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

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.