Catastrophic long-term care expenditure: associated socio-demographic and economic factors

  • Raúl del Pozo-Rubio
  • Román Mínguez-Salido
  • Isabel Pardo-GarcíaEmail author
  • Francisco Escribano-Sotos
Original Paper



An increasing number of persons across the world require long-term care (LTC). In Spain, access to LTC involves individuals incurring out-of-pocket (OOP) expenditure. There is a large body of literature on the incidence of catastrophic OOP payments in access and participation in health systems, but not in the field of LTC nor the determinants of these expenses. Our aim was to analyse the socio-demographic and economic factors associated with different levels of catastrophic LTC expenditure in the form of private out-of-pocket payments among dependent persons in Spain.

Materials and methods

The study used the Spanish Disability and Dependency Survey (SDDS) conducted by the Spanish National Statistics Institute to obtain the socioeconomic, demographic and health profiles. The households were classified into those below the poverty threshold and those above the threshold of catastrophe, using measures of impoverishment and catastrophe. We estimated two logistic regression models, one binary (impoverishment) and one ordinal (catastrophe).


The results show that OOP expenditure on LTC increases the probability of impoverishment by 18.90%. The factors associated with higher probability of experiencing catastrophe were age, being single, widowed or separated, lower levels of household income and education, higher level of dependence and living in an autonomous community with lower per capita income.


These findings highlight the need to include exemptions or insurance in the design of LTC policies to protect dependent persons from the risk of financial burden.


Catastrophic Long-term care Out-of pocket Dependence 

JEL Classification

G38 I38 J14 



This study has been funded by the XXXIII Edition Grant Spanish Association of Health Economics and Bayer HealthCare and the Spanish State Programme of R + D + I ECO2013-48217-C2-2-R and ECO2017-83771-C3-1-R.

Compliance with ethical standards

Conflict of interest

The authors of this manuscript have no conflicts of interest.

Supplementary material

10198_2019_1031_MOESM1_ESM.docx (30 kb)
Supplementary material 1 (DOCX 29 KB)


  1. 1.
    European Commission: The 2015 Ageing Report: Economic and budgetary projections for the 28 EU Member States (2013–2060). Directorate-General for Economic and Financial Affairs, Economic Policy Committee (AWG) 3, (2015)Google Scholar
  2. 2.
    World Health Organization: World report on ageing and health. World Health Organization, Geneva (2015)Google Scholar
  3. 3.
    Brodsky, J., Habib, J., Hirschfeld, M.J.: Key policy issues in long-term care. World Health Organization, Geneva (2003)Google Scholar
  4. 4.
    Colombo, F., Nozal, A.L., Mercier, J., Tjadens, F.: OECD health policy studies help wanted? Providing and paying for long-term care: providing and paying for long-term care, vol. 2011. OECD Publishing, Washington (2011)Google Scholar
  5. 5.
    Economic and Social Council of Spain: Memoria sobre la situación socioeconómica y laboral de España 2016. (2017)Google Scholar
  6. 6.
    Institute of Elderly and Social Services of Spain: Statistics Service of Attached General Department of Value, Quality and evaluation of the system to autonomy and dependence care. (2017). Accessed 28 Feb 2018
  7. 7.
    OECD: Statistics OCDE. Health data. Available at (2016). Accessed 14 Sept 2017
  8. 8.
    World Health Organization: World Health Statistics 2016: Monitoring Health for the SDGs Sustainable Development Goals. World Health Organization, Washington (2016)Google Scholar
  9. 9.
    Wagstaff, A., van Doorslaer, E.: Catastrophe and impoverishment in paying for health care: with applications to Vietnam 1993–1998. Health. Econ. 12(11), 921–934 (2003). Google Scholar
  10. 10.
    Kolasa, K., Kowalczyk, M.: Does cost sharing do more harm or more good?-a systematic literature review. BMC. Public. Health. 16(1), 992 (2016)Google Scholar
  11. 11.
    Alam, K., Mahal, A.: Economic impacts of health shocks on households in low and middle income countries: a review of the literature. Global. Health. 10(1), 21 (2014)Google Scholar
  12. 12.
    Elgazzar, H., Raad, F.: Health, nutrition and population (HNP) Discussion Paper. Out-of-pocket health spending and equity implications in the Middle East and North Africa. Who Pays? Washington, DC: The World Bank. (2010)Google Scholar
  13. 13.
    Chuma, J., Maina, T.: Catastrophic health care spending and impoverishment in Kenya. BMC. Health. Serv. Res. 12, 413 (2012)Google Scholar
  14. 14.
    Knaul, F.M., Wong, R., Arreola-Ornelas, H., Méndez, O., Bitran, R., Campino, A.C., Flórez Nieto, C.E., Giedion, U., Maceira, D., Rathe, M.: Household catastrophic health expenditures: a comparative analysis of twelve Latin American and Caribbean Countries. Salud. Publica. Mex. 53(Suppl 2), 85–95 (2011)Google Scholar
  15. 15.
    Boing, A.C., Bertoldi, A.D., Barros, A.J., Posenato, L.G., Peres, K.G.: Socioeconomic inequality in catastrophic health expenditure in Brazil. Rev. Saude. Publica. 48(4), 632–641 (2014)Google Scholar
  16. 16.
    Kronenberg, C., Barros, P.P.: Catastrophic healthcare expenditure—drivers and protection: the Portuguese case. Health. Policy. 115(1), 44–51 (2014)Google Scholar
  17. 17.
    Grigorakis, N., Floros, C., Tsangari, H., Tsoukatos, E.: Out of pocket payments and social health insurance for private hospital care: evidence from Greece. Health. Policy. 120(8), 948–959 (2016)Google Scholar
  18. 18.
    Xu, K., Evans, D.B., Kawabata, K., Zeramdini, R., Klavus, J., Murray, C.J.: Household catastrophic health expenditure: a multicountry analysis. Lancet 362(9378), 111–117 (2003)Google Scholar
  19. 19.
    Xu, K., Evans, D.B., Carrin, G., Aguilar-Rivera, A.M., Musgrove, P., Evans, T.: Protecting households from catastrophic health spending. Health. Aff. 26(4), 972–983 (2007). (Millwood)Google Scholar
  20. 20.
    Brown, M.L., Yabroff, K.R.: Economic impact of cancer in the United States. In: Schottenfeld, D., Faumeni, J. (eds.) Cancer epidemiology and prevention, pp. 202–214. Oxford University Press, New York (2006)Google Scholar
  21. 21.
    Pisu, M., Azuero, A., McNees, P., Burkhardt, J., Benz, R., Meneses, K.: The out of pocket cost of breast cancer survivors: a review. J. Cancer. Surviv. 4(3), 202–209 (2010)Google Scholar
  22. 22.
    Jan, S., Lee, S.W., Sawhney, J.P., Ong, T.K., Chin, C.T., Kim, H.S., Krittayaphong, R., Nhan, V.T., Itoh, Y., Huo, Y.: Catastrophic health expenditure on acute coronary events in Asia: a prospective study. Bull. World. Health. Organ. 94(3), 193–200 (2016)Google Scholar
  23. 23.
    Negin, J., Randell, M., Raban, M.Z., Nyirenda, M., Kalula, S., Madurai, L., Kowal, P.: Health expenditure and catastrophic spending among older adults living with HIV. Glob. Public. Health. 12(10), 1–15 (2016)Google Scholar
  24. 24.
    Xin, X.-X., Guan, X.-D., Shi, L.-W.: Catastrophic expenditure and impoverishment of patients affected by 7 rare diseases in China. Orphanet. J. Rare. Dis. 11(1), 74 (2016)Google Scholar
  25. 25.
    Kien, V.D., Van Minh, H., Giang, K.B., Dao, A., Ng, N.: Socioeconomic inequalities in catastrophic health expenditure and impoverishment associated with non-communicable diseases in urban Hanoi, Vietnam. Int. J. Equity. Health. 15(1), 169 (2016)Google Scholar
  26. 26.
    Choi, J.W., Cho, K.H., Choi, Y., Han, K.T., Kwon, J.A., Park, E.C.: Changes in economic status of households associated with catastrophic health expenditures for cancer in South Korea. Asian. Pac. J. Cancer. Prev. 15(6), 2713–2717 (2014)Google Scholar
  27. 27.
    Brinda, E.M., Kowal, P., Attermann, J., Enemark, U.: Health service use, out-of-pocket payments and catastrophic health expenditure among older people in India: the WHO Study on global AGEing and adult health (SAGE). J. Epidemiol. Community. Health. 69(5), 489–494 (2015)Google Scholar
  28. 28.
    Choi, J.W., Choi, J.W., Kim, J.H., Yoo, K.B., Park, E.C.: Association between chronic disease and catastrophic health expenditure in Korea. BMC. Health. Serv. Res. 15, 26 (2015). Google Scholar
  29. 29.
    Htet, S., Alam, K., Mahal, A.: Economic burden of chronic conditions among households in Myanmar: the case of angina and asthma. Health. Policy. Plan. 30(9), 1173–1183 (2015)Google Scholar
  30. 30.
    Wang, Z., Li, X., Chen, M.: Catastrophic health expenditures and its inequality in elderly households with chronic disease patients in China. Int. J. Equity. Health. 14, 8 (2015)Google Scholar
  31. 31.
    Arsenijevic, J., Pavlova, M., Rechel, B., Groot, W.: Catastrophic health care expenditure among older people with chronic diseases in 15 European countries. PloS. One. 11(7), e0157765 (2016)Google Scholar
  32. 32.
    Lee, J.E., Shin, H.I., Do, Y.K., Yang, E.J.: Catastrophic health expenditures for households with disabled members: evidence from the Korean health panel. J. Korean. Med. Sci. 31(3), 336–344 (2016)Google Scholar
  33. 33.
    Choi, J.W., Shin, J.Y., Cho, K.H., Nam, J.Y., Kim, J.Y., Lee, S.G.: Medical security and catastrophic health expenditures among households containing persons with disabilities in Korea: a longitudinal population-based study. Int. J. Equity. Health. 15(1), 119 (2016)Google Scholar
  34. 34.
    Muir, T.: Measuring social protection for long-term care. OECD Health Working Papers 93: (2017)Google Scholar
  35. 35.
    Del Pozo-Rubio, R., Pardo-Garcia, I., Escribano-Sotos, F.: The co-payment of the dependence from the structural reform of 2012 in Spain. Gac. Sanit. 31(1), 23–29 (2017)Google Scholar
  36. 36.
    Del Pozo Rubio, R., Escribano Sotos, F., Moya Martínez, P., Mínguez Salido, P., Pardo García, I.: El copago en dependencia en el actual contexto socioeconómico: ¿carácter recaudador y eficiente o factor de riesgo de empobrecimiento de las familias? Comunicación en las XXXV Jornadas de AES; 18 junio 2015; Granada, España. (2015)Google Scholar
  37. 37.
    National Statistics Institute of Spain: Spanish Disability and Dependency Survey 2008. Methodology (2008). Available in
  38. 38.
    Official Bulletin State: Act 39/2006 of 14th December on Promotion of personal autonomy and assistance for persons in a situation of dependency (2006)Google Scholar
  39. 39.
    Tomini, S.M., Packard, T.G., Tomini, F.: Catastrophic and impoverishing effects of out-of-pocket payments for health care in Albania: evidence from Albania Living Standards Measurement Surveys 2002, 2005 and 2008. Health. Policy. Plan. 28(4), 419–428 (2012)Google Scholar
  40. 40.
    Stiglitz, J.E.: Economics of the public sector. WW Norton & Company Ltd., New York (2000)Google Scholar
  41. 41.
    Fahrmeir, L., Kneib, T., Lang, S., Marx, B.: Regression: models, methods and applications. Springer, Berlin (2013)Google Scholar
  42. 42.
    Wooldridge, J.M.: Econometric analysis of cross section and panel data. The MIT Press, Cambridge (2010)Google Scholar
  43. 43.
    Angrist, J.D., Pischke, J.S.: Mostly harmless econometrics: an empiricist’s companion. Princeton University Press, New Jersey (2008)Google Scholar
  44. 44.
    Long, J.S., Freese, J.: Regression models for categorical dependent variables using Stata, 2nd edn. Stata Press, College Station (2006)Google Scholar
  45. 45.
    Williams, R.: Generalized ordered logit/partial proportional odds models for ordinal dependent variables. Stata. J. 6(1), 58 (2006)Google Scholar
  46. 46.
    García-Gómez, P., Hernández-Quevedo, C., Jiménez-Rubio, D., Oliva-Moreno, J.: Inequity in long-term care use and unmet need: two sides of the same coin. J. Health. Econ. 39, 147–158 (2015)Google Scholar
  47. 47.
    Hernandez Quevedo, C., Jimenez Rubio, D.: Inequity in the use of health and social care services for disabled individuals in Spain. Gac. Sanit. 25(Suppl 2(5), 85–92 (2011)Google Scholar
  48. 48.
    Del Pozo-Rubio, R., Escribano-Sotos, F.: Coste agregado e individual esperado de la Ley de Dependencia en España a partir de los modelos de simulación de Monte Carlo y Multi-Estado de Discapacidad. Hacienda. Pública. Esp. 204, 85–110 (2013)Google Scholar
  49. 49.
    National Institute of Statistics of Spain: Demography and Society. Statistics of the Continuous Census (2018)Google Scholar
  50. 50.
    Abellán García, A., Esparza Catalán, C., Pérez Díaz, J.: Evolución y estructura de la población en situación de dependencia/Evolution and structure of dependent people. Cuadernos. de. Relaciones. Laborales. 29(1), 43 (2011)Google Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Economics and FinanceUniversity of Castilla-La ManchaCuencaSpain
  2. 2.Department of Public Economy, Statistics and Economic PolicyUniversity of Castilla-La ManchaCuencaSpain
  3. 3.Department of Public Economy, Statistics and Economic PolicyUniversity of Castilla-La ManchaAlbaceteSpain
  4. 4.Department of Economics and FinanceUniversity of Castilla-La ManchaAlbaceteSpain
  5. 5.Research Group Economy, Food and SocietyUniversity of Castilla-La ManchaCiudad RealSpain

Personalised recommendations