Inequalities in financial burden of severe childhood illness on households in Lao PDR: A prospective cohort study

Lao Peoples Democratic Republic (PDR) introduced a National Health Insurance (NHI) scheme in 2016 to all provinces except Vientiane Capital City. We describe the financial impact on households related to treatment of severe childhood illness at a hospital covered by NHI, and one without NHI. We conducted a prospective cohort study (2022-2024) in Lao PDR of children aged one month to <15 years admitted with severe illness at two hospitals: Salavan Provincial Hospital (SPH) with NHI, and National Childrens Hospital (NCH) without NHI, with two-month follow-up post-discharge. Illness-related direct and indirect costs were collected. We calculated household out-of-pocket (OOP) costs, impoverishment and catastrophic health expenditure (CHE, >10% annual household expenditure) rates and analysed relative risk (RR) of CHE by socioeconomic status. 200 participants were recruited from each hospital with demographic differences observed between hospitals in urban residence (NCH 87.0%, SPH 14.5%), maternal education (primary level: NCH 95.9%, SPH 76.3%) and wealth status (wealthiest quintile: NCH 79.0%, SPH 20.5%). Median household OOP costs were higher at NCH (USD290.6 [IQR 206.9-422.9]) compared to SPH (USD92.4 [IQR 56.3-52.9]). Impoverishment at two months post-discharge was 0.5% (95%CI 0.0-3.0) at NCH and 10.2% (95%CI 6.2-15.4) at SPH. CHE rates were 34.5% (95%CI 27.9-41.1) at NCH and 26.0% (95%CI 19.9-32.1) at SPH, with higher RR in the poorest versus wealthiest households (NCH: RR 6.6, 95%CI 4.5-9.5; SPH: RR 4.9, 95%CI 1.7-13.7) and households with no formal maternal education versus secondary education (NCH: RR 2.6, 95%CI 1.2-5.5; SPH: RR 4.6, 95%CI 1.92-11.1). Direct medical costs were lower where NHI is available, but total household OOP costs and CHE rates were high at both hospitals, particularly among disadvantaged households. Additional interventions are required to prevent severe illness and provide financial protection for socioeconomically disadvantaged groups to reduce health-related economic burden on households in Lao PDR.