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Background  Road traffic injuries (RTI) are an increasing public health problem in India where out-of-pocket (OOP) expenditures on health are among the highest in the world. We estimated the OOP expenses for RTI in a large city in India.    Methods  Information on medical and non-medical expenditure was documented for RTI cases of all ages that reported alive or dead to the emergency departments of two public hospitals and a large private hospital in Hyderabad. Differential risk of catastrophic OOP total expenditure (COPE-T) and medical expenditure (COPE-M), and distress financing was assessed for 723 RTI cases that arrived alive at the study hospitals with multiple logistic regression. Catastrophic expenditure was defined as expenditure > 25% of the RTI patient’s annual household income. Variation in intensity of COPE-M in RTI was assessed using multiple classification analysis (MCA).    Results  The median OOP medical and non-medical expenditure was USD 169 and USD 163, respectively. The prevalence of COPE-M and COPE-T was 21.9% (95% CI 18.8-24.9) and 46% (95% CI 42–49.3), respectively. Only 22% had access to medical insurance. Being admitted to a private hospital (OR 5.2, 95% CI 2.7–9.9) and not having access to insurance (OR 3.8, 95% CI 1.9–7.6) were significantly associated with risk of having COPE – M. Similar results were seen for COPE - T. MCA analysis showed that the burden of OOP medical expenditure was mainly associated with in-patient days in hospital (Eta =0.191). Prevalence of distress financing was 69% (95% CI 65.5-72.3) with it being significantly higher for those reporting to the public hospitals (OR 2.8, 95% CI 1.7-4.6), those belonging to the lowest per capita annual household income quartile (OR 7.0, 95% CI 3.7-13.3), and for those without insurance access (OR 3.4, 95% CI 2.0-5.7).    Conclusions  This paper has outlined the high burden of out-of-pocket medical and total expenditure associated with RTI in India. These data reinforce the need for implementing more effective financial protection mechanisms in India against the high out-of-pocket expenditure incurred on RTI.

Burden of out-of-pocket expenditure for road traffic injuries in urban India