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We present a novel perspective on thinking about and studying healthcare spending in contexts where few health-related financial risk protection mechanisms exist and where out-of-pocket spending by households is the norm. Drawing on interviews conducted across 20 villages in two states of India, we illustrate and problematize how a complex interplay of social norms and cultural factors underpin spending decisions within households in such contexts. While our analysis draws on the fieldwork at large, we present our findings through selected narratives - stories of patients suffering from chronic breathlessness. We engage with and reveal the various ways in which social norms dynamically drive this household economy, and shape resource allocation-related decisions. We conclude that in health system contexts where out-of-pocket spending by households is the norm, it is essential to recognise the pragmatic and calculative nature of intra-household allocation of resources, and how it involves bargaining and negotiations at the intersection of social norms, economic class, caste, gender, age, and productive status. And at the same time, how all of this occurs within the economy of the family, and how it plays out differently for different members of a family is also important to recognise. Such recognition can not only help one better appreciate how this household level economy may sometimes maintain and perpetuate entrenched hierarchies and gender inequities, crucially, it can help target health related social protection policies and strategies and make them more responsive to the needs of the most vulnerable in the society and within households.
Kane et al. (Wed,) studied this question.