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Blog Post

Uncovering the Financial Risk of Primary Care in Low- and Lower-Middle Income Countries

Screenshot BMC Medicine


In global health, one of the most crucial goals is to ensure that every individual can access the services they need without suffering financial hardship. This concept, known as financial risk protection, is a cornerstone of universal health coverage (UHC). Yet, in many low- and lower-middle-income countries (LMICs), the dream of UHC remains elusive, as households grapple with high out-of-pocket (OOP) costs for essential health services. In 2018, OOP health spending accounted for 40% of current health expenditures in these countries.

A recent research article titled "Financial hardship associated with catastrophic out‑of‑pocket spending tied to primary care services in low and lower‑middle‑income countries: findings from a modeling study" delves deep into this issue. In this blog post, we'll explore why this article is not only relevant but crucial for policymakers in LMICs.

Understanding Catastrophic Health Expenditures

The study investigates the risk of catastrophic health expenditure (CHE) in 34 low-income and lower-middle-income countries. CHE is defined as OOP health spending that exceeds a threshold percentage of annual income, commonly 10%. To make this assessment, the researchers looked at 29 primary care health services across 13 disease categories, ranging from diarrheal to cardiovascular diseases.

The Alarming Impact on Vulnerable Populations

Across all the countries, diseases, and health services studied, the risk of CHE was found to be disproportionately concentrated among the poorest quintiles of the population. For instance, for a 10% CHE threshold, the risk stood at 6.8% for the lowest income quintile, in stark contrast to just 1.3% for the highest quintile.

Variations in Risk Across Diseases

The study also revealed variations in CHE risk across different disease areas. Diseases like cardiovascular disease and mental/behavioral disorders posed a much higher risk, at 7.8% and 9.8% respectively, using the same 10% threshold. Conversely, lower-cost services exhibited lower risks of CHE.

The Implications for Policymakers

Insufficient financial risk protection is a formidable barrier to achieving UHC, and catastrophic health expenditures are a pressing issue for health systems in LMICs. Beyond the immediate financial strain on households, CHE can also lead to worse health outcomes, especially among the poorest, for whom the risk of illness and financial hardship are most severe. So, what can policymakers do with this knowledge?

  1. Progressive Health Sector Priorities: By modeling the risk of CHE associated with specific disease areas and services, policymakers can make more informed decisions about resource allocation. They can prioritize interventions that not only improve health outcomes but also protect the most vulnerable from financial hardship.
  2. Expanding Essential Health Benefit Packages: Decision-makers can explicitly incorporate financial risk protection as a criterion when deciding which health interventions to include in national essential health benefit packages. This move can go a long way in shielding households from the crippling effects of unexpected healthcare costs.


In the world of health economics, the link between financial hardship and health outcomes is an area of paramount importance. This research article shines a spotlight on the financial dangers faced by individuals seeking primary care services in LMICs. It underscores the urgent need for policymakers to consider not only the clinical effectiveness of interventions but also their potential to provide financial security to those who need it most.

As these findings become part of the conversation among policymakers, there is hope that progress can be made towards a future where healthcare is not just accessible but also financially sustainable for all, regardless of their economic status. In doing so, we can take a significant step closer to the realization of UHC.