Catastrophic health expenditure and associated factors in low-, lower-middle and upper-middle-income countries: systematic review and meta-analysis

Background Reducing catastrophic health expenditure (CHE) is critical for achieving Universal Health Coverage (UHC), as high out-of-pocket healthcare spending can cause financial hardship and hinder access to care. However, evidence on CHE prevalence and associated factors in low-income (LICs), lower-middle-income (Lower-MICs), and upper-middle-income (UMICs) countries remains fragmented.Objectives To systematically review and synthesize evidence on the prevalence and factors of CHE in LICs, Lower-MICs, and UMICs.Methods Following registered protocol (PROSPERO: CRD42024521553) and PRISMA guidelines, we searched CINAHL, PubMed, Scopus, and Web of Science for studies published between 2015 and 2023. Quantitative studies that measured CHE and/or associated factors at the 10% threshold of household total expenditure/income and/or the 40% threshold of non-food expenditure were included. Risk of bias was assessed using the AXIS tool. A random-effects meta-analysis estimated the pooled prevalence of CHE, and associated factors were synthesized narratively.Results Forty studies were included. Key determinants increasing CHE risk were low income, elderly or chronically ill members, private facilities use, female-headed households, and lack of insurance, while education and employment were protective. Rural residence was generally associated with higher CHE despite mixed findings. Pooled CHE prevalence was 18% (95% CI: 14–23%) at the 10% threshold and 7% (95% CI: 5–10%) at the 40% threshold, with considerable heterogeneity (I2 > 99%). UMICs had the highest CHE prevalence, whereas LICs reported the lowest.Conclusions CHE remains considerable, particularly in Lower-MICs and UMICs, and varies across income groups. Achieving UHC requires policies to strengthen financial protection and reduce socioeconomic disparities.