Beyond free healthcare: household out-of-pocket expenditure and catastrophic health expenditure among chronic kidney disease patients attending a tertiary care hospital in Sri Lanka.

BACKGROUND: Chronic kidney disease (CKD) is a major global public health challenge associated with high morbidity, premature mortality, and substantial healthcare costs. In Sri Lanka, CKD is a public health priority due to the high prevalence of diabetes, hypertension, and chronic kidney disease of unknown etiology (CKDu). Although public healthcare services are largely free at the point of delivery, CKD imposes considerable financial pressure on households through out-of-pocket expenditure (OOPE). This study assessed the household economic burden among CKD patients attending a tertiary care hospital in Sri Lanka, measured through OOPE and catastrophic health expenditure (CHE).

METHODS: An analytical cross-sectional study was conducted from May to June 2019 among patients with CKD attending the renal clinic, ward, and hemodialysis unit of a government tertiary hospital. OOPE was assessed through direct patient interviews using a structured questionnaire developed for this study, capturing direct medical, non-medical, and indirect costs. CHE was defined as OOPE exceeding ≥ 25% and ≥ 40% of total monthly household income, reflecting different levels of financial burden. Costs were collected in Sri Lankan Rupees (LKR) and converted to United States Dollars (USD) using the 2019 average exchange rate (1 USD = 178.8 LKR). Associations between CHE and selected variables were examined using multivariable binary logistic regression.

RESULTS: A total of 272 participants were included (response rate 90.7%). Median monthly OOPE was highest for hemodialysis care (LKR 38,540 [USD 215]), followed by inpatient care (LKR 16,000 [USD 89]) and clinic care (LKR 4,050 [USD 23]). Direct non-medical costs contributed substantially in all three patient groups. At the 25% threshold, CHE occurred in 74.0% (95% CI: 64.3-82.3) of hemodialysis patients, 51.3% (95% CI: 39.7-62.8) of inpatients, and 9.6% (95% CI: 4.5-17.4) of clinic patients; overall CHE was 45.2% (95% CI: 39.2-51.3). At the 40% threshold, overall CHE was 35.7% (95% CI: 30.0-41.7). Higher age and higher income were associated with lower odds of CHE.

CONCLUSIONS: CKD imposes a substantial economic burden on households in Sri Lanka, particularly among patients receiving hemodialysis and inpatient care. Financial protection strategies should address major non-medical costs, including transport and dietary expenses, while strengthening existing social assistance programs for vulnerable households.