The socioeconomic and health system determinants of financial protection indicators: a global systematic review (2008-2023).

Introduction: To ensure financial protection (FP), a key component of achieving Universal Health Coverage, it is important to identify the most vulnerable populations to financial hardship; however, systematic evidence of the determinants of FP is lacking, especially regarding the ability of FP indicators to identify the most vulnerable populations.

Methods: We searched three English (Web of Science, Medline and Embase) and four Chinese (CNKI, Wanfang, VIP and SinoMed) language databases for articles published between 1 January 2008 and 13 September 13, 2023. Eligible studies reported associations between a socioeconomic and/or health system determinant and either catastrophic (CHE) or impoverishing health expenditures (IHE). Joanna-Briggs Institute Checklist for Analytical Cross-sectional Studies was used to assess study quality. Key patterns in the associations between determinants and FP outcomes were summarised descriptively (PROSPERO ID: 585024).

Results: We identified 52 842 potentially eligible studies, of which 85 studies, or 1 308 separate associations between a determinant and a FP outcome, were included in the review, covering all WHO regions. Some clear patterns were identified: households in rural areas, with older members, lacking private insurance, or with inpatient or outpatient care utilisation experienced a higher risk of CHE and IHE. Smaller households, or those lacking any form of health insurance, and lower income were also at higher risk, although the associations were less certain. The incidence of financial hardship was generally higher among the general versus poorer segments of the population. The capacity-to-pay CHE indicator reported a lower CHE incidence among the poor than the budget-share indicator. There was insufficient evidence on IHE, race, assets, wealth or private health insurance.

Conclusion: Only a small number of determinants were consistently associated with poor FP outcomes, and FP indicators inadequately captured financial hardship among the poor. Better FP indicators are needed to adequately identify households most at risk of experiencing financial hardship.