Examining the responsiveness of the National Health Insurance Fund to people living with hypertension and diabetes in Kenya: a qualitative study.

OBJECTIVES: To assess the responsiveness of the National Health Insurance Fund (NHIF) Supa Cover benefit package to the needs of individuals with diabetes and hypertension in Kenya. DESIGN, SETTING AND PARTICIPANTS: We carried out a qualitative study and collected data using key informant interviews (n=39) and focus group discussions (n=4) in two purposively selected counties in Western Kenya. Study participants were drawn from NHIF officials, county government officials, health facility managers, healthcare workers and individuals with hypertension and diabetes who were enrolled in NHIF. We analysed data using a thematic approach. RESULTS: Study participants reported that the NHIF Supa Cover benefit package expanded access to services for people living with hypertension and diabetes. However, the NHIF members and healthcare workers had inadequate awareness of the NHIF service entitlements. The NHIF benefit package inadequately covered the range of services needed by people living with hypertension and diabetes and the benefits package did not prioritise preventive and promotive services. Sometimes patients were discriminated against by healthcare providers who preferred cash-paying patients, and some NHIF-empanelled health facilities had inadequate structural inputs essential for quality of care. Study participants felt that the NHIF premium for the general scheme was unaffordable, and NHIF members faced additional out-of-pocket costs because of additional payments for services not available or covered. CONCLUSION: Whereas NHIF has reduced financial barriers for hypertension and diabetes patients, to enhance its responsiveness to patient needs, NHIF should implement mechanisms to increase benefit package awareness among members and providers. In addition, preventive and promotive services should be included in NHIF's benefits package and mechanisms to monitor and hold contracted providers accountable should be strengthened.

Assessing the barriers and facilitators of access to diabetic retinopathy screening in sub- Saharan Africa: a literature review.

Diabetic retinopathy (DR) is the leading cause of blindness in working age adults. An increase in visual loss has been projected for sub-Saharan Africa (SSA) with the diabetes epidemic in the region. Screening is a cost-effective way to reduce this scourge, but adequate services are scarce. This review aims to evaluate the evidence on barriers and facilitators of access to DR screening with a view to making evidence-based recommendations for the development of effective and sustainable programmes in SSA. A systematic literature search of Africa-Wide Information, Embase, Cochrane library, Global Health, and Medline databases was done using diabetic retinopathy, screening, and Sub-Saharan Africa as concepts. Google Scholar was also searched to identify relevant literature. Studies were included if they were done in SSA and reported on barriers and/or facilitators of access to DR screening. The database search yielded 616 papers and google scholar yielded 9223 papers. Of these, 54 papers were assessed for eligibility and 18 met the inclusion criteria. These were appraised with appropriate checklists. Fourteen themes were synthesised. Most were supply challenges affecting all dimensions of access and the six components of the health systems building blocks. Several studies had poor methodologies, and this has implications for the evidence provided. The findings of this review show a weakness in the health systems suggesting this is the major indirect barrier to DR screening in SSA. Measures to strengthen the health system for DR screening is strongly recommended.

Evaluating the effectiveness of the National Health Insurance Fund in providing financial protection to households with hypertension and diabetes patients in Kenya.

BACKGROUND: Non-communicable diseases (NCDs) can impose a substantial financial burden to households in the absence of an effective financial risk protection mechanism. The national health insurance fund (NHIF) has included NCD services in its national scheme. We evaluated the effectiveness of NHIF in providing financial risk protection to households with persons living with hypertension and/or diabetes in Kenya. METHODS: We carried out a prospective cohort study, following 888 households with at least one individual living with hypertension and/or diabetes for 12 months. The exposure arm comprised households that are enrolled in the NHIF national scheme, while the control arm comprised households that were not enrolled in the NHIF. Study participants were drawn from two counties in Kenya. We used the incidence of catastrophic health expenditure (CHE) as the outcome of interest. We used coarsened exact matching and a conditional logistic regression model to analyse the odds of CHE among households enrolled in the NHIF compared with unenrolled households. Socioeconomic inequality in CHE was examined using concentration curves and indices. RESULTS: We found strong evidence that NHIF-enrolled households spent a lower share (12.4%) of their household budget on healthcare compared with unenrolled households (23.2%) (p = 0.004). While households that were enrolled in NHIF were less likely to incur CHE, we did not find strong evidence that they are better protected from CHE compared with households without NHIF (OR = 0.67; p = 0.47). The concentration index (CI) for CHE showed a pro-poor distribution (CI: -0.190, p < 0.001). Almost half (46.9%) of households reported active NHIF enrolment at baseline but this reduced to 10.9% after one year, indicating an NHIF attrition rate of 76.7%. The depth of NHIF cover (i.e., the share of out-of-pocket healthcare costs paid by NHIF) among households with active NHIF was 29.6%. CONCLUSION: We did not find strong evidence that the NHIF national scheme is effective in providing financial risk protection to households with individuals living with hypertension and/diabetes in Kenya. This could partly be explained by the low depth of cover of the NHIF national scheme, and the high attrition rate. To enhance NHIF effectiveness, there is a need to revise the NHIF benefit package to include essential hypertension and/diabetes services, review existing provider payment mechanisms to explicitly reimburse these services, and extend the existing insurance subsidy programme to include individuals in the informal labour market.

Comparing estimates of household expenditures between pictorial diaries and surveys in three low- and middle-income countries.

In most low- and middle-income countries (LMICs), household out-of-pocket (OOP) health spending constitutes a major source of healthcare financing. Household surveys are commonly used to monitor OOP health spending, but are prone to recall bias and unable to capture seasonal variation, and may underestimate expenditure-particularly among households with long-term chronic health conditions. Household expenditure diaries have been developed as an alternative to overcome the limitations of surveys, and pictorial diaries have been proposed where literacy levels may render traditional diary approaches inappropriate. This study compares estimates for general household and chronic healthcare expenditure in South Africa, Tanzania and Zimbabwe derived using survey and pictorial diary approaches. We selected a random sub-sample of 900 households across urban and rural communities participating in the Prospective Urban and Rural Epidemiology study. For a range of general and health-specific categories, OOP expenditure estimates use cross-sectional survey data collected via standardised questionnaire, and data from these same households collected via two-week pictorial diaries repeated four times over 2016-2019. In all countries, average monthly per capita expenditure on food, non-food/non-health items, health, and consequently, total household expenditure reported by pictorial diaries was consistently higher than that reported by surveys (each p<0.001). Differences were greatest for health expenditure. The share of total household expenditure allocated to health also differed by method, accounting for 2% in each country when using survey data, and from 8-20% when using diary data. Our findings suggest that the choice of data collection method may have significant implications for estimating OOP health spending and the burden it places on households. Despite several practical challenges to their implementation, pictorial diaries offer a method to assess potential bias in surveys or triangulate data from multiple sources. We offer some practical guidance when considering the use of pictorial diaries for estimating household expenditure.

Understanding the treatment burden of people with chronic conditions in Kenya: A cross-sectional analysis using the Patient Experience with Treatment and Self-Management (PETS) questionnaire.

In Kenya, non-communicable diseases (NCDs) are an increasingly important cause of morbidity and mortality, requiring both better access to health care services and self-care support. Evidence suggests that treatment burdens can negatively affect adherence to treatment and quality of life. In this study, we explored the treatment and self-management burden among people with NCDs in in two counties in Western Kenya. We conducted a cross-sectional survey of people newly diagnosed with diabetes and/or hypertension, using the Patient Experience with Treatment and Self-Management (PETS) instrument. A total of 301 people with diabetes and/or hypertension completed the survey (63% female, mean age = 57 years). They reported the highest treatment burdens in the domains of medical and health care expenses, monitoring health, exhaustion related to self-management, diet and exercise/physical therapy. Treatment burden scores differed by county, age, gender, education, income and number of chronic conditions. Younger respondents (<60 years) reported higher burden for medication side effects (p<0.05), diet (p<0.05), and medical appointments (p = 0.075). Those with no formal education or low income also reported higher burden for diet and for medical expenses. People with health insurance cover reported lower (albeit still comparatively high) burden for medical expenses compared to those without it. Our findings provide important insights for Kenya and similar settings where governments are working to achieve universal health coverage by highlighting the importance of financial protection not only to prevent the economic burden of seeking health care for chronic conditions but also to reduce the associated treatment burden.

Factors Influencing the Implementation of Remote Delivery Strategies for Non-Communicable Disease Care in Low- and Middle-Income Countries: A Narrative Review.

Objectives: The COVID-19 pandemic has disrupted health care for non-communicable diseases (NCDs) and necessitated strategies to minimize contact with facilities. We aimed to examine factors influencing implementation of remote (non-facility-based) delivery approaches for people with hypertension and/or diabetes in low- and middle-income countries (LMICs), to inform NCD care delivery during health service disruption, including humanitarian crises. Methods: Our narrative review used a hermeneutic and purposive approach, including primary studies conducted in LMICs, which assessed implementation factors influencing remote NCD care delivery. Results were analyzed using the Consolidated Framework for Implementation Research. Results: Twenty-eight included studies revealed the strong influence of both internal organizational and broader contextual factors, such as community health worker policies or technological environment. Addressing patients' specific characteristics, needs and resources was important for implementation success. Conclusion: This review highlighted the multiple, complex, interdependent factors influencing implementation of remote NCD care in LMICs. Our findings may inform actors designing NCD care delivery in contexts where facility-based access is challenging. Implementation research is needed to evaluate context-adapted e-Health, community-based, and simplified clinical management strategies to facilitate remote NCD care.

Implementation of fixed-dose combination therapy for secondary prevention of atherosclerotic cardiovascular disease among Syrian refugees in Lebanon: a qualitative evaluation.

BACKGROUND: We report findings of a qualitative evaluation of fixed-dose combination therapy for patients with established atherosclerotic cardiovascular disease (ASCVD) attending Médecins Sans Frontières (MSF) clinics in Lebanon. Cardiovascular disease is a leading cause of death and disability worldwide, and humanitarian actors are increasingly faced with the challenge of providing care for chronic diseases such as ASCVD in settings where health systems are disrupted. Secondary prevention strategies, involving 3-5 medications, are known to be effective for patients at risk of heart attack or stroke, but supply and adherence are challenging in humanitarian settings. Fixed dose combination therapy, combining two or more medications in one tablet, may be a strategy to address this. METHODS: The evaluation was nested within a prospective mixed-methods study in which eligible ASCVD patients were followed for 1 year during (i) 6 months of usual care then (ii) 6 months of fixed dose combination (FDC) therapy. After 1 year, we conducted in-depth interviews with a purposive sample of patients, MSF staff and external stakeholders. Interviews focused on acceptability and sustainability of the fixed dose therapy intervention. Interview data were analysed thematically, informed by thea Theoretical Framework of Acceptability. Additional attention was paid to non-typical cases in order to test and strengthen analysis. RESULTS: Patients and health care providers were positive about the FDC intervention. For patients, acceptability was related to ease of treatment and trust in MSF staff, while, for staff, it was related to perceived improvements in adherence, having a good understanding of the medication and its use, and fitting well with their priorities for patient's wellbeing. External stakeholders were less familiar with FDC therapy. While external clinicals expressed concerns about treatment inflexibility, non-clinician stakeholder interviews suggested that cost-effectiveness would have a major influence on FDC therapy acceptability. Sustainability was tied to the future role of MSF care provision and coherence with the local health system. CONCLUSIONS: For patients and clinic staff, FDC was an acceptable treatment approach for secondary prevention of ASCVD disease in two MSF clinics in Lebanon. Sustainability is more complex and calls for better alignment of care with public systems.

An evaluation of the evidence brief for policy development process in WHO EVIPNet Europe countries.

BACKGROUND: Evidence briefs for policy (EBPs) represent a potentially powerful tool for supporting evidence-informed policy-making. Since 2012, WHO Evidence-Informed Policy Network (EVIPNet) Europe has been supporting Member States in developing EBPs. The aim of this study was to evaluate the process of developing EBPs in Estonia, Hungary and Slovenia. METHODS: We used a rapid appraisal approach, combining semi-structured interviews and document review, guided by the Medical Research Council (MRC) process evaluation framework. Interviews were conducted with a total of 20 individuals familiar with the EBP process in the three study countries. Data were analysed thematically, and emerging themes were related back to the MRC framework components (implementation, mechanisms of impact, and context). We also reflected on the appropriateness of this evaluation approach for EVIPNet teams without evaluation research expertise to conduct themselves. RESULTS: The following themes emerged as important to the EBP development process: how the focus problem is prioritized, who initiates this process, EBP team composition, EBP team leadership, availability of external support in the process, and the culture of policy-making in a country. In particular, the EBP process seemed to be supported by early engagement of the Ministry of Health and other stakeholders as initiators, clear EBP team roles and expectations, including a strong leader, external support to strengthen EBP team capacity and cultural acceptance of the necessity of evidence-informed policy-making. Overall, the evaluation approach was considered feasible by the EBP teams and captured rich qualitative data, but may be limited by the absence of external reviewers and long lag times between the EBP process and the evaluation. CONCLUSIONS: This process occurs in a complex system and must be conceptualized in each country and each EBP project in a way that fits local policy-making culture, priorities, leadership and team styles, roles and available resources. The use of a rapid appraisal approach, combining qualitative interviews and document review, is a feasible method of process evaluation for EVIPNet member countries.

Scaling up the primary health integrated care project for chronic conditions in Kenya: study protocol for an implementation research project.

INTRODUCTION: Amid the rising number of people with non-communicable diseases (NCDs), Kenya has invested in strengthening primary care and in efforts to expand existing service delivery platforms to integrate NCD care. One such approach is the AMPATH (Academic Model Providing Access to Healthcare) model in western Kenya, which provides the platform for the Primary Health Integrated Care Project for Chronic Conditions (PIC4C), launched in 2018 to further strengthen primary care services for the prevention and control of hypertension, diabetes, breast and cervical cancer. This study seeks to understand how well PIC4C delivers on its intended aims and to inform and support scale up of the PIC4C model for integrated care for people with NCDs in Kenya. METHODS AND ANALYSIS: The study is guided by a conceptual framework on implementing, sustaining and spreading innovation in health service delivery. We use a multimethod design combining qualitative and quantitative approaches, involving: (1) in-depth interviews with health workers and decision-makers to explore experiences of delivering PIC4C; (2) a cross-sectional survey of patients with diabetes or hypertension and in-depth interviews to understand how well PIC4C meets patients' needs; (3) a cohort study with an interrupted time series analysis to evaluate the degree to which PIC4C leads to health benefits such as improved management of hypertension or diabetes; and (4) a cohort study of households to examine the extent to which the national hospital insurance chronic care package provides financial risk protection to people with hypertension or diabetes within PIC4C. ETHICS AND DISSEMINATION: The study has received approvals from Moi University Institutional Research and Ethics Committee (FAN:0003586) and the London School of Hygiene & Tropical Medicine (17940). Workshops with key stakeholders at local, county, national and international levels will ensure early and wide dissemination of our findings to inform scale up of this model of care. We will also publish findings in peer-reviewed journals.

Implementing Single-Pill Combination Therapy for Hypertension: A Scoping Review of Key Health System Requirements in 30 Low- and Middle-Income Countries.

Objective: The World Health Organization (WHO) included single-pill combination (SPC) antihypertensive medications on their 2019 essential medicines list (EML) to encourage uptake and improved hypertension control. We documented key national-level facilitators (SPCs on national EMLs, recommendation for SPCs in national hypertension guidelines and availability of SPCs on the market) supporting uptake of SPCs in the 30 most populous low- and middle-income countries (LMICs). Methods: A hierarchical information gathering strategy was used including literature and web searches, the use of organisational databases and personal communications with colleagues to obtain information on (1) whether SPC antihypertensives are on national EMLs, (2) whether SPC antihypertensives are recommended in national hypertension guidelines and (3) whether SPCs are available on the market. Results: Eleven of 30 LMICs had all facilitators in place being Egypt, Kenya, Nigeria, Sudan, China, the Philippines, Thailand, Iran, Argentina, Colombia and Mexico. Twenty-six countries had national hypertension guidelines (or similar) in place with SPCs being recommended in 18 of these. Apart from Afghanistan, SPCs were available on the market in all countries. The facilitator least present was the inclusion of SPC antihypertensives on national EMLs at 12 of 29 (Turkey does not have an EML). Conclusion: This study demonstrated that many LMICs have made significant progress in their uptake of SPC antihypertensives and several had included SPCs on their EMLs and guidelines prior to their inclusion on the WHO EML. Despite this progress, the uptake of SPC antihypertensives in LMICs could be improved including through their further inclusion on EMLs.

Are We There Yet? Exploring the Use of Single-Pill Combination Therapy in the Management of Raised Blood Pressure in Australia.

OBJECTIVE: Single-pill combination (SPC) therapy is recommended as first-line therapy for most patients in global hypertension guidelines due to benefits of improved adherence and blood pressure (BP) control. We aimed to understand factors affecting SPC use in the management of raised BP in Australia. DESIGN: A mixed-method study comprising of qualitative (policy review and interviews) and quantitative (Pharmaceutical Benefits Scheme [PBS] data) approaches. MAIN OUTCOME MEASURES: Australian and international hypertension guideline recommendations regarding SPC use; the Australian registration and subsidy approval processes of SPCs; use of SPCs on the PBS; cost-analysis of PBS-listed SPCs compared to free-drug combinations; perceptions of healthcare providers towards SPCs. RESULTS: The 2016 Australian Heart Foundation's "Guideline for the diagnosis and management of hypertension in adults" does not recommend combination therapy (including SPCs) as first-line treatment. Additional challenges in the uptake of SPCs include: (1) the additional PBS requirements and barriers imposed for the listing of SPCs. (2) Script volumes for SPCs have not matched the rise in the number of SPCs listed for subsidy, have plateaued since 2016 and remained significantly lower than single constituent scripts. (3) SPCs are not subsidised by the PBS for initial treatment. Most SPCs provided substantial cost savings for individual patients compared to free-drug combinations. Health care providers were positive about the cost-saving and convenience of SPCs, however perceived negatives included inflexibility of SPCs during dose titration, medicine shortages, and potential adverse effects when initiating treatment with multiple drugs. CONCLUSION: The safety, efficacy and cost-saving potential of SPCs have been established in the literature but several roadblocks in the existing health system in Australia impede uptake. Interventions addressing these barriers may facilitate improved uptake, which may in turn improve blood pressure control in Australia.

Factors associated with the availability and affordability of essential cardiovascular disease medicines in low- and middle-income countries: A systematic review.

Despite their potential to prevent or delay the onset and progression of cardiovascular disease (CVD), medicines for CVD remain unavailable and unaffordable to many in low- and middle-income countries (LMICs). We systematically reviewed the literature to identify factors associated with availability and affordability of CVD medicines in LMICs. A protocol for this study was registered on the PROSPERO register of systematic reviews (CRD42019135393). We searched Medline, EMBASE, Global Health, Cumulative Index to Nursing and Allied Health Literature, EconLit, Social Policy and Practice, and Africa Wide Information for studies analyzing factors associated with the presence of medicines (availability) or the price of these medicines as it relates to ability to pay (affordability) in LMICs. We performed a narrative synthesis of the results using an access to medicines framework that examines influences at different levels of the health system. We did not conduct a meta-analysis because of the differences in analytic approaches and outcome measures in different studies. The search was conducted in accordance with PRISMA guidelines. Of 43 studies meeting inclusion criteria, 41 were cross-sectional. Availability and affordability were defined and measured in different ways. A range of factors such as sociodemographic characteristics, facility tier, presence of medicines on national essential medicine lists, and international subsidy programs were examined. The studies had variable quality and findings were often inconsistent. We find gaps in the literature on factors associated with availability and affordability of CVD medicines, particularly at the health program level. We conclude that there is a need for experimental and quasi-experimental studies that could identify causal factors and effective responses. Such studies would help further our understanding of how complex multifactorial influences impact these outcomes, which could inform policy decisions. Along with this, greater standardization of definitions and measurement approaches of availability and affordability are needed to allow for more effective comparisons.

Essential medicines for cardiovascular diseases in India: Rapid appraisal of policies and processes at the subnational level.

Background The burden of cardiovascular diseases (CVDs) and response to health systems vary widely at the subnational level in India. Our study aimed to assess the variation in state-level access to medicines for CVDs by comparing the essential medicines lists (EMLs) at the national and subnational levels in India and by rapid appraisal of the existing policies and processes of drug procurement. Methods We assessed the inclusion of six classes of medicines for CVDs in the recent and publicly available national and subnational EMLs from July to September 2018 in the states of Telangana and Madhya Pradesh. We examined the drug procurement and distribution policies and processes using documentary review and five key informant interviews between March and June 2018. Results The WHO's EML, India's national EML, and 21 of 28 publicly available (75%) Indian state and Union Territory EMLs included all six classes of essential medicines for CVDs. However, some medicines were not included in the policy packages of essential medicines meant for primary health centres. Both the states used centralized tendering and decentralized distribution as part of the public sector drug procurement process. The requirement was based on the previous year's consumption. The approximate time between procurement planning and distribution was 7-8 months in both the states. Conclusion Substantial variation exists in the selection of drugs for CVDs in EMLs at the subnational level in India. Improving forecasting techniques for requirement of medicines and reducing time lags between forecasting and distribution to health facilities may allow for better access to essential medicines.

Implementing Fixed Dose Combination Medications for the Prevention and Control of Cardiovascular Diseases.

Highlights:  - Despite clinical evidence of its effectiveness in secondary prevention of cardiovascular disease, uptake of fixed dose combination therapy (FDCs) for CVD has been poor.- A symposium was held bringing together stakeholders on this issue, including from academia, government and NGOs.- The conclusion made was that what is now needed to improve implementation of FDCs is country-specific health systems analyses to design appropriate implementation strategies.- Implementation strategies must look beyond listing on the WHO Essential Medicines List to consider approaches to improving FDC availability, accessibility, affordability, and adherence.- Strategies might include incorporation of FDCs into the WHO HEARTS technical package, simplified treatment and monitoring algorithms, decentralisation of medicine dispensing and task-sharing for treatment management.

The household economic burden of non-communicable diseases in 18 countries.

Background: Non-communicable diseases (NCDs) are the leading cause of death globally. In 2014, the United Nations committed to reducing premature mortality from NCDs, including by reducing the burden of healthcare costs. Since 2014, the Prospective Urban and Rural Epidemiology (PURE) Study has been collecting health expenditure data from households with NCDs in 18 countries. Methods: Using data from the PURE Study, we estimated risk of catastrophic health spending and impoverishment among households with at least one person with NCDs (cardiovascular disease, diabetes, kidney disease, cancer and respiratory diseases; n=17 435), with hypertension only (a leading risk factor for NCDs; n=11 831) or with neither (n=22 654) by country income group: high-income countries (Canada and Sweden), upper middle income countries (UMICs: Brazil, Chile, Malaysia, Poland, South Africa and Turkey), lower middle income countries (LMICs: the Philippines, Colombia, India, Iran and the Occupied Palestinian Territory) and low-income countries (LICs: Bangladesh, Pakistan, Zimbabwe and Tanzania) and China. Results: The prevalence of catastrophic spending and impoverishment is highest among households with NCDs in LMICs and China. After adjusting for covariates that might drive health expenditure, the absolute risk of catastrophic spending is higher in households with NCDs compared with no NCDs in LMICs (risk difference=1.71%; 95% CI 0.75 to 2.67), UMICs (0.82%; 95% CI 0.37 to 1.27) and China (7.52%; 95% CI 5.88 to 9.16). A similar pattern is observed in UMICs and China for impoverishment. A high proportion of those with NCDs in LICs, especially women (38.7% compared with 12.6% in men), reported not taking medication due to costs. Conclusions: Our findings show that financial protection from healthcare costs for people with NCDs is inadequate, particularly in LMICs and China. While the burden of NCD care may appear greatest in LMICs and China, the burden in LICs may be masked by care foregone due to costs. The high proportion of women reporting foregone care due to cost may in part explain gender inequality in treatment of NCDs.

Healthcare utilization and out-of-pocket expenditures associated with depression in adults: a cross-sectional analysis in Nepal.

BACKGROUND: Despite attempts to improve universal health coverage (UHC) in low income countries like Nepal, most healthcare utilization is still financed by out-of-pocket (OOP) payments, with detrimental effects on the poorest and most in need. Evidence from high income countries shows that depression is associated with increased healthcare utilization, which may lead to increased OOP expenditures, placing greater stress on families. To inform policies for integrating mental healthcare into UHC in LMIC, we must understand healthcare utilization and OOP expenditure patterns in people with depression. We examined associations between symptoms of depression and frequency and type of healthcare utilization and OOP expenditure among adults in Chitwan District, Nepal. METHODS: We analysed data from a population-based survey of 2040 adults in 2013, who completed the PHQ-9 screening tool for depression and answered questions about healthcare utilization. We examined associations between increasing PHQ-9 score and healthcare utilization frequency and OOP expenditure using negative binomial regression. We also compared utilization of specific outpatient service providers and their related costs among adults with and without probable depression, determined by a PHQ-9 score of 10 or more. RESULTS: We classified 80 (3.6%) participants with probable depression, 70.9% of whom used some form of healthcare in the past year compared to 43.9% of people without probable depression. Mean annual OOP healthcare expenditures were $118 USD in people with probable depression, compared to $110 USD in people without. With each unit increase in PHQ-9 score, there was a 14% increase in total healthcare visits (95% CI 7-22%, p < 0.0001) and $9 USD increase in OOP expenditures (95% CI $2-$17; p < 0.0001). People with depression sought most healthcare from pharmacists (30.1%) but reported the greatest expenditure on specialist doctors ($36 USD). CONCLUSIONS: In this population-based sample from Central Nepal, we identified dose-dependent increases in healthcare utilization and OOP expenditure with increasing PHQ-9 scores. Future studies should evaluate whether provision of mental health services as an integrated component of UHC can improve overall health and reduce healthcare utilisation and expenditure, thereby alleviating financial pressures on families.