Khurshid Alam

Abstract
Background

The burden of out-of-pocket (OOP) healthcare expenses for pregnancy-related conditions is a significant concern in resource-prone countries. Bangladesh and Pakistan, two historically connected countries with similar socioeconomic standings, rank among the highest globally in OOP share in total health expenditures. Excessive OOP costs pose financial barriers to maternal healthcare utilisation, leading to catastrophic health expenditures (CHE) and deepening poverty. Our study aims to compare pregnancy-related OOP expenditures between Bangladesh and Pakistan, examining key disparities in spending patterns and financial burden.

Methods

This study utilises data from the Bangladesh Household Income and Expenditure Survey (HIES) 2022 and published secondary evidence for Pakistan in the absence of primary data. For Bangladesh, we included all women of reproductive age who reported pregnancy-related health issues in the past 30 days or were hospitalised in the last 12 months. We estimated the share of OOP in total household expenditure on pregnancy-related healthcare, assessed CHE using budget share, actual, and normative food expenditure methods, and evaluated impoverishment effects. Descriptive and equity-based analyses were conducted to examine expenditure variations across socioeconomic groups.

Results

In Bangladesh, pregnancy-related OOP expenditures (USD 434.4) accounted for 50% of total household healthcare spending (USD 892.6). The share of OOP in total household expenditure was significantly higher for private healthcare facilities (USD 417.1) and among rural women (USD 384.8). Low-income households spent a greater proportion (two-thirds) of their total expenditure on pregnancy-related care. The CHE incidence was around 94.6%-80.9% among the lowest quintile households and 26.8%-66.5% among rural households under normative capacity-to-pay (CTP) method. Impoverishment rates were highest, with 31.7% low-income and 3.9% rural households falling into poverty due to OOP expenses. In Pakistan, OOP costs for pregnancy care were significantly higher in private facilities (USD 209.88-255.49) than in public facilities (USD 23.30-63.87).

Conclusion

Pregnancy-related OOP healthcare costs constitute a significant financial burden in Bangladesh and Pakistan, with higher expenses in private facilities. Low-income and rural families in Bangladesh face the greatest hardship, often leading to financial catastrophe and poverty. Strengthening public healthcare funding, expanding maternal health insurance, and regulating private sector pricing could reduce OOP costs and improve maternal healthcare equity.