Thesis Report.

ABSTRACT

Background: Chronic kidney disease (CKD) requiring hemodialysis imposes substantial
financial burden on patients and families, even with government subsidies. This study
examined catastrophic health expenditure, associated factors, and coping mechanisms
among CKD patients undergoing maintenance hemodialysis in Gandaki Province, Nepal.
Methods: A multi-method cross-sectional study was conducted among 270 CKD patients
selected randomly from all government dialysis centers across Gandaki Province.
Quantitative data on out-of-pocket expenses, household expenditure, and catastrophic
health expenditure (CHE defined as health payments ≥40% of capacity to pay) were
collected using semi-structured questionnaires. Summary measures were presented as
mean, standard deviation, median and inter-quartile range, and inferential statistics were
done using chi-square test and binary logistic regression. Qualitative in-depth interviews
with 15 participants explored coping mechanisms using the Brief COPE framework.
Results: Nearly two-thirds (64.81%, 95% CI 59.11%-70.51%) of households experienced
catastrophic health expenditure despite universal free dialysis coverage. Mean six-month
out-of-pocket expenditure was NPR 79,240, with indirect costs (transportation and
relocation) exceeding direct medical costs. Inpatient admission independently increased
CHE odds more than four-fold (AOR 4.41, 95% CI 1.68-11.60), while borrowing from
social networks reduced odds by 58% (AOR 0.417, 95% CI 0.229-0.762) and decreasing
socioeconomic status increased the odds of catastrophic health expenditure by more than
four times. Distress financing was pervasive, 94.8% depleted savings, 35.6% borrowed
from relatives, and 17.8% sold assets. Qualitative findings revealed common coping

strategies as religious faith, emotional support, instrumental support, acceptance, and self-
distraction and venting, humor and denial as less common used ones. Despite

acknowledging government support as lifesaving, participants highlighted coverage gaps:
medicine unavailability through insurance, delayed allowances, waiting time for spot in
free dialysis and complete lack of transportation support.Conclusions: Expansion of free hemodialysis services to district-level facilities has eased
both financial burdens and access barriers for many patients in Gandaki Province. Yet,
existing protection mechanisms still fall short. Addressing indirect costs, strengthening
transplant support, and further decentralizing care remain essential to prevent dialysis
patients from inflicting catastrophic health expenditure.

Keywords: Catastrophic health expenditure, Chronic kidney disease, coping mechanisms
hemodialysis, Nepal