{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,19]],"date-time":"2026-08-19T19:26:58Z","timestamp":1787167618533,"version":"build-2736575974"},"reference-count":37,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2024,3,12]],"date-time":"2024-03-12T00:00:00Z","timestamp":1710201600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2024,3,12]],"date-time":"2024-03-12T00:00:00Z","timestamp":1710201600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"name":"National Institute for Health Research (NIHR) Global Health Research Unit on Respiratory Health","award":["AC19040"],"award-info":[{"award-number":["AC19040"]}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Health Serv Res"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>In Malaysia, asthma is a common chronic respiratory illness. Poor asthma control may increase out-of-pocket payment for asthma care, leading to financial hardships Malaysia provides Universal Health Coverage for the population with low user fees in the public health system to reduce financial hardship. We aimed to determine out-of-pocket expenditure on outpatient care for adult patients with asthma visiting government-funded public health clinics. We examined the catastrophic impact and medical impoverishment of these expenses on patients and households in Klang District, Malaysia.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This is a cross-sectional face-to-face questionnaire survey carried out in six government-funded public health clinics in Klang District, Malaysia. We collected demographic, socio-economic profile, and outpatient asthma-related out-of-pocket payments from 1003 adult patients between July 2019 and January 2020. Incidence of catastrophic health expenditure was estimated as the proportion of patients whose monthly out-of-pocket payments exceeded 10% of their monthly household income. Incidence of poverty was calculated as the proportion of patients whose monthly household income fell below the poverty line stratified for the population of the Klang District. The incidence of medical impoverishment was estimated by the change in the incidence of poverty after out-of-pocket payments were deducted from household income. Predictors of catastrophic health expenditure were determined using multivariate regression analysis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>We found the majority (80%) of the public health clinic attendees were from low-income groups, with 41.6% of households living below the poverty line. About two-thirds of the attendees reported personal savings as the main source of health payment. The cost of transportation and complementary-alternative medicine for asthma were the main costs incurred. The incidences of catastrophic expenditure and impoverishment were 1.69% and 0.34% respectively. The only significant predictor of catastrophic health expenditure was household income. Patients in the higher income quintiles (Q2, Q3, Q4) had lower odds of catastrophic risk than the lowest quintile (Q1). Age, gender, ethnicity, and poor asthma control were not significant predictors.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>The public health system in Malaysia provides financial risk protection for adult patients with asthma. Although patients benefited from the heavily subsidised public health services, this study highlighted those in the lowest income quintile still experienced financial catastrophe and impoverishment, and the risk of financial catastrophe was significantly greater in this group. It is crucial to ensure health equity and protect patients of low socio-economic groups from financial hardship.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12913-024-10731-8","type":"journal-article","created":{"date-parts":[[2024,3,12]],"date-time":"2024-03-12T14:02:11Z","timestamp":1710252131000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["Assessing catastrophic health expenditure and impoverishment in adult asthma care: a cross-sectional study of patients attending six public health clinics in Klang District, Malaysia"],"prefix":"10.1186","volume":"24","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9610-467X","authenticated-orcid":false,"given":"Norita","family":"Hussein","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chiu Wan","family":"Ng","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rizawati","family":"Ramli","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Su May","family":"Liew","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nik Sherina","family":"Hanafi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ping Yein","family":"Lee","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ai Theng","family":"Cheong","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sazlina Shariff","family":"Ghazali","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hilary","family":"Pinnock","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew","family":"Stoddart","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J\u00fcrgen","family":"Schwarze","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ee Ming","family":"Khoo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2024,3,12]]},"reference":[{"issue":"12","key":"10731_CR1","doi-asserted-by":"publisher","first-page":"204","DOI":"10.1186\/1471-2458-12-204","volume":"19","author":"T To","year":"2012","unstructured":"To T, Stanojevic S, Moores G, Gershon AS, Bateman ED, Cruz AA, Boulet LP. Global asthma prevalence in adults: findings from the cross-sectional world health survey. BMC Public Health. 2012;19(12):204.","journal-title":"BMC Public Health"},{"issue":"1","key":"10731_CR2","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/1471-2466-9-24","volume":"9","author":"K Bahadori","year":"2009","unstructured":"Bahadori K, Doyle-Waters MM, Marra C, et al. Economic burden of asthma: a systematic review. BMC Pulm Med. 2009;9(1):1\u201316.","journal-title":"BMC Pulm Med"},{"key":"10731_CR3","doi-asserted-by":"crossref","unstructured":"Chan YY, Teh CH, Lim KK et al. Lifestyle, chronic diseases and self-rated health among Malaysian adults: results from the 2011 National Health and Morbidity Survey (NHMS). BMC Public Health. 2015;15(1).","DOI":"10.1186\/s12889-015-2080-z"},{"key":"10731_CR4","unstructured":"NHMS. 2002. https:\/\/iku.moh.gov.my\/images\/IKU\/Document\/REPORT\/2006\/Asthma.pdf (accessed 12 October 2020)."},{"issue":"5","key":"10731_CR5","doi-asserted-by":"publisher","first-page":"e1021","DOI":"10.1002\/hsr2.1021","volume":"6","author":"N Hussein","year":"2023","unstructured":"Hussein N, Liew SM, Hanafi NS, Lee PY, Cheong AT, Ghazali SS, Chinna K, Pang YK, Kassim A, Parker RA, Schwarze J, Sheikh A, Pinnock H, Khoo EM, RESPIRE Collaborators. Asthma control and care among six public health clinic attenders in Malaysia: a cross-sectional study. Health Sci Rep. 2023;6(5):e1021.","journal-title":"Health Sci Rep"},{"issue":"3","key":"10731_CR6","first-page":"600","volume":"33","author":"PWK Chan","year":"2002","unstructured":"Chan PWK, Hussain S, Ghani NH, Debruyne JA, Liam CK. The direct cost of treating bronchial asthma in a teaching hospital in Malaysia. Southeast Asian J Trop Med Public Health. 2002;33(3):600\u20133.","journal-title":"Southeast Asian J Trop Med Public Health"},{"key":"10731_CR7","doi-asserted-by":"publisher","first-page":"6","DOI":"10.1016\/j.vhri.2017.05.001","volume":"15","author":"YV Yong","year":"2018","unstructured":"Yong YV, Shafie AA. How much does management of an asthma-related event cost in a Malaysian suburban hospital? Value Health Reg Issues. 2018;15:6\u201311.","journal-title":"Value Health Reg Issues"},{"key":"10731_CR8","unstructured":"https:\/\/www.who.int\/data\/gho\/indicator-metadata-registry\/imr-details\/107 (accessed 12 May 2021)."},{"issue":"12","key":"10731_CR9","doi-asserted-by":"publisher","first-page":"e0279212","DOI":"10.1371\/journal.pone.0279212","volume":"17","author":"S Rai","year":"2022","unstructured":"Rai S, Gautam S, Yadav GK, Niraula SR, Singh SB, Rai R, Poudel S, Sah RB. Catastrophic health expenditure on chronic non-communicable diseases among elder population: a cross-sectional study from a sub-metropolitan city of Eastern Nepal. PLoS ONE. 2022;17(12):e0279212.","journal-title":"PLoS ONE"},{"key":"10731_CR10","volume-title":"Monitoring health for the SDGs, Sustainable Development Goals","author":"World health statistics 2017","year":"2017","unstructured":"World health statistics 2017. Monitoring health for the SDGs, Sustainable Development Goals. Geneva: World Health Organization; 2017."},{"key":"10731_CR11","unstructured":"Ng CW, Hairi NN, Ng CJ, Kamarulzaman A. Universal Health Coverage in Malaysia: Issues and Challenges (2014)."},{"key":"10731_CR12","unstructured":"Department of Statistics Malaysia. Household Income and Basic Amenities Survey Report 2019. 2020;3\u201357. Available from: https:\/\/www.dosm.gov.my\/v1\/index(accessed 9 May 2021)."},{"key":"10731_CR13","unstructured":"Hwong WY, Sivasampu S, Aisyah A, Shantha Kumar C, Goh PP, Hisham AN. National Healthcare Establishment & Workforce Statistics (primary care). National Clinical Research Centre; 2012."},{"key":"10731_CR14","doi-asserted-by":"publisher","first-page":"e4","DOI":"10.1017\/S146342362000002X","volume":"21","author":"F Fadzil","year":"2020","unstructured":"Fadzil F, Jaafar S, Ismail R. 40 years of Alma Ata Malaysia: targeting equitable access through organisational and physical adaptations in the delivery of public sector primary care. Prim Health Care Res Dev. 2020;21:e4.","journal-title":"Prim Health Care Res Dev"},{"issue":"6","key":"10731_CR15","doi-asserted-by":"publisher","first-page":"2078","DOI":"10.1111\/hex.13352","volume":"24","author":"WM Koh","year":"2021","unstructured":"Koh WM, Abu Bakar AI, Hussein N, et al. Sociocultural influences on asthma self-management in a multicultural society: a qualitative study amongst Malaysian adults. Health Expect. 2021;24(6):2078\u201386.","journal-title":"Health Expect"},{"issue":"1","key":"10731_CR16","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1038\/s41533-019-0118-x","volume":"29","author":"SN Ramdzan","year":"2019","unstructured":"Ramdzan SN, Pinnock H, Liew SM, et al. Perceptions of complementary\/alternative medicine use and influence on evidence-based asthma medicine adherence in Malaysian children. npj Prim Care Respir Med. 2019;29(1):1\u20137.","journal-title":"npj Prim Care Respir Med"},{"key":"10731_CR17","unstructured":"National Health and Morbidity Survey (NHMS). 2011. Available from: https:\/\/iku.moh.gov.my\/images\/IKU\/Document\/REPORT\/NHMS2011 (accessed 12 Jan 2022)."},{"issue":"1","key":"10731_CR18","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s12916-017-0823-7","volume":"15","author":"H Pinnock","year":"2017","unstructured":"Pinnock H, Parke HL, Panagioti M, et al. Systematic meta-review of supported self-management for asthma: a healthcare perspective. BMC Med. 2017;15(1):1\u201332.","journal-title":"BMC Med"},{"key":"10731_CR19","unstructured":"National Health and Morbidity Survey (NHMS). 2019: Non-communicable diseases, healthcare demand, and health literacy\u2014Key Findings. 2020. Available from: http:\/\/iku.gov.my\/images\/IKU\/Document\/REPORT\/NHMS2019\/NHMS2019Infographic.pdf (accessed 12 May 2021)."},{"key":"10731_CR20","unstructured":"Global Strategy for Asthma Management and Prevention Updated. 2020. Accessed May 12, 2021. www.ginasthma.org."},{"key":"10731_CR21","unstructured":"World Development Indicators. The World Bank. 2019. Available from: https:\/\/data.worldbank.org\/indicator\/PA.NUS.FCRF?locations=MY."},{"key":"10731_CR22","unstructured":"Merlis M. Family out-of-pocket spending for health services: a continuing source of financial insecurity. Commonw Fund. 2002;(509):4\u201315."},{"key":"10731_CR23","unstructured":"O\u2019Donnell O, van Doorslaer E, Wagstaff A, Lindelow M. 2008. Analyzing health equity using household survey data: A guide to techniques and their implementation: Catastrophic Payments in Health Care. World Bank Publications. 2008; 203\u2013212. Available from: https:\/\/openknowledge.worldbank.org\/handle\/10986\/6896."},{"key":"10731_CR24","unstructured":"The World Bank. Available from: https:\/\/datahelpdesk.worldbank.org\/knowledgebase\/articles\/1986160-what-are-quintiles."},{"key":"10731_CR25","unstructured":"World Health Organization. Available from: https:\/\/www.who.int\/health-topics\/financial-protection."},{"issue":"2","key":"10731_CR26","doi-asserted-by":"publisher","first-page":"e0264422","DOI":"10.1371\/journal.pone.0264422","volume":"17","author":"M Sayuti","year":"2022","unstructured":"Sayuti M, Sukeri S. Assessing progress towards sustainable development goal 3.8.2 and determinants of catastrophic health expenditures in Malaysia. PLoS ONE. 2022;17(2):e0264422.","journal-title":"PLoS ONE"},{"key":"10731_CR27","doi-asserted-by":"publisher","first-page":"e0172229","DOI":"10.1371\/journal.pone.0172229","volume":"12","author":"HM Lim","year":"2017","unstructured":"Lim HM, Sivasampu S, Khoo EM, Mohamad Noh K. Chasm in primary care provision in a universal health system: findings from a nationally representative survey of health facilities in Malaysia. PLoS ONE. 2017;12:e0172229.","journal-title":"PLoS ONE"},{"key":"10731_CR28","doi-asserted-by":"publisher","first-page":"115","DOI":"10.4103\/1817-1737.82438","volume":"6","author":"MA Alshagga","year":"2011","unstructured":"Alshagga MA, Al-Dubai SA, Muhamad Faiq SS, Yusuf AA. Use of complementary and alternative medicine among asthmatic patients in primary care clinics in Malaysia. Annals Thorac Med. 2011;6:115\u20139.","journal-title":"Annals Thorac Med"},{"key":"10731_CR29","doi-asserted-by":"publisher","first-page":"e032303","DOI":"10.1136\/bmjopen-2019-032303","volume":"10","author":"TTM Kieu","year":"2020","unstructured":"Kieu TTM, Trinh HN, Pham HTK. Et alDirect non-medical and indirect costs of diabetes and its associated complications in Vietnam: an estimation using national health insurance claims from a cross-sectional. surveyBMJ Open. 2020;10:e032303.","journal-title":"surveyBMJ Open"},{"key":"10731_CR30","unstructured":"Ibrahim N, Pozo-Martin F, Gilbert C. Direct non-medical costs double the total direct costs to patients undergoing cataract surgery in Zamfara state, Northern Nigeria: a case series. BMC Health Serv Res 2005; 163."},{"key":"10731_CR31","first-page":"e000434","volume":"2","author":"MG Shrime","year":"2017","unstructured":"Shrime MG, Hamer M, Mukhopadhyay S, et al. Effect of removing the barrier of transportation costs on surgical utilisation in Guinea, Madagascar, and the Republic of CongoBMJ. Global Health. 2017;2:e000434.","journal-title":"Global Health"},{"issue":"5","key":"10731_CR32","doi-asserted-by":"publisher","first-page":"976","DOI":"10.1007\/s10900-013-9681-1","volume":"38","author":"ST Syed","year":"2013","unstructured":"Syed ST, Gerber BS, Sharp LK. Traveling towards disease: transportation barriers to health care access. J Community Health. 2013;38(5):976\u201393.","journal-title":"J Community Health"},{"key":"10731_CR33","doi-asserted-by":"publisher","first-page":"1159","DOI":"10.1002\/hec.1209","volume":"16","author":"E Van Doorslaer","year":"2007","unstructured":"Van Doorslaer E, O\u2019Donnell O, Rannan-Eliya RP, et al. Catastrophic payments for health care in Asia. Health Econ. 2007;16:1159\u201384.","journal-title":"Health Econ"},{"key":"10731_CR34","unstructured":"World Development Indicators.: Data by Country, Malaysia. The World Bank. Available from: https:\/\/databank.worldbank.org\/source\/world-development-indicators."},{"key":"10731_CR35","doi-asserted-by":"crossref","first-page":"1","DOI":"10.3402\/gha.v5i0.18892","volume":"5","author":"H Van Minh","year":"2012","unstructured":"Van Minh H, Xuan Tran B. Assessing the household financial burden associated with the chronic non-communicable diseases in a rural district of Vietnam. Glob Health Action. 2012;5:1\u20137.","journal-title":"Glob Health Action"},{"issue":"1","key":"10731_CR36","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s12913-014-0675-1","volume":"15","author":"JW Choi","year":"2015","unstructured":"Choi JW, Choi JW, Kim JH, Yoo KB, Park EC. Association between chronic disease and catastrophic health expenditure in Korea. BMC Health Serv Res. 2015;15(1):1\u20138.","journal-title":"BMC Health Serv Res"},{"key":"10731_CR37","unstructured":"Lo Ying Ru J, Allotey P. World Health Day 2018\u2013 Lessons from Malaysia on Universal Health Coverage. World Health Organisation. 2018. Available from: https:\/\/www.who.int\/malaysia\/news\/commentaries\/detail\/world-health-day-lessons-from-malaysia-on-universal-health-coverage."}],"container-title":["BMC Health Services Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12913-024-10731-8.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12913-024-10731-8\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12913-024-10731-8.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,3,12]],"date-time":"2024-03-12T14:04:45Z","timestamp":1710252285000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmchealthservres.biomedcentral.com\/articles\/10.1186\/s12913-024-10731-8"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,3,12]]},"references-count":37,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2024,12]]}},"alternative-id":["10731"],"URL":"https:\/\/doi.org\/10.1186\/s12913-024-10731-8","relation":{},"ISSN":["1472-6963"],"issn-type":[{"value":"1472-6963","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,3,12]]},"assertion":[{"value":"25 January 2023","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"15 February 2024","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"12 March 2024","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Ethical approval was obtained from the National Medical Research Ethics Committee, Ministry of Health, Malaysia (NMRR-18-2707-42719) and the sponsor, the Academic and Clinical Central Office for Research and Development, University of Edinburgh, United Kingdom (AC19040). A written informed consent was obtained from all adult patients upon recruitment. All methods in this study were performed in accordance with guidelines and regulations as stated in Good Clinical Practice.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Consent to publish was obtained from the participants of this study to publish de-identified data.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"Authors EMK, PYL, ATC and HP declare no competing non-financial interest but the following competing financial interests: grants from the National Institute for Health Research (NIHR) Global Health Research Unit on Respiratory Health (RESPIRE). EMK reports personal fees from AstraZeneca; and is the President of the International Primary Care Respiratory Group and the Primary Care Respiratory Group Malaysia. All other authors declare no competing financial or non-financial interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"327"}}