The goal of universal health coverage is challenging for chronically under-resourced health systems. Although household out-of-pocket payments are the most important source of health financing in low-income countries, relatively little is known about the drivers of primary health care expenditure and the predictability of the burden associated with high fee-for-service payments. This study describes out-of-pocket health expenditure and investigates demand- and supply-side drivers of excessive costs in the Democratic Republic of Congo (DRC), a central African country in the midst of a process of reforming its health financing system towards universal health coverage. A population-based household survey was conducted in four provinces of the DRC in 2014. Data included type, level and utilization of health care services, accessibility to care, patient satisfaction and disaggregated health care expenditure. Multivariate logistic regressions of excessive expenditure for outpatient care using alternative thresholds were performed to explore the incidence and predictors of atypically high expenditure incurred by individuals. Over 17% (17.5%) of individuals living in sample households reported an illness or injury without being hospitalized. Of 3341 individuals reporting an event in the four-week period prior to the survey, 65.6% sought outpatient care with an average of one visit (SD = 0.0). The overall mean expenditure per visit was US$ 6.7 (SD = 10.4) with 29.4% incurring excessive expenditure. The main predictors of a financial risk burden included utilizing public services offering the complementary benefit package, dissatisfaction with care received, being a member of a large household, expenditure composition, severity of illness, residence and wealth (p < .05). The insured status influenced the expenditure level, with no association with catastrophe. Those who did not seek care when needed reported financial constraints as the major reason for postponing or foregoing care. Wealth-related inequities were found in service and population coverage and in out-of-pocket payment for outpatient care. Burdensome expenditure for primary care and its key drivers are of utmost importance. Forthcoming health financing reform agendas must incorporate a strategy for getting data used in the design of financial risk protection. Realizing equitable and efficient access to outpatient care is a vital ingredient for sustainable health systems.

Tuberculosis (TB) is a major global public health problem which affects poorest individuals the worst. A high proportion of patients incur ‘catastrophic costs’ which have been shown to result in severe financial hardship and adverse health outcomes. Data on catastrophic cost incidence is not routinely collected, and current definitions of this indicator involve several practical and conceptual barriers to doing so. We analysed data from TB programmes in India (Bangalore), Bangladesh and Tanzania to determine whether dissaving (the sale of assets or uptake of loans) is a useful indicator of financial hardship. Data were obtained from prior studies of TB patient costs in Bangladesh (N = 96), Tanzania (N = 94) and Bangalore (N = 891). These data were analysed using logistic and linear multivariate regression to determine the association between costs (absolute and relative to income) and both the presence of dissaving and the amounts dissaved. After adjusting for covariates such as age, sex and rural/urban location, we found a significant positive association between the occurrence of dissaving and total costs incurred in Tanzania and Bangalore. We further found that, for patients in Bangalore an increase in dissaving of $10 USD was associated with an increase in the cost-income ratio of 0.10 (p < 0.001). For low-income patients in Bangladesh, an increase in dissaving of $10 USD was associated with an increase in total costs of $7 USD (p <0.001). Dissaving is potentially a convenient proxy for catastrophic costs that does not require usage of complex patient cost questionnaires. It also offers an informative indicator of financial hardship in its own right, and could therefore play an important role as an indicator to monitor and evaluate the impact of financial protection and service delivery interventions in reducing hardship and facilitating universal health coverage. Further research is required to understand the patterns and types of dissaving that have the strongest relationship with financial hardship and clinical outcomes in order to move toward evidence-based policy making.

Paying for health care may exclude poor people. Burkina Faso adopted the DOTS strategy implementing “free care” for Tuberculosis (TB) diagnosis and treatment. This should increase universal health coverage and help to overcome social and economic barriers to health access. Straddling 2007 and 2008, in-depth interviews were conducted over a year among smear-positive pulmonary tuberculosis patients in six rural districts of Burkina Faso. Out-of-pocket expenses (direct costs) associated with TB were collected according to the different stages of their healthcare pathway. Median direct cost associated with TB was US$101 (n = 229) (i.e. 2.8 months of household income). Respectively 72% of patients incurred direct costs during the pre-diagnosis stage (i.e. self-medication, travel, traditional healers' services), 95% during the diagnosis process (i.e. user fees, travel costs to various providers, extra sputum smears microscopy and chest radiology), 68% during the intensive treatment (i.e. medical and travel costs) and 50% during the continuation treatment (i.e. medical and travel costs). For the diagnosis stage, median direct costs already amounted to 35% of overall direct costs. The patient care pathway analysis in rural Burkina Faso showed substantial direct costs and healthcare system delay within a “free care” policy for TB diagnosis and treatment. Whether in terms of redefining the free TB package or rationalizing the care pathway, serious efforts must be undertaken to make “free” health care more affordable for the patients. Locally relevant for TB, this case-study in Burkina Faso has a real potential to document how health programs' weaknesses can be identified and solved.

In theory, the removal of user fees puts health services within reach of everyone, including the very poor. When Burkina Faso adopted the DOTS strategy for the control of tuberculosis, the intention was to provide free tuberculosis care. In 2007-2008, interviews were used to collect information from 242 smear-positive patients with pulmonary tuberculosis who were enrolled in the national tuberculosis control programme in six rural districts. The median direct costs associated with tuberculosis were estimated at 101 United States dollars (US$) per patient. These costs represented 23% of the mean annual income of a patient's household. During the course of their care, three quarters of the interviewed patients apparently faced "catastrophic" health expenditure. Inadequacies in the health system and policies appeared to be responsible for nearly half of the direct costs (US$ 45 per patient). Although the households of patients developed coping strategies, these had far-reaching, adverse effects on the quality of lives of the households' members and the socioeconomic stability of the households. Each tuberculosis patient lost a median of 45 days of work as a result of the illness. For a population living on or below the poverty line, every failure in health-care delivery increases the risk of "catastrophic" health expenditure, exacerbates socioeconomic inequalities, and reduces the probability of adequate treatment and cure. In Burkina Faso, a policy of "free" care for tuberculosis patients has not met with complete success. These observations should help define post-2015 global strategies for tuberculosis care, prevention and control.