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Measurement of Catastrophic Health Expenditure in India: A Systematic Review and Meta-Analysis

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Abstract

Introduction

The escalating burden of catastrophic health expenditure (CHE) poses a significant threat to individuals and households in India, where out-of-pocket expenditure (OOP) constitutes a substantial portion of healthcare financing. With rising OOP in India, a proper measurement to track and monitor CHE due to health expenditure is of utmost important. This study focuses on synthesizing findings, understanding measurement variations, and estimating the pooled incidence of CHE by health services, reported diseases, and survey types.

Method

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a thorough search strategy was employed across multiple databases, between 2010 and 2023. Inclusion criteria encompassed observational or interventional studies reporting CHE incidence, while exclusion criteria screened out studies with unclear definitions, pharmacy revenue-based spending, or non-representative health facility surveys. A meta-analysis, utilizing a random-effects model, assessed the pooled CHE incidence. Sensitivity analysis and subgroup analyses were conducted to explore heterogeneity.

Results

Out of 501 initially relevant articles, 36 studies met inclusion criteria. The review identified significant variations in CHE measurements, with incidence ranging from 5.1% to 69.9%. Meta-analysis indicated the estimated incidence of CHE at a 10% threshold is 0.30 [0.25–0.35], indicating a significant prevalence of financial hardship due to health expenses. The pooled incidence is estimated by considering different sub-groups. No statistical differences were found between inpatient and outpatient CHE. However, disease-specific estimates were significantly higher (52%) compared to combined diseases (21%). Notably, surveys focusing on health reported higher CHE (33%) than consumption surveys (14%).

Discussion

The study highlights the intricate challenges in measuring CHE, emphasizing variations in recall periods, components considered in out-of-pocket expenditure, and diverse methods for defining capacity to pay. Notably, the findings underscore the need for standardized definitions and measurements across studies. The lack of uniformity in reporting exacerbates the challenge of comparing and comprehensively understanding the financial burden on households.

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Acknowledgements

The team mentioned in the Methods section consists of three independent reviewers, Umenthla Srikanth Reddy, Adrita Banerjee, and Tapasya Raj, who extracted papers and data from the selected papers. The authors acknowledge the contribution of Adrita Banerjee, Tapasya Raj and Shreya Singh in editing the manuscript and providing valuable feedback. The author also acknowledges the journal editor for meticulously reviewing the manuscript, as well as the anonymous reviewers for their valuable suggestions and feedback.

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  1. International Institute for Population Sciences (IIPS), Mumbai, India

    Umenthala Srikanth Reddy

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Correspondence to Umenthala Srikanth Reddy.

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No funding has been received for the study; the paper is a part of PhD thesis.

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Ethical approval for this type of study is not required by our institute.

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Reflexivity statement

The author is a PhD student, this work is a part of his thesis. The author has an understanding and experience of health financing in India.

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USR has conceptualised and designed the work. USR has collected the data and did analysis. Interpretation of the results were done by USR under the guidance of Prof. K.S. James (PhD supervisor). All the results were discussed with USR’s supervisor. The paper was drafted by USR. The critical revision was done by USR.

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Reddy, U.S. Measurement of Catastrophic Health Expenditure in India: A Systematic Review and Meta-Analysis. Appl Health Econ Health Policy 22, 471–483 (2024). https://doi.org/10.1007/s40258-024-00885-1

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