The Benefits and Challenges of Implementing Teleophthalmology in Low-Resource Settings: A Systematic Review.

Technology has significantly changed medical practice, including diagnosis, treatment, and availability. Telemedicine use in the specialty of ophthalmology seems to be a promising field. In underserved populations, limited coverage of ophthalmic healthcare facilities results in a higher burden of eye-related diseases and visual impairment. The main obstacle preventing these individuals from receiving eye care consultations is difficulty in access and transportation. There is an urgent need for eye care facilities for these people, and teleophthalmology has the potential to provide eye care facilities to these underserved people. Teleophthalmology was reported as cost-effective, time-saving, reliable, and efficient for underserved populations. However, teleophthalmology has certain limitations in its implementation in the form of a high initial cost of equipment, problems with consistent electricity and internet supply, and the reluctance of people in certain regions toward acceptance of teleophthalmology. This systematic review assessed the benefits and challenges of implementing teleophthalmology in low-resource settings.

Oral Health Care Out-of-Pocket Costs and Financial Hardship: A Scoping Review.

The objective of this study is to characterize how financial hardship related to oral health care (OHC) out-of-pocket (OOP) spending has been conceptualized, defined, and measured in the literature and to identify evidence gaps in this area. This scoping review follows Arksey and O'Malley's framework and synthesizes financial hardship from OHC concepts, methodologies, and evidence gaps. We searched Ovid-Medline, Ovid-Embase, PubMed, Web of Science, Scopus, EconLit, Business Source Premier, and the Cochrane Library. Gray literature was sourced from institutional websites (World Health Organization, United Nations, World Bank Group, Organisation for Economic Co-operation and Development, and governmental health agencies) as well as ProQuest Dissertations and Thesis Global. We used defined inclusion and exclusion criteria to select studies published between 2000 and 2023. Of the 1,876 records, 65 met our criteria. The studies conceptualized financial hardship as catastrophic spending, impoverishment, negative coping strategies, bankruptcy, financial burden, food insecurity, and personal financial hardship experience. We found heterogeneity in defining OHC OOP payments and services. Also, financial hardship was frequently measured as catastrophic health expenditure using cross-sectional designs and national household spending surveys from high-income and to a lesser extent lower-middle-income countries. We identify and discuss challenges in terms of conceptualizing financial hardship, study designs, and measurement instruments in the OHC context. Some of the common evidence gaps identified include studying the causal relationship in financial hardship from OHC, assessing the financial hardship and unmet dental needs due to cost relationship, and distinguishing the effect between pain/discomfort and esthetic/cosmetic dental treatments on financial hardship. Financial hardship in OHC needs further exploration and the use of consistent definitions as well must distinguish between treatments alleviating pain/discomfort from esthetic/cosmetic treatments. Our study is relevant for policy makers and researchers aiming to monitor financial protection of OOP payments on OHC in the wake of universal health coverage for oral health.

Financial hardship of tuberculosis patients registered under National Tuberculosis Elimination Programme (NTEP) in rural India: A longitudinal study.

BACKGROUND: India shares a significant proportion of the Tuberculosis (TB) burden of the world. TB diagnosis, treatment, and success are complicated by the chronic nature of the disease as well as additional stressors including financial, psychological, and social hardships, adverse events associated with management, and poor compliance towards anti-tuberculosis medications. METHODS: This is a longitudinal study conducted in the Tuberculosis Units (TUs) of rural field practice areas of the Department of Community Medicine and Family Medicine in a tertiary care hospital in Odisha. 168 diagnosed TB patients from the TUs were enrolled after registration in NTEP and were followed up every month for 6 months or treatment completion. TB patient's cost estimate tool was used to collect data regarding the cost incurred by the patients before and during the diagnosis as well as in the post-diagnosis or treatment period. RESULTS AND CONCLUSION: Out-of-pocket expenditure was calculated as direct, indirect, and total cost in the pre and post-diagnostic phases of the disease. The median pre and post-diagnosis direct, indirect and total costs were ₹ 12,805, ₹ 16,960 and ₹ 31,192, respectively, with almost 62 % of participants spending more than 20 % of their annual income. In this study, 41 % of participants had to stop working for more than 60 days, and 53.1 % faced distress financing due to the disease. Through this study, we found that more than half of rural TB patients still visit private health facilities, and 20 % start anti-TB drugs by purchasing them from private pharmacies, which incur substantial out-of-pocket expenditure. Most participants faced catastrophic costs associated with hospitalisation, lower family income, and a delay in disease diagnosis.

Monitoring financial healthcare protection in Brazil: evolution, inequalities, and associated factors.

OBJECTIVES: Although catastrophic health spending is the main measure for assessing financial healthcare protection, it varies considerably in methodological and empirical terms, which hinders comparison between studies. The aim of this study was to measure the prevalence of catastrophic health spending in Brazil in 2003, 2009, and 2018, its associated factors, and disparities in prevalence distribution according to socioeconomic status. STUDY DESIGN: This was a time series study. METHODS: Data from the Household Budget Surveys were used. Prevalence of catastrophic health spending was measured as a percentage of the budget and ability to pay, considering thresholds of 10, 25, and 40%. It was determined whether household, family, and household head characteristics influence the likelihood of incurring catastrophic health spending. Households were stratified by income deciles, consumption, and wealth score. RESULTS: There was an increase in prevalence of catastrophic health spending between 2003 and 2009 in Brazil and a slight reduction in 2018. The wealth score showed more pronounced distributional effects between the poor and the rich, with the former being the most affected by catastrophic health spending. Consumption showed greater percentage variations in the prevalence of catastrophic health spending. The prevalence of catastrophic health spending was positively associated with the presence of older adults, age and female household head, rural area, receipt of government benefits, and some degree of food insecurity. CONCLUSIONS: The poorest families are most affected by catastrophic health spending in Brazil, requiring more effective and equitable policies to mitigate financial risk.

End-of-life emergency department use and healthcare expenditures among older adults: A nationally representative study.

BACKGROUND: Emergency department (ED) visits at end-of-life may cause financial strain and serve as a marker of inadequate access to community services and health care. We sought to examine end-of-life ED use, total healthcare spending, and out-of-pocket spending in a nationally representative sample. METHODS: Using Medicare Current Beneficiary Survey data, we conducted a pooled cross-sectional analysis of Medicare beneficiaries aged 65+ years with a date of death between July 1, 2015 and December 31, 2021. Our primary outcomes were ED visits, total healthcare spending, and out-of-pocket spending in the 7, 30, 90, and 180 days preceding death. We estimated a series of zero-inflated negative binomial models identifying patient characteristics associated with the primary outcomes. RESULTS: Among 3812 older adult decedents, 610 (16%), 1207 (31.7%), 1582 (41.5%), and 1787 (46.9%) Medicare beneficiaries had ED visits in the final 7, 30, 90, and 180 days, respectively, of life. For Medicare beneficiaries with at least one ED visit in the final 30 days of life, the median total and out-of-pocket costs were, respectively, $12,500 and $308, compared, respectively, with $278 and $94 for those without any ED visits (p < 0.001 for both comparisons). Having a diagnosis of dementia (odds ratio [OR] 0.71; 95% confidence interval [CI] 0.51-0.99; p = 0.04) and being on hospice status during the year of death (OR 0.56; 95% CI 0.48-0.66; p = <0.001) were associated with a decreased likelihood of having an ED visit. Having dementia was associated with a decreased likelihood of having any healthcare spending (OR 0.50; 95% CI 0.36-0.71; p = 0.001) and any out-of-pocket spending (OR 0.51; 95% CI 0.36-0.72; p = <0.001). CONCLUSIONS: One in three older adults visit the ED in the last month of life, and approximately one in two utilize ED services in the last half-year of life, with evidence of associated considerable total and out-of-pocket spending.

Changes in the Epidemiological Landscape of Diabetes in South Korea: Trends in Prevalence, Incidence, and Healthcare Expenditures.

Diabetes is a serious public health concern that significantly contributes to the global burden of disease. In Korea, the prevalence of diabetes is 12.5% among individuals aged 19 and older, and 14.8% among individuals aged 30 and older as of 2022. The total number of people with diabetes among those aged 19 and older is estimated to be 5.4 million. The incidence of diabetes decreased from 8.1 per 1,000 persons in 2006 to 6.3 per 1,000 persons in 2014, before rising again to 7.5 per 1,000 persons in 2019. Meanwhile, the incidence of type 1 diabetes increased significantly, from 1.1 per 100,000 persons in 1995 to 4.8 per 100,000 persons in 2016, with the prevalence reaching 41.0 per 100,000 persons in 2017. Additionally, the prevalence of gestational diabetes saw a substantial rise from 4.1% in 2007 to 22.3% in 2023. These changes have resulted in increases in the total medical costs for diabetes, covering both outpatient and inpatient services. Therefore, effective diabetes prevention strategies are urgently needed.

Healthcare spending versus mortality in central nervous system cancer: Has anything changed?

Background: The financial implications of central nervous system (CNS) cancers are substantial, not only for the healthcare service and payers, but also for the patients who bear the brunt of direct, indirect, and intangible costs. This study sought to investigate the impact of healthcare spending on CNS cancer survival using recent US data. Methods: This study used public data from the Disease Expenditure Project 2016 and the Global Burden of Disease Study 2019. The primary outcome was the annual healthcare spending trend from 1996 and 2016 on CNS tumors adjusted for disease prevalence, alongside morbidity and mortality. Secondary outcomes included drivers of change in healthcare expenditures for CNS cancers. Subgroup analysis was performed stratified by age group, expenditure type, and care type provided. Results: There was a significant increase in total healthcare spending on CNS cancers from $2.72 billion (95% CI: $2.47B to $2.97B) in 1996 to $6.85 billion (95% CI: $5.98B to $7.57B) in 2016. Despite the spending increase, the mortality rate per 100 000 people increased, with 5.30 ±â€…0.47 in 1996 and 7.02 ±â€…0.47 in 2016, with an average of 5.78 ±â€…0.47 deaths per 100 000 over the period. The subgroups with the highest expenditure included patients aged 45 to 64, those with private insurance, and those receiving inpatient care. Conclusions: This study highlights a significant rise in healthcare costs for CNS cancers without corresponding improvements in mortality rate, indicating a mismatch of healthcare spending, contemporary advances, and patient outcomes as it relates to mortality.

Hypertension-Associated Expenditures Among Privately Insured US Adults in 2021.

BACKGROUND: There are no recent estimates for hypertension-associated medical expenditures. This study aims to estimate hypertension-associated incremental medical expenditures among privately insured US adults. METHODS: We conducted a retrospective cohort study using IQVIA's Ambulatory Electronic Medical Records-US data set linked with PharMetrics Plus claims data. Among privately insured adults aged 18 to 64 years, hypertension was identified as having ≥1 diagnosis code or ≥2 blood pressure measurements of ≥140/90 mm Hg, or ≥1 antihypertensive medication in 2021. Annual total expenditures (in 2021 $US) were estimated using a generalized linear model with gamma distribution and log-link function adjusting for demographic characteristics and cooccurring conditions. Out-of-pocket expenditures were estimated using a 2-part model that included logistic and generalized linear model regression. Overlap propensity score weights from logistic regression were used to obtain a balanced sample on hypertension status. RESULTS: Among the 393 018 adults, 156 556 (40%) were identified with hypertension. Compared with individuals without hypertension, those with hypertension had $2926 (95% CI, $2681-$3170) higher total expenditures and $328 (95% CI, $300-$355) higher out-of-pocket expenditures. Adults with hypertension had higher total inpatient ($3272 [95% CI, $1458-$5086]) and outpatient ($2189 [95% CI, $2009-$2369]) expenditures when compared with those without hypertension. Hypertension-associated incremental total expenditures were higher for women ($3242 [95% CI, $2915-$3569]) than for men ($2521 [95% CI, $2139-$2904]). CONCLUSIONS: Among privately insured US adults, hypertension was associated with higher medical expenditures, including higher inpatient and out-of-pocket expenditures. These findings may help assess the economic value of interventions effective in preventing hypertension.

The financial burden of noncommunicable diseases from out-of-pocket expenditure in sub-Saharan Africa: a scoping review.

The growing financial burden of noncommunicable diseases (NCDs) in sub-Saharan Africa (SSA) hinders the attainment of the sustainable development goals. However, there has been no updated synthesis of evidence in this regard. Therefore, our study summarizes the current evidence in the literature and identifies the gaps. We systematically search relevant databases (PubMed, Scopus, ProQuest) between 2015 and 2023, focusing on empirical studies on NCDs and their financial burden indicators, namely, catastrophic health expenditure (CHE), impoverishment, coping strategies, crowding-out effects and unmet needs for financial reasons (UNFRs) in SSA. We examined the distribution of the indicators, their magnitudes, methodological approaches and the depth of analysis. The 71 included studies mostly came from single-country (n = 64), facility-based (n = 52) research in low-income (n = 22), lower-middle-income (n = 47) and upper-middle-income (n = 10) countries in SSA. Approximately 50% of the countries lacked studies (n = 25), with 46% coming from West Africa. Cancer, cardiovascular disease (CVD) and diabetes were the most commonly studied NCDs, with cancer and CVD causing the most financial burden. The review revealed methodological deficiencies related to lack of depth, equity analysis and robustness. CHE was high (up to 95.2%) in lower-middle-income countries but low in low-income and upper-middle-income countries. UNFR was almost 100% in both low-income and lower-middle-income countries. The use of extreme coping strategies was most common in low-income countries. There are no studies on crowding-out effect and pandemic-related UNFR. This study underscores the importance of expanded research that refines the methodological estimation of the financial burden of NCDs in SSA for equity implications and policy recommendations.

The role of digital financial inclusion in China on urban-rural disparities in healthcare expenditures.

Introduction: The digital financial inclusion (DFI) provides opportunities to improve the relative capacity to pay for healthcare services by rural residents who are usually underserved by traditional finance in China. This paper provides empirical evidence on how the development of DFI affects the healthcare expenditure disparities between urban and rural residents. Methods: We employed the fixed effects model and instrumental variable method to estimate the impact of DFI on the Theil index of urban-rural disparities in healthcare expenditures, using panel data from 31 provinces (2011 ~ 2020) in China. We further adopted a moderating effect model to test whether the intensity of the impact would vary depending on the level of local government health expenditures. Results: The results suggest a negative association between the development level of DFI and the urban-rural healthcare expenditure disparities in China. For every 1% increase in the DFI index, the Theil index of urban-rural disparities in healthcare expenditures would fall by 0.0013. After changing the measurement method for the dependent variable and adjusting the sample, the results remain robust. Moreover, the result of the moderating effect model indicates that, a high level of government health expenditures is conducive to the impact of DFI. Discussion: Our research reveals that DFI plays an important role in bridging the urban-rural gap in healthcare expenditures. This finding provides new information for addressing the issue of urban-rural healthcare inequality in China. Chinese government needs to accelerate the construction of digital infrastructure and increase the penetration rate of digital tools in rural areas to promote the beneficial effects of DFI. Additionally, it is also necessary for local government to address the unbalanced allocation of medical resources between urban and rural areas, especially the shortage of rural human resources.

Medical Costs of Nontuberculous Mycobacterial Pulmonary Disease, South Korea, 2015-2019.

Nontuberculous mycobacterial pulmonary disease (NTM-PD) prevalence is a rising public health concern. We assessed the long-term healthcare systems perspective of costs incurred by 147 NTM-PD patients at a tertiary hospital in South Korea. Median cumulative total medical cost in managing NTM-PD patients was US $5,044 (interquartile range US $3,586-$9,680) over 49.7 months (interquartile range 33.0-68.2 months) of follow-up. The major cost drivers were diagnostic testing and medication, accounting for 59.6% of total costs. Higher costs were associated with hospitalization for Mycobacterium abscessus infection and pulmonary comorbidities. Of the total medical care costs, 50.2% were patient co-payments resulting from limited national health insurance coverage. As South Korea faces significant problems of poverty during old age and increasing NTM-PD prevalence, the financial and socio-economic burden of NTM-PD may become a major public health concern that should be considered with regard to adequate strategies for NTM-PD patients.

Associations Between Rehabilitation Utilization and Out-of-Pocket Costs Among Older Adults With Breast Cancer in the United States.

OBJECTIVE: To examine the association between rehabilitation utilization within 12 months of breast cancer diagnosis and out-of-pocket costs in the second year (12-24mo after diagnosis). DESIGN: Secondary analysis of the 2009-2019 Surveillance, Epidemiology and End Results-Medicare linked database. Individuals who received rehabilitation services were propensity-score matched to individuals who did not receive services. Overall and health care service-specific models were examined using generalized linear models with a gamma distribution. SETTING: Inpatient and outpatient medical facilities. PARTICIPANTS: A total of 35,212 individuals diagnosed with nonmetastatic breast cancer and were continuously enrolled in Medicare Fee-For Service (parts A, B, and D) in the 12 months before and 24 months postdiagnosis. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Individual cost responsibility, a proxy for out-of-pocket costs, which was defined as deductibles, coinsurance, and copayments during the second year after diagnosis (12-24mo postdiagnosis). RESULTS: The mean individual cost responsibility was higher in individuals who used rehabilitation than those who did not ($4013 vs $3783), although it was not a clinically meaningful difference (d=0.06). Individuals who received rehabilitative services had significantly higher costs attributed to individual provider care ($1634 vs $1476), institutional outpatient costs ($886 vs $812), and prescription drugs ($959 vs $906), and significantly lower costs attributed to institutional inpatient costs ($455 vs $504), and durable medical equipment ($81 vs $86). CONCLUSIONS: Older adults with breast cancer who received rehabilitation services had higher cost responsibility during the second year after diagnosis than those who did not. Future work is needed to examine the relationship between rehabilitation and out-of-pocket costs across longer periods of time and in conjunction with perceived benefit.

Frequency of use and cost in Japan of first-line palliative chemotherapies for recurrent or metastatic squamous cell carcinoma of the head and neck.

BACKGROUND: Over the last decade, novel anticancer drugs have improved the prognosis for recurrent or metastatic squamous cell carcinoma of the head and neck (RM-SCCHN). However, this has increased healthcare expenditures and placed a heavy burden on patients and society. This study investigated the frequency of use and costs of select palliative chemotherapy regimens in Japan. METHODS: From July 2021 to June 2022 in 54 healthcare facilities, we gathered data of patients diagnosed with RM-SCCHN and who had started first-line palliative chemotherapy with one of eight commonly used regimens. Patients with nasopharyngeal carcinomas were excluded. The number of patients receiving each regimen and the costs of each regimen for the first month and per year were tallied. RESULTS: The sample comprised 907 patients (674 were < 75 years old, 233 were ≥ 75 years old). 330 (36.4%) received Pembrolizumab monotherapy, and 202 (22.3%) received Nivolumab monotherapy. Over 90% of patients were treated with immune checkpoint inhibitors as monotherapy or in combination with chemotherapy. Treatment regimens' first-month costs were 612 851-849 241 Japanese yen (JPY). The cost of standard palliative chemotherapy until 2012 was about 20 000 JPY per month. The incremental cost over the past decade is approximately 600 000-800 000 JPY per month, a 30- to 40-fold increase in the cost of palliative chemotherapy for RM-SCCHN. CONCLUSION: First-line palliative chemotherapy for RM-SCCHN exceeds 600 000 JPY monthly. Over the last decade, the prognosis for RM-SCCHN has improved, but the costs of palliative chemotherapy have surged, placing a heavy burden on patients and society.

Economic Burden of Huntington's Disease: Analysis from a Brazilian Tertiary Care Perspective.

Background: Huntington's disease (HD) exerts significant impacts on individuals and families worldwide. Nevertheless, data on its economic burden in Brazil are scarce, revealing a critical gap in understanding the associated healthcare costs. Objective: This study was conducted at a tertiary neurology outpatient clinic in Brazil with the aim of assessing annual healthcare service utilization and associated costs for HD patients. Methods: We conducted a cross-sectional observational study involving 34 HD patients. A structured questionnaire was applied to collect data on direct medical costs (outpatient services, medications), non-medical direct costs (complementary therapies, mobility aids, home adaptations), and indirect costs (lost productivity, caregiver costs, government benefits) over one year. Results: Significant economic impacts were observed, with average annual direct medical costs of $4686.82 per HD patient. Non-medical direct and indirect costs increased the financial burden, highlighting extensive resource utilization beyond healthcare services. Thirty-three out of 34 HD patients were unemployed or retired, and 16 relied on government benefits, reflecting broader socioeconomic implications. Despite the dataset's limitations, it provides crucial insights into the economic impact of HD on patients and the Brazilian public health system. Conclusions: The findings underscore the urgent need for a more comprehensive evaluation of the costs to inform governmental policies related to HD. Future research is needed to expand the data pool and develop a nuanced understanding of the economic burdens of HD to help formulate effective healthcare strategies for patients.

What Interventions Work to Reduce Cost Barriers to Primary Healthcare in High-Income Countries? A Systematic Review.

High-income countries like Aotearoa New Zealand are grappling with inequitable access to healthcare services. Out-of-pocket payments can lead to the reduced use of appropriate healthcare services, poorer health outcomes, and catastrophic health expenses. To advance our knowledge, this systematic review asks, "What interventions aim to reduce cost barriers for health users when accessing primary healthcare in high-income countries?" The search strategy comprised three bibliographic databases (Dimensions, Embase, and Medline Web of Science). Two authors selected studies for inclusion; discrepancies were resolved by a third reviewer. All articles published in English from 2000 to May 2022 and that reported on outcomes of interventions that aimed to reduce cost barriers for health users to access primary healthcare in high-income countries were eligible for inclusion. Two blinded authors independently assessed article quality using the Critical Appraisal Skills Program. Relevant data were extracted and analyzed in a narrative synthesis. Forty-three publications involving 18,861,890 participants and 6831 practices (or physicians) met the inclusion criteria. Interventions reported in the literature included removing out-of-pocket costs, implementing nonprofit organizations and community programs, additional workforce, and alternative payment methods. Interventions that involved eliminating or reducing out-of-pocket costs substantially increased healthcare utilization. Where reported, initiatives generally found financial savings at the system level. Health system initiatives generally, but not consistently, were associated with improved access to healthcare services.

Does vertical integration increase the costs for primary care inpatients? Evidence from a national pilot programme in China.

OBJECTIVE: To assess the impact of vertical integration (VI) within County-Level Integrated Health Organisations (CIHOs) on the costs of primary care inpatients. METHODS: This study assessed Xishui, a national pilot county for CIHOs, using inpatient claims data. The treatment group comprised 10,118 inpatients from 5 vertically integrated township health centres (THCs), while the control group consisted of 21,165 inpatients from 19 non-vertically integrated THCs. The periods from July 2020 to December 2021 and January 2022 to December 2022 were defined as pre- and post-policy intervention, respectively. The primary outcome variables were total health expenditures (THS), out-of-pocket (OOP) expenditures, and the proportion of OOP expenditures. Propensity score matching was employed to align inpatient demographics and disease characteristics between the groups, followed by a difference-in-differences analysis to evaluate the outcomes. FINDINGS: VI significantly increased THS (ß = 0.1337, p < 0.01) and OOP expenditures per case (ß = 0.1661, p < 0.001), but the increase in the proportion of OOP expenditures per case was not significant (ß = 0.0029, p > 0.05). For the basic medical insurance for urban and rural residents, THS per case (ß = 0.1343, p < 0.01) and OOP expenditures (ß = 0.1714, p < 0.001) significantly increased. For the basic medical insurance system for employees, THS per case also increased significantly (ß = 0.1238, p < 0.01), but the change in OOP expenditure proportion per case was not significant (ß = 0.1020, p > 0.05). The THS per case led by Xishui County People's Hospital, the leading county medical sub-centre (CMSC), significantly increased (ß = 0.1753, p < 0.01), whereas the increase led by Xishui County Traditional Chinese Medicine Hospital was not significant (ß = 0.0742, p > 0.05). Increases in OOP expenditures per case were significant in CMSCs led by the People's Hospital and the Traditional Chinese Medicine Hospital (ß = 0.1782, p < 0.01 and ß = 0.0757, p < 0.05, respectively). CONCLUSION: VI significantly increased THS and OOP expenditures for primary care inpatients. However, VI could exacerbate economic disparities in disease burden across different insurance categories.

Getting the right tail right: Modeling tails of health expenditure distributions.

Health expenditure data almost always include extreme values, implying that the underlying distribution has heavy tails. This may result in infinite variances as well as higher-order moments and bias the commonly used least squares methods. To accommodate extreme values, we propose an estimation method that recovers the right tail of health expenditure distributions. It extends the popular two-part model to develop a novel three-part model. We apply the proposed method to claims data from one of the biggest German private health insurers. Our findings show that the estimated age gradient in health care spending differs substantially from the standard least squares method.

Estimating the out-of-pocket health expenditure in patients under 5 years with severe malnutrition in Afghanistan in 2023: Findings from a cross-sectional study.

Introduction: This study, of significant importance to healthcare professionals, policymakers, researchers, and organizations involved in child healthcare and malnutrition in Afghanistan, aimed to estimate the out-of-pocket expenditure (OOPE) in patients under 5 years old with severe malnutrition in a children's hospital in Herat Province, Afghanistan. Method: This study employed a meticulously designed cross-sectional descriptive-analytical approach with practical results. The research population consisted of families with malnourished children under 5 who were referred to Herat Children's Hospital. Data was collected using a comprehensive standard World Health Organization questionnaire to gather demographic information from children in Herat. A carefully selected convenience sampling method was used, with 300 referring patients participating in face-to-face interviews with the supervisors of these children. After obtaining personal consent and coordinating with health officials, interviews were conducted with the caregivers of children under 5 who suffered from severe malnutrition. The data was then analyzed using robust descriptive statistics, quantitative variables, mean and standard deviation, frequency, and relative frequency. Multiple regression analysis was used to determine the factors that most influenced direct payments from patients' pockets, ensuring the reliability and validity of the findings. Results: The results showed that OOPE in both households with seven and less than seven people and more than seven people was 68%. The findings indicated that among the residents of Herat referred to the studied hospital, these people spent 54% of the treatment costs directly out of pocket. In contrast, people in the rural areas of Herat pay 69% of the treatment costs to receive medical services straight out of pocket. The critical point is that 93% of the families have incurred catastrophic expenses to treat their children suffering from severe malnutrition. The research revealed that the patient's location and the education level of the head of the household were the most significant factors affecting out-of-pocket payments by patients. Conclusion: Increasing OOPE in rural Afghanistan poses a significant obstacle to equitable healthcare services and access to appropriate medicines. To support the goal of universal healthcare coverage, geographic imbalances, and broad health financing options must be addressed. Strengthening insurance coverage and more government assistance can significantly reduce these patients' out-of-pocket payments.