Assessing intervention effects on healthcare-related financial protection in low and middle-income countries: a rapid evidence review

Financial protection is a key goal for universal health coverage, but globally this indicator has been lagging, especially for low-income households. Understanding how to improve it is urgent. This rapid evidence review examined the effectiveness of interventions which affected financial protection in health across low- and middle-income countries (LMICs). A systematic search of published literature identified empirical studies reporting on outcomes such as out-of-pocket expenditure (OOPE), catastrophic spending, impoverishment, and care foregone for financial reasons, with data extracted and categorized using structured tools. A narrative synthesis was used to interpret the evidence. The review included 214 studies published between 1999 and 2024, covering interventions in 39 countries. About one-quarter of studies assessed equity, often revealing mixed or regressive effects. Financial protection is affected through multiple channels but evaluations still largely focus on health-sector specific interventions, failing to examine potentially impactful wider policies. Insurance schemes were the most studied intervention type, with mixed results. Demand-side financing, such as vouchers or cash transfers, and user fee reforms often struggled to benefit the poorest due to structural barriers and indirect costs. Provider payment reforms were more likely than other categories to show adverse effects, including unintended supplier behaviour changes that drove up OOPE and costs to the system. Less frequently evaluated interventions, such as social protection and behaviour change programs, showed some positive effects. Whilst no single intervention consistently ensured financial protection, the evidence points to the value of interventions that act across multiple sectors and health areas. Designing reforms with an explicit objective of improving financial protection, with local context, system capacity, and equity in mind and adjusting based on continuous monitoring, can support achievement of improved and equitable financial protection.