Out-of-pocket expenditure on medicine for chronic patients and its economic impact on Indian households: a systematic review and meta-analysis

Vollständiger Abstract

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Background Out-of-pocket expenditure (OOPE) on medicines constitutes a substantial component of healthcare spending in India, particularly among patients with chronic diseases requiring continuous treatment. This systematic review and meta-analysis aimed to synthesise evidence on medicine-related OOPE in India and assess its magnitude and variation across disease categories, healthcare settings, and provider sectors. Methods We conducted a systematic review and meta-analysis in accordance with PRISMA 2020 guidelines, with the protocol registered in PROSPERO (CRD420251018386). PubMed, Scopus, and Web of Science were searched for peer-reviewed studies published from 1 January 2008 to 31 March 2025. Two reviewers independently screened studies, extracted data, and assessed methodological quality using Joanna Briggs Institute Critical Appraisal tools. Monetary estimates were standardised to constant 2024 Indian Rupees (INR) using the Consumer Price Index. Random-effects meta-analyses were performed for compatible outcomes, while disease-specific estimates derived from the same study population were synthesised descriptively to avoid treating correlated observations as independent. Findings Thirty studies were included in the systematic review, of which 11 contributed to the quantitative meta-analysis. Among patients with chronic diseases, the pooled mean annual medicine-related OOPE was ₹9,550.58 per patient (95% CI: ₹3,642.60–₹15,458.57), with substantial between-study heterogeneity ( I 2 = 99.2%). The pooled mean was numerically higher for chronic than non-chronic conditions (₹9,550.58 vs. ₹4,383.79), although the subgroup difference was not statistically significant ( p = 0.0989). Approximately 51% of individuals incurred medicine-related OOPE (95% CI: 43–59%). Among inpatients, pooled medicine OOPE per episode was ₹3,271.20 (95% CI: ₹852.31–₹5,690.10) in public facilities and ₹4,135.81 (95% CI: −₹2,244.42–₹10,516.04) in private facilities, with no statistically significant subgroup difference ( p = 0.8039). Medicines accounted for approximately 30–50% of total OOPE during inpatient care and 60–80% during outpatient care. In the disease-specific analysis, four independent estimates of medicine-related OOPE among patients with diabetes were quantitatively pooled, yielding a pooled mean of ₹6,510.20 per patient (95% CI: ₹1,994.35–₹11,026.05), with substantial heterogeneity ( I 2 = 99.3%). Estimates for rheumatic disease, hypertension, cancer, acid peptic disease, and thyroid disorders were presented descriptively because of limited evidence and non-independent estimates from the same study population. Interpretation Medicine-related OOPE represents a substantial financial burden in India, particularly for patients requiring long-term treatment for chronic diseases. However, considerable heterogeneity and limited evidence within several subgroup analyses warrant cautious interpretation of pooled estimates. Strengthening public-sector medicine supply, improving access to affordable essential and generic medicines, and extending financial protection to outpatient medicines may help reduce household financial burden and advance Universal Health Coverage in India. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420251018386 , PROSPERO registration: CRD420251018386.