1 Murphy A, et al. BMJ Global Health 2019;4:e001475. doi:10.1136/bmjgh-2019-001475 Coping with healthcare costs for chronic illness in low-income and middle- income countries: a systematic literature review Adrianna Murphy,  1 Catherine McGowan, 2,3 Martin McKee, 1 Marc Suhrcke, 4,5 Kara Hanson 6 Research To cite: Murphy A, McGowan C, McKee M, et al. Coping with healthcare costs for chronic illness in low-income and middle-income countries: a systematic literature review. BMJ Global Health 2019;4:e001475. doi:10.1136/ bmjgh-2019-001475 Handling editor Soumyadeep Bhaumik ► Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10. 1136bmjgh-2019-001475). Received 8 February 2019 Revised 25 June 2019 Accepted 29 June 2019 For numbered affliations see end of article. Correspondence to Dr Adrianna Murphy; adrianna.murphy@lshtm.ac.uk © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ. ABSTRACT Background Experiencing illness in low-income and middle-income countries (LMICs) can incur very high out-of-pocket (OOP) payments for healthcare and, while the existing literature typically focuses on levels of expenditure, it rarely examines what happens when households do not have the necessary money. Some will adopt one or more ‘coping strategies’, such as borrowing money, perhaps at exorbitant interest rates, or selling assets, some necessary for their future income, with detrimental long-term effects. This is particularly relevant for chronic illnesses that require consistent, long-term OOP payments. We systematically review the literature on strategies for fnancing OOP costs of chronic illnesses in LMICs, their correlates and their impacts on households. Methods We searched MEDLINE, EconLit, EMBASE, Global Health and Scopus on 22 October 2018 for literature published on or after 1 January 2000. We included qualitative or quantitative studies describing at least one coping strategy for chronic illness OOP payments in a LMIC context. Our narrative review follows Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. Results Forty-seven papers were included. Studies identifed coping strategies for chronic illness costs that are not traditionally addressed in fnancial risk protection research (eg, taking children out of school, sending them to work, reducing expenditure on food or education, quitting work to give care). Twenty studies reported socioeconomic or other correlates of coping strategies, with poorer households and those with more advanced disease more vulnerable to detrimental strategies. Only six studies (three cross-sectional and three qualitative) included evidence of impacts of coping strategies on households, including increased labour to repay debts and discontinuing treatment. Conclusions Monitoring of fnancial risk protection provides an incomplete picture if it fails to capture the effect of coping strategies. This will require qualitative and longitudinal research to understand the long-term effects, especially those associated with chronic illness in LMICs. BACKGROUND Financial risk protection has long been recog- nised as a core objective of universal health coverage (UHC), now included explicitly in the United Nations Sustainable Devel- opment Goal (SDG) 3 on health and well- being. Thus, the relevant target is to ‘Achieve universal health coverage, including finan- cial risk protection, access to quality essential Key questions What is already known? ► Extensive research shows that chronic illnesses can increase household expenditure, but the range of strategies households use to cope with chronic out- of-pocket healthcare payments, the determinants of these strategies and their long-term impact on households, are less well understood. What are the new fndings? ► Households with chronic illnesses employ a range of strategies not traditionally captured in fnancial pro- tection research, for example, taking children out of school or stopping treatment, and there is also het- erogeneity within single types of coping strategies (eg, sale of productive vs non-productive assets). ► Very few studies have considered determinants of detrimental coping strategies, while qualitative work suggests coping strategies can lead to long- term indebtedness, exacerbated illness, stigma and strained social relationships. What do the new fndings imply? ► Efforts to monitor fnancial protection must consider a wider range of strategies used by households with chronic illness to cope with healthcare costs, as a failure to account for their impacts will underesti- mate the gap in fnancial risk protection. ► More qualitative and longitudinal research is need- ed to inform ways to support vulnerable groups and more comprehensively monitor fnancial risk pro- tection, particularly in LMICs underrepresented in health systems research. on 22 August 2019 by guest. Protected by copyright. http://gh.bmj.com/ BMJ Glob Health: first published as 10.1136/bmjgh-2019-001475 on 21 August 2019. Downloaded from