Content area
Objective
The study aimed to assess the prevalence of financial catastrophe and explore patients’ perceived effectiveness of the government support programme related to chronic kidney disease.
Design
Cross-sectional mixed-method study.
Participants
A total of 120 patients receiving free regular haemodialysis under the government’s Deprived Citizen Support Programme for at least 6 months were included in the quantitative study, and 9 patients participated in the qualitative study.
Main outcome measures
Prevalence of financial catastrophe and factors associated with financial catastrophe among chronic kidney disease patients undergoing haemodialysis.
Methods
A convergent parallel mixed-method approach was carried out from 15 June to 15 December 2024, among chronic kidney disease patients undergoing haemodialysis at the National Kidney Center. Quantitative data were collected through face-to-face interviews using a semi-structured questionnaire. Financial catastrophe was defined as out-of-pocket (OOP) healthcare payments ≥40% of a household’s disposable income, following the WHO-recommended threshold for severe financial burden. OOP expenditures were assessed over 6 months, and associations were tested using χ2 and binary logistic regression at a 95% CI in SPSS V.25.0. For the qualitative arm, in-depth interviews were conducted with nine purposively selected patients, and inductive thematic analysis was applied to explore the perceived effectiveness of the government support programme. The quantitative and qualitative findings were then integrated to achieve convergence and divergence, allowing for a comprehensive understanding of the extent and context of financial hardship among patients.
Results
The prevalence of financial catastrophe was 72.5%. The factors associated with financial catastrophe were the presence of complications (adjusted OR (AOR): 3.67, 95% CI 1.019 to 13.27), patients without financial support (AOR: 2.77, 95% CI 1.016 to 7.56) and reduction in food expenses (AOR: 0.313, 95% CI 0.109 to 0.896). Qualitative findings on awareness regarding government subsidies, financial strain, barriers to receiving treatment and perceived effectiveness of the programme revealed key aspects of utilisation and effectiveness of the government support programme.
Conclusion
The prevalence of financial catastrophe was substantially high, which highlights the importance of addressing economic challenges in chronic kidney disease care. The study emphasised the need to strengthen financial protection through the expansion of government subsidies and improved insurance coverage.
Full text
Correspondence to Swastika Poudel; [email protected]
Strengths and limitations of this study
The use of a mixed-method design provided a comprehensive understanding of the financial burden faced by chronic kidney disease patients undergoing haemodialysis.
Cross-verification of participants’ health expenditure data was done with the available medical bills to enhance the accuracy and reliability of the findings.
This study relied on self-reported household expenditure data, which may have resulted in an under- or over-estimation of actual expenditure. Additionally, some medical costs, such as hospitalisation expenses due to complications, may have been underestimated.
The selection of one single institution setting and inclusion of only those patients already enrolled in the government’s Deprived Citizen Support Programme may limit the generalisability of the findings and introduce selection bias, as financial catastrophe among patients outside this subsidy scheme may differ.
Introduction
Chronic kidney disease (CKD) is defined as the presence of kidney damage or an estimated glomerular filtration rate (GFR) less than 60 mL/min/1.73 m2 that lasts for 3 months or more, regardless of the aetiology.1 It encompasses distinct pathophysiological processes, poor renal function and a progressive decline in GFR.2 It has now emerged as a global frontrunner in non-communicable diseases which was the 11th greatest cause of mortality in 2019, accounting for 2.53% of total fatalities.3 The number of deaths due to the end stage of CKD was 3.78 million in 1990 (40.4% of all deaths) and has reached 7.73 million in 2020 (66.7% of all deaths). The treatment of CKD is expensive, per se. An estimated cost of over 1 trillion dollars was spent on end-stage renal disease globally. Thus, it is bound to inflict a significant socioeconomic and public health burden in resource-constrained settings.4
Renal replacement therapy (RRT) is a life-saving treatment for millions of CKD patients worldwide. However, the percentage of these individuals who receive RRT is below subpar. In low- and middle-income countries (LMICs), only 2%–5% of patients have access to RRT, compared with 60% in high-income countries.5 The major causes of financial catastrophe in LMICs were found to be kidney diseases which accounted for an estimated 188 million people.6 Studies have estimated that in LMICs, 35.6% of people with renal disease experience catastrophic health expenditures (CHE).7 A study by Bradshaw et al in India showed that 91% of the patients experienced catastrophic health expenditure and 77% engaged in distress financing.8
CKD is also a newly acknowledged public health issue in Nepal. It is estimated to affect 6% of Nepal’s population.9 Every year, around 2600 new cases of CKD patients acquire late-stage renal disease in Nepal.10 The Deprived Citizen Support Programme has been providing free lifelong haemodialysis to eligible patients in Nepal since 2016. Under this initiative, economically disadvantaged individuals receive haemodialysis services at government-designated hospitals, with all essential consumables, including dialysers and dialysate, supplied free of charge. To access these services, patients are required to present a poverty declaration certificate issued by their respective District Public Health Office.11 According to the Department of Health Services annual report 2021/22, CKD had the third highest number of service users using free treatment under the impoverished citizens’ service.12 However, the dialysis subsidy for a session is insufficient to cover all the hidden costs.10
With the rising prevalence of CKD, the economic burden that it brings to already beleaguered patients, caregivers and the whole country has been a major concern and a difficult challenge to cope with. Many countries conducted cost analysis of different types of RRT, including dialysis and transplantation. However, in Nepal, very few studies examined the out-of-pocket (OOP) and CHE of CKD, and most of them were quantitative in nature. Therefore, this study aimed to assess financial catastrophe and its associated factors among CKD patients in Nepal. Additionally, it aimed to explore the utilisation and perceived effectiveness of the government-funded programmes, providing critical insights into the current scenario of the ongoing chronic disease support programme of the government in Nepal.
Methods
Study design and setting
A cross-sectional study, using mixed-methods with a convergent parallel design, was conducted to collect data from CKD patients. National Kidney Center, Kathmandu, Nepal, was purposively selected as it has the highest number of dialysis machines and is the major hub for CKD patients undergoing haemodialysis. Data collection was done from 15 June to 15 December 2024.
Study population
The study population consisted of all stage V CKD patients receiving free haemodialysis under the government’s Deprived Citizen Support Programme at the National Kidney Center during the data collection periods.
Inclusion criteria
Patients over 18 years of age.
Undergoing regular haemodialysis therapy for at least 6 months.
Able to give consent to participate in the study.
In the case of a patient lacking information, his/her family member or caretaker who had been taking care for at least 6 months was included in the study.
Exclusion criteria
Those who had been diagnosed with mental health conditions.
Those who were undergoing haemodialysis for less than 6 months.
Sample size and sampling technique
Quantitative arm
The sample size was calculated by the single-proportion formula of a cross-sectional study. The proportion of financial catastrophe was used based on the study by Thapa et al, 2019 among haemodialysis patients of hospitals in Pokhara Metropolitan City, and it was 78% respectively,10 taking p=78%, q=22%, Z α/2=1.96 (at 5% level of significance) and Precision (d)=10% of p. Based on this formula, the calculated sample size was 108. By adding 10% to adjust the non-response rate, the final estimated sample size was 120. The selection of study samples was done with the list of dialysis patients. All the patients who fell under the inclusion criteria were conveniently selected.
Qualitative arm
The purposive sampling technique was used to recruit CKD patients undergoing haemodialysis at the National Kidney Center, Kathmandu, Nepal. Nine patients were selected for in-depth interviews. Those for whom quantitative data had not been previously collected were selected for the interviews based on their availability and willingness to participate. In addition, only patients who had been on subsidised haemodialysis for at least 6 months were included to ensure that participants had adequate treatment experience to meaningfully reflect on the perceived effectiveness of the government support programme.
Data collection tool and technique
Quantitative arm
Face-to-face interviews were conducted using a pretested semi-structured questionnaire, which was prepared from the extensive literature review. A copy of the questionnaire has been provided as online supplemental file 1. The questionnaire consists of five parts: sociodemographic characteristics of the respondents, background information regarding disease conditions, information on health expenditure (within the past 6 months), information on household expenditure (within the past 6 months) and calculation of financial catastrophe. A 6-month recall period was chosen to minimise recall bias while adequately capturing the regular health expenses of CKD patients undergoing haemodialysis. Health expenditure information obtained from the participants was cross-verified by reviewing the available medical bills.
Qualitative arm
Interview guidelines were developed based on a thorough literature review and guidance from the supervisor. Subsequently, the guidelines were tested for coherence and flow, and necessary modifications were made. Face-to-face interviews were conducted by female public health researchers. Rapport building was maintained before interviews by clearly explaining the purpose of the research and highlighting the significance of their honest and open responses. During the interviews, the respondents were granted the freedom to express their opinions concerning the events, behaviours and beliefs regarding the objectives of the study, and where further clarification was needed, respondents were probed, which helped the researcher to get the needed information. Each interview lasted on average 20–25 min and was conducted in a safe and comfortable environment where they were relaxed to express their views. With the written informed consent of the participants, all interviews were audio-recorded. The interviews were conducted in the Nepali language, and the gathered notes and audio recordings were first transcribed into Nepali and then translated into English for analysis. A copy of the interview guide used for the qualitative component of the study has been provided as online supplemental file 2 (Interview Guide).
Data management and analysis
Quantitative arm
Data were entered, filtered, coded, cross-checked and exported to IBM SPSS V.25 for statistical analysis. Descriptive analysis was conducted using frequency, percentage, median and IQR. Inferential analysis was conducted to identify the association between the independent variable and financial catastrophe. To assess the distribution of the data, a normality test was conducted using the Kolmogorov-Smirnov test and Shapiro-Wilk test, Q-Q plot, Skewness and Kurtosis, Histogram, and Box and Whisker plot. Bivariate analysis was performed using the χ2 test and Mann-Whitney U test at a 95% CI, with a p value of <0.05 considered statistically significant. Variables with a p value of <0.2 in the bivariate analysis were included in a binary logistic regression model to ensure that potentially important variables were not prematurely excluded because some factors that might not exhibit a strong association in bivariate analysis could become significant in the multivariate model after adjustment. Additionally, variables with cell counts of less than 5 were not included in the multivariate analysis.
Qualitative arm
The audio recordings from the qualitative interviews were transferred to a computer immediately following each interview, and transcription was done in Nepali on the same day. Transcripts were later translated into English for analysis. The data saturation was achieved after the ninth interview, as no new themes emerged during the final two interviews. Dependability was established by having two independent coders develop a set of codes, assessing their consistency, resolving discrepancies through discussion and finalising the coding process for reliability. Confirmability was strengthened through regular and detailed debriefing sessions with the supervisor, along with detailed documentation of the research process to minimise bias. The researcher remained conscious of their own perspectives, experiences and assumptions that could influence the study. Transferability was enhanced by maintaining a comprehensive audit trail, documenting the coding process, analytical decisions and methodological adjustments, ensuring transparency and allowing the findings to be applicable in similar contexts. Themes were generated from the codes using an inductive approach.
Operational definition
Financial catastrophe
It is the payments for health services exceeding 40.0% of household disposable income after subsistence needs are met.13
Per capita income
It has been categorised as below the poverty line and above the poverty line based on the Nepal Living Standards Survey IV 2022–2023. It was estimated at NRs. 72 908 per person per year.14
Direct medical cost
Medical costs comprise costs of outpatient care, hospitalisation, diagnosis and investigations, medications, emergency care and health-related equipment.
Direct non-medical cost
It comprised costs of food, travel, accommodation during health service utilisation, relocation, special diet and paid caregiver for CKD.
Indirect cost
It comprises the cost per hour loss during each outpatient visit and income losses of patients/family members for each inpatient’s hospital stay. The transportation time, waiting time and time spent with the service provider were calculated and converted into hour losses. The human capital approach is used to calculate the cost per hour loss and income losses. This approach was used to estimate the value of human capital as the current value of his or her earnings as a proxy for future productivity.15 The time was valued based on the minimum unskilled labour wage provided by the Nepal Government, which is NRs. 15 000 per month and NRs. 77 per hour.16
Complication
It included infection, vascular access failure and anaemia due to dialysis-related causes.
Results
Quantitative arm
Sociodemographic characteristics of respondents
Table 1 presents the sociodemographic characteristics of all sampled participants. The median age of participants was 43 years, with an IQR of 35.25–56.75 years. Female patients accounted for 65.0%, 75.0% were literate, Dalit/Janjati/Madhesi (72.5%) and Hindu religion (65.0%). The majority of the respondents were married (83.3%). More than two-thirds of the participants were unemployed (70.0%). Most of them lived in a nuclear family (54.2%), and in 69.2% of the participants’ families, there were fewer than five members. Regarding poverty status, about one-fourth of the participants (24.2%) were below the poverty line, while 75.8% were above the poverty line. Almost two-thirds of the participants (63.3%) were from urban municipalities, and only 36.7% were from rural municipalities.
Table 1
Sociodemographic characteristics of respondents
| Characteristics | Frequency | Percentage |
| Age (in completed years) | ||
| Median (IQR) | 43 (35.25–56.75) | |
| Gender | ||
| Male | 78 | 65.0 |
| Female | 42 | 35.0 |
| Educational status | ||
| Illiterate | 30 | 25.0 |
| Literate | 90 | 75.0 |
| Religion | ||
| Hindu | 78 | 65.0 |
| Non-Hindu | 42 | 35.0 |
| Ethnicity | ||
| Brahmin/Chhetri | 33 | 27.5 |
| Dalit/Janjati/Madhesi | 87 | 72.5 |
| Marital status | ||
| Married | 100 | 83.3 |
| Unmarried | 20 | 16.7 |
| Occupation | ||
| Unemployed | 84 | 70.0 |
| Employed | 36 | 30.0 |
| Family type | ||
| Nuclear | 65 | 54.2 |
| Joint | 55 | 45.8 |
| Family size | ||
| <5 | 83 | 69.2 |
| ≥5 | 37 | 30.8 |
| Per capita income | ||
| Below poverty line | 29 | 24.2 |
| Above poverty line | 91 | 75.8 |
| Place of residence | ||
| Rural | 44 | 36.7 |
| Urban | 76 | 63.3 |
Clinical characteristics of respondents
Among stage V CKD patients, the duration of illness was evenly split, with 50.0% of patients having lived with CKD for 5 years or less, and 50.0% for more than 5 years. Similarly, 50.8% of respondents had been receiving haemodialysis for more than 5 years, the majority (70.8%) underwent haemodialysis three times per week and most sessions lasted 4 hours (91.7%). Regarding comorbidities, 21.7% of patients had none, 56.6% had one and 21.7% had multiple comorbid conditions. Additionally, 73.3% of patients reported no complications, while 26.7% experienced complications (table 2).
Table 2
Clinical characteristics of respondents
| Characteristics | Frequency | Percentage |
| Duration of illness (in years) | ||
| <5 | 60 | 50.0 |
| ≥5 | 60 | 50.0 |
| Duration of haemodialysis | ||
| <5 | 59 | 49.2 |
| ≥5 | 61 | 50.8 |
| Frequency of haemodialysis per week | ||
| Two | 35 | 29.2 |
| Three | 85 | 70.8 |
| Duration of haemodialysis per session (in hours) | ||
| 3.5 | 10 | 8.3 |
| 4 | 110 | 91.7 |
| Presence of comorbidity | ||
| None | 26 | 21.7 |
| Single | 68 | 56.6 |
| Multimorbidity | 26 | 21.7 |
| Presence of complication | ||
| Yes | 32 | 26.7 |
| No | 88 | 73.3 |
OOP expenditure of CKD patients
Among various cost components, hospitalisation cost (median: US$462.95, IQR: 249.28–1682.65) and allopathic medicines (median: US$351.13, IQR: 213.67–641.01) were the largest contributors to direct medical expenses. For direct non-medical costs, paid caregiver incurred the highest median expense at US$854.68 (427.34–1175.18), followed by relocation cost at US$142.45 (IQR: 106.83–178.06). The indirect costs due to illness included a median income loss of US$32.90 (IQR: 13.16–62.51) and a median cost per hour of productivity lost estimated at US$4.65 (IQR: 2.74–10.96). Overall, the total median OOP expenditure was US$824.35 (IQR: 535.59–1550.24), underscoring the significant financial impact of the illness (table 3).
Table 3
Out-of-pocket expenditure by cost parameter
| Cost parameters | N | Median (IQR) |
| Direct medical cost (in US$) | ||
| OPD visit cost | 56 | 6.05 (3.63–11.39) |
| Hospitalisation cost | 36 | 462.95 (249.28–1682.65) |
| Diagnosis and investigation | 120 | 148.86 (88.31–155.98) |
| Complementary medicine cost | 11 | 42.73 (28.48–128.20) |
| Allopathic medicine cost | 119 | 351.13 (213.67–641.01) |
| Health-related equipment cost | 29 | 37.39 (15.31–113.42) |
| Emergency care cost | 23 | 235.04 (49.85–356.12) |
| Direct non-medical cost (in US$) | ||
| Food cost during OPD visit | 49 | 4.27 (2.31–7.12) |
| Travel cost | 45 | 7.12 (2.71–12.11) |
| Relocation cost | 11 | 142.45 (106.83–178.06) |
| Special diet | 57 | 128.20 (85.46–213.67) |
| Paid caregiver | 13 | 854.68 (427.34–1175.18) |
| Indirect cost (in US$) | ||
| Cost per hour loss | 56 | 4.65 (2.74–10.96) |
| Income losses | 38 | 32.90 (13.16–62.51) |
| Total OOP expenditure (in US$) | 824.35 (535.59–1550.24) | |
US$1=NRs. 140.4 according to Nepal Rastra Bank 2024.
OOP, out-of-pocket; OPD, outpatient department.
Payment coping strategies
A significant majority (78.3%) used a government scheme to cover illness-related expenses, and nearly two-fifths (40.4%) enrolled in health insurance. Over two-fifths (44.2%) received financial support from friends, relatives or neighbours. A smaller proportion (7.5%) borrowed from banks, 17.5% of participants sold assets, very few respondents (1.7%) undertook additional paid work and about one-fifth (20%) reduced food expenses to cover medical costs (table 4).
Table 4
Payment coping strategies in chronic kidney disease patients
| Characteristics | Frequency | Percentage |
| Utilisation of government scheme | ||
| Yes | 94 | 78.3 |
| No | 26 | 21.7 |
| Type of government scheme | ||
| Health insurance | 38 | 40.4 |
| Social welfare allowance (local government) | 19 | 20.2 |
| Both | 37 | 39.4 |
| Financial support from friends, relatives or neighbours | ||
| Yes | 53 | 44.2 |
| No | 67 | 55.8 |
| Loan from bank | ||
| Yes | 9 | 7.5 |
| No | 111 | 92.5 |
| Assets sold | ||
| Yes | 21 | 17.5 |
| No | 99 | 82.5 |
| Additional paid work | ||
| Yes | 2 | 1.7 |
| No | 118 | 98.3 |
| Reduction in food expenses | ||
| Yes | 24 | 20.0 |
| No | 96 | 80.0 |
Household expenditure
The median cost for food expenditure was US$854.68 (512.81–1068.35). Likewise, the median cost for non-food expenditure was US$1194.41 (822.99–1803.20). Hence, the median cost for total household consumption expenditure was US$1291.28 (864.83–1908.70) (table 5).
Table 5
Household expenditure of chronic kidney disease patients
| Cost parameters (in US$) | Median (IQR) |
| Total food expenditure | 854.68 (512.81–1068.35) |
| Non-food expenditure | 1194.41 (822.99–1803.20) |
| Total household consumption expenditure | 1291.28 (864.83–1908.70) |
US$1=NRs. 140.4 according to Nepal Rastra Bank 2024.
Prevalence of financial catastrophe
Figure 1 depicts the prevalence of financial catastrophe among the CKD patients. Out of the total sampled (120), the majority (72.5%) of the patients incurred financial catastrophe with high OOP payments, while 27.5% did not incur financial catastrophe.
Associated factors of financial catastrophe
Binary logistic regression was conducted for variables such as religion, marital status, place of residence, presence of complications, financial support, assets sold and reduction in food expenses.
The final model in the logistic regression resulted in the presence of complication, financial support and reduction in food expenses being found to be statistically significant. The patients with complications had three times (adjusted OR (AOR): 3.67, 95% CI 1.019 to 13.27) higher odds of incurring financial catastrophe than those patients who did not have any complications. Similarly, the patient who did not have any financial support was two times (AOR: 2.77, 95% CI 1.016 to 7.56) more likely to incur financial catastrophe as compared with those receiving financial support. The patient who had reduced their food expenditure had 0.3 times (AOR: 0.313, 95% CI 0.109 to 0.896) lower odds of experiencing financial catastrophe than those patients who had not reduced their food expenditure (table 6).
Table 6
Associated factors of financial catastrophe
| Variables | Financial catastrophe | P value | COR | P value | AOR | |
| Presence | Absence | |||||
| Religion | ||||||
| Non-hindu | 24 (57.1%) | 18 (42.9%) | 0.006* | 0.317 (0.13 to 0.72) | 0.121 | 0.47 (0.18 to 1.21) |
| Hindu | 63 (80.8%) | 15 (19.2%) | Ref | |||
| Marital status | ||||||
| Never married | 12 (60.0%) | 8 (40.0%) | 0.170 | 0.5 (0.18 to 1.36) | 0.187 | 0.45 (0.14 to 1.46) |
| Married | 75 (75.0%) | 25 (25.0%) | Ref | |||
| Place of residence | ||||||
| Urban | 59 (77.6%) | 17 (22.4%) | 0.098 | 1.98 (0.87 to 4.49) | 0.342 | 1.58 (0.61 to 4.05) |
| Rural | 28 (63.6%) | 16 (36.4%) | ||||
| Presence of complication | ||||||
| Yes | 28 (87.5%) | 4 (12.5%) | 0.026* | 3.44 (1.1 to 10.73) | 0.047* | 3.67 (1.019 to 13.27) |
| No | 59 (67.0%) | 29 (33.0%) | Ref | |||
| Financial support | ||||||
| No | 44 (65.7%) | 23 (34.3%) | 0.060 | 2.24 (0.95 to 5.27) | 0.046* | 2.77 (1.016 to 7.56) |
| Yes | 43 (81.1%) | 10 (18.9%) | Ref | |||
| Assets sold | ||||||
| Yes | 12 (57.1%) | 9 (42.9%) | 0.083 | 0.42 (0.16 to 1.13) | 0.066 | 0.32 (0.097 to 1.079) |
| No | 75 (75.8%) | 24 (24.2%) | ||||
| Reduction on food expenses | ||||||
| Yes | 12 (50.0%) | 12 (50.0%) | 0.006* | 0.28 (0.11 to 0.71) | 0.030* | 0.313 (0.109 to 0.896) |
| No | 75 (78.1%) | 21 (21.9%) | Ref | |||
Ref: Reference categories are Hindu for religion, married for marital status, rural for place of residence, no for presence of complication, yes for financial support, no for assets sold and no for reduction on food expenses.
*Significant at p value <0.05.
AOR, adjusted OR; COR, crude OR.
Qualitative arm
Awareness about government subsidies
Most participants gained awareness about government subsidies for CKD treatment through informal sources, such as discussions with family members familiar with the programmes. The majority were knowledgeable about the eligibility requirements and the process for obtaining free services, including the necessary documents: a formal prescription from a licensed healthcare provider, a recommendation letter from the local municipality confirming financial hardship, and a certificate from the Health Office.
Formalities for getting free hemodialysis service required the name of the patient, duration of diagnosis, checkup card signed by a doctor from another hospital. It also needs a recommendation letter from the municipality stating that the patient is suffering from this disease and can’t bear any medical costs. It doesn’t take any long time to complete this process. It takes around 8–10 days to obtain the free dialysis service. (Participant 1)
Financial strain
For many participants, both medical and non-medical expenses became a significant financial burden, straining the economic stability of entire households. All participants appeared to face the financial hardship caused by the high costs of treatment, with none avoiding the economic challenges imposed.
A patient facing financial hardship expressed his frustration by saying, “I am facing difficulty in paying for the services and treatments and even struggling to afford rent and basic necessities. I have also sold assets, including land and vehicles, to cover the costs and even had to take a loan” (Participant 8).
Barriers to receiving treatment
Many participants had to relocate to Kathmandu for dialysis due to a lack of quality services in their hometowns. Most attended haemodialysis sessions alone as their family members were occupied with work or studies. While medicines were accessible at local pharmacies near the National Kidney Center, obtaining them through insurance required visits to other hospitals with long waiting time and frequent unavailability of prescribed drugs. Participant 9 shared an incident about the price gouging of medicine under health insurance, stating that,
I purchase medicine from health insurance at a subsidized rate. The medicines and injections that are prescribed by the doctors are not available under the health insurance scheme, they even give us medicines of different brands. When we buy injection from another medical store, we get it on NRs 650 but if we get it from health insurance, they make a bill of NRs1400 from which we have to pay 10% of the amount.
Effectiveness of the programme
The government’s support programme offers crucial support to CKD patients via free haemodialysis and a monthly social welfare allowance of NRs. 5000. However, numerous patients expressed that it is inadequate since it fails to address other medical costs, travel or consultation fees. While patients are appreciative of the services, they are concerned about the unforeseen expenses and suggest areas for improvement, including free transportation, improved access to drugs and the elimination of the 10% health insurance copayment. Overall, the programme is beneficial; there are still areas that need to be dealt with so that it could more effectively alleviate the financial strain experienced by CKD patients.
The government subsidy is quite helpful. The cost for dialysis is not affordable for everyone. Since it is free of cost, almost everyone who are suffering from CKD are able to get haemodialysis. They have also provided us social welfare allowance of NRs 5000 every month. However, only haemodialysis is provided free of cost. All other service cost should be paid by ourselves so it is not adequate. (Participant 7)
Participant 4 expressed his concern about the hidden cost with the statement,
Only haemodialysis is free. We have to bear many medical treatments such as medicines, diagnosis and investigation, transportation costs, etc. Also, I require two haemodialysis sessions each week and sometimes my wife comes with me. As she is a working woman, she needs to take leave from the office, which result in work loss days.
Mixed-method findings
Convergent findings
Quantitative and qualitative data underscore the huge financial toll on CKD patients with concurrently high OOP expenditures. Although free haemodialysis and welfare allowances provided by the government are crucial for healthcare accessibility, they are often inadequate and pose a significant challenge to improving affordability in their current capacity.
Divergent findings
Utilisation of government schemes is high, as shown by quantitative analysis. However, qualitative findings unravel the shortcomings, notably the failure to appropriately address the hidden costs, like transport and medication. Moreover, qualitative findings point to barriers such as long wait times and limited medicine availability under insurance, which are not taken into consideration in the quantitative findings.
Discussion
The rising burden of CKD is becoming a critical global health challenge, especially as it leads to severe financial hardship for patients. In countries like Nepal, without proper insurance coverage, patients bear high OOP costs. This study quantified OOP expenditures, financial catastrophe and its associated factors. The study also explored patients’ perceived effectiveness of government programme relating to CKD.
The findings demonstrate that total median OOP expenditure was US$824.35 over a 6-month period. Several studies reported similarly very high OOP health expenditure among CKD patients. Previous studies reported a mean annual cost of haemodialysis treatment of US$2337 and a median annual cost of US$1964 which are comparable to our estimate for CKD patients.17 18 Similarly, a study in Udupi of India reported monthly US$190 of OOP expenditure, which is quite similar to our study findings.19 In contrast to this, another study in India showed a monthly median OOP expenditure of US$478 which is higher than our OOP health payment.20 This significant variation might be due to the difference in the perspective of cost measurement and the socioeconomic status of participants. A significant amount of OOP was obtained from the direct medical expenses in which hospitalisation and allopathic medicine costs were found to be the major contributors, which is supported by a large body of evidence.21–23 Paid caregiver cost represented the highest expenses among direct non-medical cost, aligning with the study in South Korea which demonstrated that formal caregiver costing carried a huge proportion of OOP and was associated with a higher risk of CHE.24 Indirect costs such as median income losses (US$32.9) and productivity cost per hour loss (US$4.65) accounted for a small proportion of total OOP expenditure. Consistent with our findings, a study carried out in Enugu, Nigeria and a systematic review with meta-analysis have also revealed that indirect cost constitutes a smaller share of the overall financial burden.25 26
Our study used the cut-off value of at least more than or equal to 40.0% of a household’s capacity to pay to be catastrophic. Previous studies also used a cut-off of 40% of their capacity to pay.27 However, defining a cut-off for CHE has always been debated, WHO also recommends a 40% of non-food expenditure.28 In contrast, some studies have adopted a 10% cut-off,29 30 whereas others have used 20% of annual household income.21
The prevalence of financial catastrophe was found to be 72.5% among CKD patients undergoing haemodialysis. This prevalence is significantly higher than the national CHE estimates (10.3%) for the general population in Nepal.31 These differences may be due to the elevated financial burden among haemodialysis patients, given the nature of the disease and frequency of treatment sessions. This highlights the disproportionate economic strain experienced by patients living with chronic, expensive-to-treat conditions such as CKD. Although the government’s Deprived Citizen Support Programme provides subsidies for haemodialysis, these subsidies are often insufficient to offset the cumulative cost of care. Patients continue to bear significant expenses, resulting in ongoing OOP spending and a heightened risk of financial catastrophe. Our finding is consistent with previous research conducted in LMICs. Two studies in Kerala of India found that 91% and 67.4% of CKD patients incurred CHE.8 32 In Thailand, despite the presence of the Universal Coverage Scheme, approximately 50% of patients on haemodialysis reported facing CHE.33 Studies from Ethiopia and Nigeria reported CHE of 90% and 97%.17 34 Even in high-income countries like Australia, 78% faced financial hardship and 54% experienced financial catastrophe.35 In contrast, lower CHE prevalence (18.7%) has been demonstrated in dialysis patients in Kurdistan.36 Likewise, South Korea and China reported 3.5% and 25% among chronic disease patients.37 38 These differences may reflect variation in healthcare financing system and insurance coverage. The variation in CHE across countries is driven not only by income levels but also by the design of health systems, particularly the extent of insurance coverage, the comprehensiveness of benefit packages, and whether medicines, diagnostics, transportation and indirect costs are covered. In settings such as Nepal and other LMICs, where OOP spending remains the dominant mode of healthcare financing, dialysis patients are particularly vulnerable to catastrophic financial consequences.
This shows a significant association between the presence of complications and the prevalence of financial catastrophe, with an AOR of 3.67. Specifically, our findings suggest that the CKD patients with complications are more likely to experience financial catastrophe compared with those without any complications. This observation aligns with a study conducted by Meshkat et al in Iran in 2022, which also reported a significant relationship between complications and CHE.39 This link could be explained by the fact that complications increase the level of care required. Patients with complications often require longer hospital stays, more frequent hospital visits, additional diagnostic procedures and numerous medications, all of which significantly increase treatment-related costs. This explanation is further supported by the higher hospitalisation and medication costs found in this study.
This study demonstrates a clear statistical association between financial support and the prevalence of financial catastrophe. Our findings indicate that the patients who did not have any financial support from friends, relatives or neighbours to pay for the illness are significantly more vulnerable to experiencing financial catastrophe. This observation aligns with a study conducted in Australia, which similarly revealed that access to financial resources reduced the likelihood of having financial hardship.40 Consistent with our findings, Dodd et al emphasised the importance of financial support in treatment adherence and continuity among CKD patients.41
Similarly, the study found that CKD patients who had reduced their food expenses were less likely to experience financial catastrophe compared with those who did not reduce their food expenses. This suggests that reducing food expenditure may serve as a coping strategy to manage rising healthcare costs. Similar findings have been reported in a systematic literature review by Murphy et al, which provides evidence of a reduction in food expenditure for coping with healthcare costs for chronic illness.42 Likewise, a study in China showed that health shocks caused by unexpected medical spending led households to significantly reduce expenditure on food.43 However, while reducing food expenses may delay financial catastrophe, it raises concerns about nutritional compromise, especially for CKD patients with specific dietary needs. Beyond the statistical association, this coping strategy has significant clinical implications: inadequate dietary intake can accelerate protein-energy wasting, impair immune function, worsen functional status and potentially lead to more frequent hospitalisations, ultimately increasing long-term healthcare costs. Furthermore, unsupervised dietary restriction may contradict CKD-specific dietary guidance, particularly for haemodialysis patients who require higher protein intake. Overall, these findings underscore the intersection between financial hardship and food insecurity among CKD patients. Food-related coping strategies should be viewed not only as socioeconomic consequences but as modifiable determinants of clinical outcomes. Therefore, there is a need for policies and integrated programmes that not only address OOP expenditures but also ensure adequate nutritional support and social protection for patients with CKD.
The qualitative findings of this study focused on insightful lived experiences of patients while using the government programme, mainly identifying the financial burden and challenges faced by patients while assessing the subsidised services. An important theme that emerged was the participants’ awareness regarding government subsidies, specifically the lifelong free haemodialysis services. Most participants were familiar with the process for accessing the services, revealing similar findings in previous studies in Nepal, where patients likewise illustrated good knowledge about accessing free dialysis.44 Although this contradicts the findings in another study, which exposed a lack of awareness among patients about the Deprived Citizen Support Programme, indicating that awareness may vary depending on the particular programme or the population group.45
Although the subsidised dialysis was a boon, participants constantly stressed that the financial strain they continued to face, mainly due to OOP expenses on medications, diagnostic tests, accommodation and transportation, was posing a significant financial burden to them. These findings were reinforced by earlier studies in Nepal, which uncovered that despite the free dialysis procedure under programmes like the Deprived Citizen Support Scheme, patients still incur substantial direct and indirect costs.44 The economic burden made patients and their whole family vulnerable to financial instability. Participants also explained a variety of coping strategies, involving borrowing money and selling family assets. These statements correspond with findings from another study in Nepal, where households had to resort to distress financing methods in response to costly healthcare expenses.46 Patient somehow managed to receive immediate care with these strategies; however, it ultimately resulted in long-term financial vulnerability. The limited availability and disproportionate increase in drug prices covered by the health insurance programme, along with the need for patients to relocate their homes in cities to receive quality dialysis services, were also brought up by the patients as significant hurdles. Another study conducted in India raised similar concerns about the issues of lack of medications and insufficient diagnostic equipment at the primary healthcare level.47
People had different opinions regarding the effectiveness of the government programme. Some patients appreciated the subsidies, while a few expressed that these supports were inadequate to meet all the treatment-related costs. This corresponds to findings from a Singapore-based study in which most patients expressed that they had financial difficulties in meeting all the expenses incurred from treatment (medications, investigations, consultation fees).48 Moreover, the study reported overall satisfaction with the behaviour and care provided by hospital staff, highlighting respectful communication and supportive interactions. This is supported by another study in Nepal, where patients similarly noted positive experiences with healthcare providers.44 Participants also proposed suggestions for improvement, such as ensuring the consistent availability of prescribed medications under health insurance services, providing free or subsidised transportation, as well as broadening the scope of insurance schemes to encompass both direct and indirect costs. Similar recommendations were made in a study carried out in India, which underscored the importance of comprehensive financial protection measures, including free ambulance services and transportation subsidies for remote areas.49
The study has several methodological strengths and limitations that should be considered when interpreting the findings. The use of a convergent mixed-methods design allowed a comprehensive understanding of both the extent of financial catastrophe and the contextual factors influencing it. Cross-verification of participants’ health expenditure data with available medical bills enhanced the accuracy and reliability of the findings. However, this study relied on self-reported household expenditure data, which may have resulted in an under- or over-estimation of actual costs. Additionally, some medical expenses, such as hospitalisation due to complications, may also have been underestimated. Conducting the study in a single institution and including only patients enrolled in the government’s Deprived Citizen Support Programme limits generalisability and may introduce selection bias, as patients outside the subsidy programme may face different levels of financial burden.
Conclusion
The prevalence of financial catastrophe among CKD patients undergoing haemodialysis was high (72.5%). Complications, lack of financial support and reduced food expenditure were significantly associated with financial catastrophe. Despite existing government support, patients continue to incur substantial treatment-related expenses. Strengthening subsidy and insurance programmes to better cover medications, investigations and transportation may help reduce the economic burden. Policymakers and programme managers should consider these priorities when improving CKD care financing in Nepal.
Contributors SPou: contributed to the conception and design of the study, data collection, data analysis, interpretation of results, drafting of the manuscript and final approval of the version to be published. DKY: provided academic supervision, contributed to study design, critical revision of the manuscript for intellectual content and final approval of the version to be published. VKK: contributed to methodology development, interpretation of findings, manuscript revision and approved the final manuscript. GNG: provided guidance on study design and implementation, critically reviewed the manuscript and approved the final version. SPok: assisted in literature review, data collection and analysis, participated in manuscript drafting and approved the final manuscript. AP: contributed to formatting, referencing and administrative support during manuscript preparation; reviewed and approved the final version. AGA: assisted in data analysis, revised the work critically, reviewed and approved the final manuscript. Each author has read and approved the final version of the manuscript and agrees to be accountable for all aspects of the work. SPou is the guarantor of this work.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
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