastrophic health expenditure
The predictors of catastrophic health expenditure are presented in Tables 4 and 5, and only significant associations are present in text.
Table 4
Marginal effects of logistic regression for determinants of Cata10
VARIABLES | Pooled | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 |
Age groups [Ref: 31–40 years] | | | | | | | |
< 10 years | 0.012* | 0.014 | 0.015 | 0.018* | 0.018* | 0.016* | 0.018* | 0.019* |
| (0.006) | (0.010) | (0.010) | (0.010) | (0.010) | (0.010) | (0.010) | (0.010) |
11–21 years | 0.017*** | 0.027*** | 0.025*** | 0.027*** | 0.027*** | 0.027*** | 0.027*** | 0.027*** |
| (0.005) | (0.007) | (0.007) | (0.007) | (0.007) | (0.007) | (0.007) | (0.007) |
21–30 years | -0.007 | -0.006 | -0.004 | -0.002 | -0.003 | -0.004 | -0.004 | -0.003 |
| (0.004) | (0.006) | (0.006) | (0.006) | (0.006) | (0.006) | (0.006) | (0.006) |
41–50 years | 0.013*** | 0.025*** | 0.026*** | 0.026*** | 0.026*** | 0.025*** | 0.025*** | 0.025*** |
| (0.005) | (0.006) | (0.006) | (0.006) | (0.006) | (0.006) | (0.006) | (0.006) |
51–60 years | 0.041*** | 0.069*** | 0.072*** | 0.072*** | 0.072*** | 0.072*** | 0.072*** | 0.071*** |
| (0.005) | (0.007) | (0.007) | (0.007) | (0.007) | (0.007) | (0.007) | (0.007) |
> 60 years | 0.003 | 0.007** | 0.007* | 0.007* | 0.007* | 0.007* | 0.007* | 0.007* |
| (0.002) | (0.004) | (0.004) | (0.004) | (0.004) | (0.004) | (0.004) | (0.004) |
Marital status [Ref: Married] | | | | | | | |
Divorced/Separated | 0.010 | 0.017* | 0.018* | 0.016* | 0.016* | 0.018* | 0.014 | 0.016 |
| (0.007) | (0.010) | (0.010) | (0.010) | (0.010) | (0.010) | (0.009) | (0.010) |
Widow(er) | 0.021*** | 0.030*** | 0.031*** | 0.031*** | 0.031*** | 0.031*** | 0.031*** | 0.032*** |
| (0.005) | (0.006) | (0.006) | (0.006) | (0.006) | (0.006) | (0.006) | (0.006) |
Single | 0.017*** | 0.025*** | 0.023*** | 0.024*** | 0.024*** | 0.023*** | 0.024*** | 0.025*** |
| (0.005) | (0.008) | (0.008) | (0.008) | (0.008) | (0.008) | (0.008) | (0.008) |
Rural location | 0.012** | 0.020*** | 0.018*** | 0.019*** | 0.018*** | 0.017*** | 0.016*** | 0.017*** |
| (0.005) | (0.004) | (0.004) | (0.004) | (0.004) | (0.004) | (0.004) | (0.004) |
Consumption quantile [Ref: Highest | | | | | | | |
Lowest | 0.008** | -0.030*** | -0.025*** | -0.021*** | -0.019*** | -0.020*** | -0.021*** | -0.020*** |
| (0.004) | (0.005) | (0.005) | (0.005) | (0.005) | (0.005) | (0.005) | (0.005) |
Middle | -0.009** | -0.038*** | -0.035*** | -0.033*** | -0.033*** | -0.034*** | -0.034*** | -0.034*** |
| (0.004) | (0.005) | (0.005) | (0.005) | (0.005) | (0.005) | (0.005) | (0.005) |
Regions (oblasts) [Ref: Bishkek] | | | | | | | |
Issyk-Kul | 0.021** | | 0.018*** | 0.020*** | 0.020*** | 0.020*** | 0.020*** | |
| (0.009) | | (0.006) | (0.006) | (0.006) | (0.006) | (0.006) | |
Jalal-Abad | 0.011 | | 0.013** | 0.015** | 0.016*** | 0.015*** | 0.013** | |
| (0.009) | | (0.006) | (0.006) | (0.006) | (0.006) | (0.006) | |
Naryn | 0.275*** | | 0.290*** | 0.286*** | 0.290*** | 0.285*** | 0.283*** | |
| (0.012) | | (0.009) | (0.009) | (0.009) | (0.009) | (0.009) | |
Batken | 0.037*** | | 0.058*** | 0.057*** | 0.059*** | 0.059*** | 0.055*** | |
| (0.010) | | (0.007) | (0.006) | (0.007) | (0.006) | (0.006) | |
Osh | 0.060*** | | 0.062*** | 0.063*** | 0.068*** | 0.069*** | 0.065*** | |
| (0.010) | | (0.007) | (0.007) | (0.007) | (0.007) | (0.007) | |
Talas | -0.020** | | -0.007 | -0.006 | -0.003 | -0.005 | -0.005 | |
| (0.009) | | (0.006) | (0.006) | (0.006) | (0.006) | (0.006) | |
Chui | 0.131*** | | 0.142*** | 0.142*** | 0.144*** | 0.143*** | 0.138*** | |
| (0.010) | | (0.007) | (0.007) | (0.007) | (0.007) | (0.007) | |
Osh city | 0.165*** | | 0.190*** | 0.188*** | 0.193*** | 0.194*** | 0.184*** | |
| (0.017) | | (0.010) | (0.010) | (0.010) | (0.010) | (0.009) | |
Standard errors in parentheses; *** p < 0.01, ** p < 0.05, * p < 0.1 |
Table 5
Marginal effects of logistic regression for the determinants of Cata40
VARIABLES | Pooled | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 |
Age groups [Ref: 31–40 years] | | | | | | | |
< 10 years | -0.008 | -0.014 | -0.013 | -0.009 | -0.009 | -0.011 | -0.008 | -0.014 |
| (0.008) | (0.011) | (0.011) | (0.011) | (0.011) | (0.011) | (0.011) | (0.011) |
11–21 years | 0.015*** | 0.017** | 0.015* | 0.018** | 0.018** | 0.016** | 0.017** | 0.013 |
| (0.006) | (0.008) | (0.008) | (0.008) | (0.008) | (0.008) | (0.008) | (0.009) |
21–30 years | -0.014** | -0.010 | -0.006 | -0.003 | -0.004 | -0.006 | -0.005 | -0.009 |
| (0.006) | (0.007) | (0.008) | (0.008) | (0.008) | (0.007) | (0.007) | (0.008) |
41–50 years | 0.017*** | 0.025*** | 0.027*** | 0.028*** | 0.028*** | 0.027*** | 0.027*** | 0.019** |
| (0.006) | (0.008) | (0.008) | (0.008) | (0.008) | (0.008) | (0.008) | (0.008) |
51–60 years | 0.055*** | 0.102*** | 0.107*** | 0.107*** | 0.107*** | 0.107*** | 0.108*** | 0.093*** |
| (0.007) | (0.009) | (0.009) | (0.009) | (0.009) | (0.009) | (0.009) | (0.009) |
> 60 years | 0.005 | 0.014*** | 0.013*** | 0.014*** | 0.013*** | 0.013*** | 0.014*** | 0.014*** |
| (0.003) | (0.005) | (0.005) | (0.005) | (0.005) | (0.005) | (0.005) | (0.005) |
Marital status [Ref: Married] | | | | | | | |
Divorced/Separated | 0.024*** | 0.045*** | 0.047*** | 0.045*** | 0.045*** | 0.046*** | 0.041*** | 0.046*** |
| (0.008) | (0.011) | (0.011) | (0.011) | (0.011) | (0.011) | (0.011) | (0.012) |
Widow(er) | -0.014** | -0.014* | -0.014* | -0.015* | -0.015* | -0.014* | -0.014* | -0.015* |
| (0.006) | (0.008) | (0.008) | (0.008) | (0.008) | (0.008) | (0.008) | (0.008) |
Single | -0.007 | -0.006 | -0.002 | -0.003 | -0.003 | -0.002 | -0.004 | -0.003 |
| (0.006) | (0.009) | (0.009) | (0.009) | (0.009) | (0.009) | (0.009) | (0.009) |
Rural location | -0.009 | -0.002 | -0.006 | -0.004 | -0.006 | -0.008* | -0.009* | -0.008* |
| (0.006) | (0.005) | (0.005) | (0.005) | (0.005) | (0.005) | (0.005) | (0.005) |
Consumption quantile [Ref: Highest | | | | | | |
Lowest | -0.080*** | -0.116*** | -0.111*** | -0.105*** | -0.102*** | -0.102*** | -0.104*** | -0.100*** |
| (0.005) | (0.006) | (0.006) | (0.006) | (0.006) | (0.006) | (0.006) | (0.006) |
Middle | -0.063*** | -0.094*** | -0.092*** | -0.089*** | -0.088*** | -0.089*** | -0.089*** | -0.088*** |
| (0.005) | (0.006) | (0.006) | (0.006) | (0.006) | (0.006) | (0.006) | (0.006) |
Regions (oblasts) [Ref: Bishkek] | | | | | | | |
Issyk-Kul | -0.093*** | | -0.094*** | -0.092*** | -0.091*** | -0.089*** | -0.091*** | |
| (0.012) | | (0.008) | (0.008) | (0.008) | (0.008) | (0.008) | |
Jalal-Abad | -0.024** | | -0.048*** | -0.046*** | -0.044*** | -0.044*** | -0.048*** | |
| (0.012) | | (0.008) | (0.008) | (0.008) | (0.008) | (0.008) | |
Naryn | 0.179*** | | 0.181*** | 0.177*** | 0.182*** | 0.179*** | 0.174*** | |
| (0.014) | | (0.010) | (0.010) | (0.010) | (0.010) | (0.010) | |
Batken | -0.004 | | 0.012 | 0.010 | 0.014 | 0.016* | 0.007 | |
| (0.013) | | (0.009) | (0.009) | (0.009) | (0.009) | (0.009) | |
Osh | -0.061*** | | -0.062*** | -0.060*** | -0.054*** | -0.051*** | -0.056*** | |
| (0.012) | | (0.009) | (0.009) | (0.009) | (0.009) | (0.009) | |
Talas | -0.043*** | | -0.044*** | -0.041*** | -0.035*** | -0.036*** | -0.039*** | |
| (0.014) | | (0.009) | (0.009) | (0.009) | (0.009) | (0.009) | |
Chui | 0.108*** | | 0.105*** | 0.106*** | 0.109*** | 0.109*** | 0.101*** | |
| (0.013) | | (0.009) | (0.009) | (0.009) | (0.009) | (0.009) | |
Osh city | 0.151*** | | 0.167*** | 0.165*** | 0.173*** | 0.176*** | 0.161*** | |
| (0.019) | | (0.011) | (0.011) | (0.011) | (0.011) | (0.011) | |
Standard errors in parentheses; *** p < 0.01, ** p < 0.05, * p < 0.1 |
Households with a sick member who was between 11–20 (1.7 percentage-point increase in likelihood), 41–50 (1.3 percentage-point increase in likelihood), and 51–60 years old (4.1 percentage-point increase in likelihood) were more likely to incur Cata10 relative to when a sick member was between 31–40 years old. Households headed by individuals who were widowed (2.1 percentage-point increase in likelihood) or single (1.7 percentage-point increase in likelihood) were more likely to incur Cata10 when they were sick and sought care relative to those headed married individuals. The magnitude of these associations increased to about 3.0 and 2.5 percentage-point respectively when analyses were disaggregated by year. Rural households with a sick member who sought care were about 1.2 percentage-point more likely to incur Cata10 relative to urban households, and the magnitude of association decreased to about 2.0 percentage-point when analyses were disaggregated.
Although the magnitude of association was small, while households who belonged to the lowest consumption expenditure quantile were more likely to incur Cata10, households who belonged to the middle quantile was less likely to incur Cata10 when a member was sick and sought care. Belonging to the lowest quantile was associated with a 0.8 percentage-point increase in the likelihood of incurring Cata10 while belonging to the middle quantile was associated with a 0.9 percentage-point decrease in the likelihood of incurring Cata10. These associations were also observed in the disaggregated analyses. Relative to the richest and most developed region in the Kyrgyz Republic (Bishkek), household who resided in Issyk-Kul, Naryn, Osh, Osh city, and Chui were more likely to incur Cata10 when a member was sick and sought care. The magnitude of the association strongest in Naryn, Chui, and Osh city regions suggesting a stronger association in these regions.
[Table 4 here]
Households with a sick member who was between 11–20 (1.5 percentage-point increase in likelihood), 41–50 (1.7 percentage-point increase in likelihood), and 51–60 years old (5.5 percentage-point increase in likelihood) were more likely to incur Cata40 relative to when a sick member was between 31–40 years old. The magnitude of the significant association remained relatively the same when analyses were disaggregated (Table 5). Relative to households headed by married heads, there was a 2.4 percentage-point increase in the likelihood of incurring Cata40 when a sick member who sought care belonged to households headed by divorced or separated heads. The magnitude of this association increased to about 4.5 percentage-point when analyses were disaggregated by year. Although at varying magnitudes, households that belonged to lower and middle consumption quantiles were less likely to incur Cata40 when a household member was sick and sought care (see Table 5 for more details). Relative to richest and most developed region (Bishkek), while household who resided in Issyk-Kul, Jalal-Abad, Osh, and Talas were less likely to incur Cata40 when a member was sick and sought care, households who resided in Naryn, Chui and Osh city were more likely to incur Cata40 when a member was sick and sought care. The magnitude of the association in Naryn, Chui, and Osh city regions were stronger than those in the other regions suggesting a stronger association (see Table 5 for more details).
[Table 5 here]