Paper short abstract

Uganda’s healthcare relies on out‑of‑pocket payments, driving household debt and inequality. Structural adjustment and donor dependence constrain state capacity, with women bearing disproportionate burdens. A rights‑based, redistributive approach is needed.

Paper long abstract

Uganda’s health financing model illustrates enduring tensions at the heart of development studies: the legacies of structural adjustment, the persistence of neoliberal austerity, and uneven consequences of aid‑dependent systems. Despite decades of reform, healthcare provision remains heavily reliant on out‑of‑pocket payments, a mechanism that forces households to absorb costs directly and reproduces cycles of indebtedness and inequality. Drawing on policy documents and qualitative accounts, this paper situates Uganda’s reliance on user‑financing within broader debates on the political economy of development, showing how conditionalities and debt regimes have constrained state capacity to deliver equitable healthcare.

The analysis foregrounds the gendered dimensions of health financing: women, as primary caregivers and managers of household health, disproportionately bear the burden through unpaid labour, informal borrowing, and reduced consumption. This dynamic exemplifies how neoliberal development paradigms intersect with developmental feminism, where liberal frameworks such as gender mainstreaming and Women in Development expand programmatic visibility but often depoliticise structural inequalities.

By examining Uganda’s health system as a case of postcolonial development under constraint, the paper advances three contributions to development studies. First, it highlights how out‑of‑pocket financing entrenches inequality and undermines social citizenship. Second, it demonstrates the paradox of the postcolonial state, which remains central to legitimising healthcare provision yet is disciplined by external financial regimes. Third, it calls for a rights‑based and redistributive approach to health financing that prioritises universal health coverage, social protection, and debt relief. Uganda’s experience is situated within wider debates on the future of development, sovereignty, and justice in Sub‑Saharan Africa.

Paper short abstract

Framed by capability and financialization of health perspectives, this study using NSSO 2017–18 shows India’s uninsured populations faces high catastrophic spending and financial distress, worsened by private-sector reliance. Findings call for stronger public investment and private sector regulation

Paper long abstract

India’s ‘missing middle’- individuals ineligible for government funded insurance yet lacking adequate financial protection remain a policy blind spot and understudied in national debates. Grounded in the capability approach and literature on financialization of health, this study conceptualises catastrophic health expenditures and financial distress as both a constraint on household capabilities and a symptom of broader health system dysfunctions. Using a nationally representative data from the National Sample Survey on Social Consumption: Health (NSSO 2017–18), the study examines risk of CHE and financial distress for the this uninsured group.

The analysis employs linear probability models with state fixed effects and propensity score matching to address observable selection into private healthcare. Results show that non-communicable diseases (NCDs) and injuries considerably raise the risk of CHE and distress financing among the missing middle. Reliance on private providers further intensifies vulnerability, reflecting the cumulative effects of limited public investment, expanding corporate consolidation, and weak regulatory oversight in the health sector.

These findings challenge prevailing assumptions that the missing middle can self-finance healthcare through market-based mechanisms. Even relatively moderate-income households face substantial financial strain when confronting chronic or acute health needs in a predominantly private, increasingly financialized system. The evidence underscores the need to strengthen public sector capacity and introduce stronger regulatory safeguards for private healthcare. Addressing these gaps is essential for advancing meaningful financial protection and achieving universal health coverage in India.

Paper short abstract

India have amongst the highest burden of out-of-pocket health expenditure in the world. In contrast other neighbouring South Asia countries have pioneered universal healthcare systems. So, India will benefit from enacting framework legislation on the right to healthcare to stem privatisation.

Paper long abstract

South Asia is the only region in the world which stands-out with the highest burden of out-of-pocket health expenditure. In India, the largest country in the region, 45 percent of current healthcare expenditure continues to be borne by patients and their caregivers. Healthcare costs are the single most important reason for household impoverishment. The Indian government spends less than 1.5 percent of GDP on healthcare. This underinvestment also exacerbates acute healthcare inequalities among genders, ethnicities, classes, religions and castes. This paper will contrast India’s corrosive privatisation with the universal healthcare models in South Asian and beyond. In contrast, neighbouring Sri Lanka has long been a pioneer in building a system of free universal healthcare. Nepal, Maldives and Bhutan have also built innovative healthcare systems while guaranteeing the constitutional right to free healthcare. Globally, fifty-eight per cent of countries guarantee the right to health for all citizens in their constitutions. Many countries in Europe, Asia and Latin America have also enacted framework laws to protect the right to health. Similarly, this analysis will make the case for the enactment of framework legislation on the right to healthcare in India to stem privatisation and emulate more egalitarian South Asian countries.

Paper short abstract

Drawing on longitudinal qualitative data from India, this paper examines how families facing precarity negotiate health and nutrition amid unstable livelihoods. Using Strong Structuration Theory, it shows how limited resources and moral reasoning shape trade-offs that reproduce vulnerability.

Paper long abstract

This paper examines how families living in conditions of precarity and socio-economic uncertainty negotiate health and nutrition within limited resources and structural constraint. We draw from longitudinal qualitative data conducted in Uttar Pradesh and Goa over three phases between December 2022 and May 2025. Drawing on repeated interviews with multiple members across 40 households, the study interrogates how health and wellbeing are continuously negotiated within intersecting regimes of food insecurity, labour precarity, and care. We show that while food insecurity exacerbated ill-health, health concerns were often deprioritised in favour of securing food and livelihoods. Adversities in one domain often compounded vulnerabilities in the other, revealing their interdependence within constrained socio-economic contexts. Health conditions—both sudden and chronic—were negotiated through difficult trade-offs. Drawing on Strong Structuration Theory (Stones, 2005), the study conceptualises family responses to health needs as situated within a dynamic interplay between external and internal structures. External conditions—such as unstable work, dependence on the informal economy, low wages, food inflation, marital transitions, seasonality and barriers to healthcare—constrain what forms of choices are materially possible. At the same time, internal structures—families’ interpretations, moral reasoning, and dispositions—mediate how these constraints are understood and acted upon. This leads to actions that have short and long-term outcomes. Together, these interactions produce a recursive loop in which health-related choices both emerge from and further reinforce/strain the very structural conditions that shape them.

Paper short abstract

Where health is funded privately, payments for healthcare easily lead to personal indebtedness yet there are significant knowledge gaps especially in terms of experiences from the majority world. Here we start to consider what we know and work towards a preliminary research agenda.

Paper long abstract

Where health is funded privately, payments for healthcare easily lead to personal indebtedness. Debts for health are a phenomenon that is well-researched for the USA and to some extent other higher-income countries, but the majority world largely remains terra incognita. Yet qualitative evidence, such as from financial inclusion research, suggests health expenses are crucial to why many people become entrapped in debt. Meanwhile, recent scholarship notes “structural changes that are turning healthcare into a playing field for capitalist actors”, suggesting systemic links between financialisation, profit-making, rising health expenses, and indebtedness. As research from other issue-fields suggests, when the public provision of basic services declines or is politically eschewed in favour of profit-oriented and financialised providers, households face greater debt and risk burdens.

Our paper offers a preliminary attempt to crack open the black box regarding health-related indebtedness in the majority world, reviewing some of the key issues and challenges and identifying research gaps. We consider what global evidence tells us about the causes, manifestations, and consequences of medical indebtedness, and the possible links between these. For example, when publicly funded healthcare erodes and new for-profit providers, blended finance arrangements, or outsourcing models enter – how does this affect patients and their families? How does health-related indebtedness manifest – e.g. different types of debt, treatment inequalities, or even hospital incarceration – and how do people cope? In turn, health-related indebtedness may have consequences such as delayed treatment-seeking, worsened gender inequalities, descent into debt traps, while creating political and systemic-level repercussions.