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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.

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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.

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Paper short abstract

Focusing on DEG hospital investments and the Indo-German UHC programme, this study shows how German development finance may reinforce healthcare financialisation in India, contributing to high out-of-pocket costs, inequities, and health-related debt.

Paper long abstract

Health-sector financialisation has increasingly positioned healthcare in low- and middle-income countries as a site for capital accumulation, with significant implications for affordability, access, and household financial risk. Development Finance Institutions (DFIs) play a growing role in this process, operating at the intersection of public mandates and profit-oriented investment logics. In India, rapid corporatisation of healthcare—supported by transnational finance—has coincided with persistently high out-of-pocket expenditure, raising concerns about health-related indebtedness. Yet the role of European, and specifically German, development finance in shaping these dynamics remains under-examined.

This exploratory qualitative study analyses German development engagement in India’s healthcare sector and its implications for financialisation and equity. Drawing on desk reviews and fourteen semi-structured interviews, it examines two linked case studies: a DEG-financed corporate hospital chain, and the Indo-German Programme on Universal Health Coverage (IG-UHC), which provides technical assistance to India’s publicly funded health insurance scheme, PM-JAY.

Findings show that DEG-financed hospital investments were embedded in opaque financing arrangements, limiting transparency and accountability, while prioritising high-margin specialised services. Reported practices of overcharging and restricted access to subsidised care contributed to continued out-of-pocket payments even among insured populations, increasing risks of exclusion and health-related debt. At the policy level, IG-UHC demonstrated limited influence in addressing structural drivers of financial hardship within PM-JAY.

Overall, the study argues that German development engagement risks reinforcing financialised healthcare pathways without adequately addressing their equity consequences, underscoring the need for stronger public accountability.

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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.

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This paper presents research conducted with families of Pitt-Hopkins Syndrome patients in Brazil, in order to explore the gradual changes in the coordinated care services offered by the Unified Health System (SUS), as well as the ensuing health-related debts associated with the costs of treatment.

Paper long abstract

The experience of users of the Brazilian Unified Health System (SUS, Sistema Único de Saúde) reveals that effective access to publicly funded universal healthcare occurs through hybrid arrangements, in which public services coexist with medical insurance, direct payments, litigation, and various forms of credit. Thus the consolidation of a universal healthcare system has coexisted with the expansion of a private sector in face of limitations in supply, financing, and coverage of the public system. Private consultations paid for to avoid waiting lists, tests performed outside the public system to expedite diagnoses, and access to private therapies unavailable at SUS comprise a daily repertoire of care management that systematically has to rely on financial services such as credit cards, installment plans, and often loans. Chronic and rare conditions, as well as disabilities, make this hybrid regime particularly relevant. Unlike isolated episodes of illness, these conditions require continuous, multidisciplinary, and highly specialized care. The associated costs are cumulative and unpredictable. This paper presents an ongoing research project conducted with families of Pitt-Hopkins Syndrome patients in Brazil, a neurodevelopmental disorder that requires care ranging from neurology to physical and occupational therapy. Our aim is to explore the gradual changes in the coordinated care services offered by SUS for Pitt-Hopkins Syndrome patients, as well as the ensuing health-related debts associated with the costs of treatment. By doing so, we hope to shed light into the growing financialisation processes at the core of a universal public health system in a middle-income country such as Brazil.

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Kenya’s 2023 SHI is framed as pro-poor UHC, yet access to care is conditional on registration and paid-up contributions. Targeting and digital checks filter eligibility; and outsourced purchasing favours private providers – raising risks of exclusion & household health debt.

Paper long abstract

Kenya’s 2023 Social Health Insurance (SHI) reform is framed as a transformative, pro-poor pathway to universal health coverage (UHC). This paper argues that despite the progressive rhetoric, SHI assembles market logics and debt-prone form of UHC. It expands the role of insurance and private providers, while access becomes increasingly conditional and stratified.

We draw on 48 elite interviews (2024) and documentary analysis of laws, regulations, budgets, and donor/technical reports (2022–2025), to trace how this model is assembled. We identify four linked mechanisms. First, “universality” is implemented as compulsory insurance membership, where registration and paid-up status makes access conditional, including for publicly-funded primary care services, shifting risk to households. Second, selective inclusion is institutionalised through proxy means testing and differentiated entitlements, creating administrative exclusion and encouraging private “top-ups”. Third, purchasing rules (such as “money follows services”) and outsourced claims administration route public funds through mixed markets, privileging private providers amid chronic underinvestment in public facilities. Fourth, actuarial and credit logics deepen financialisation through premium-financing loans, leading to household health debt.

We show how SHI design can lead to exclusion at the point of care, and debt-based coping for households. The paper offers an empirically-grounded account of how UHC reforms can institutionalise conditional access and health debts in high-informality settings. We conclude by outlining alternatives proposed by Kenyan actors, including tax-financed entitlements and sustained investment in public provision

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This paper examines the rapid growth of household indebtedness linked to healthcare access in Argentina under the Milei administration. It analyses how radical neoliberal reforms, within and beyond the health system, shift healthcare costs onto households, generating new forms of health-related debt

Paper long abstract

The self-described “anarcho-capitalist” administration of Javier Milei in Argentina represents an extreme expression of a broader global trend toward the radicalisation of neoliberalism. Since late 2023, this agenda has had profound effects on health policy, combining draconian austerity with regulatory reforms that have accelerated the marketisation and commercialisation of healthcare, while simultaneously undermining key social determinants of health.

Argentina’s healthcare system consists of three interrelated subsystems, all severely affected by these reforms: the public health sector has faced dismantling and underfunding; the social health insurance subsystem, linked to formal employment, has been weakened by labour deregulation and declining contributions; and the private health insurance sector has been deregulated, enabling sharp premium increases well above inflation. These changes have been compounded by a dramatic rise in the price of medicines.

Together, these transformations have shifted healthcare costs away from public and solidarity-based arrangements onto individuals and households. As a result, many households increasingly rely on debt to access treatments, medicines and diagnostic services. Household indebtedness should therefore be understood as a political and structural issue, rather than a merely private one, as it reflects and reinforces constraints on the effective enjoyment of the right to health.

While official statistics show dramatic rising household indebtedness, little is known about the specific role of healthcare-related expenses. This paper addresses this gap through an empirically grounded analysis based on policy analysis, official data, human rights reports and qualitative interviews. It contributes to debates on health-related debt in the Global South under radical neoliberal reform.

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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.

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This paper examines the role of Development Finance Institutions (DFI) in the financialisation of healthcare in the Global South and presents case studies of health debt and related harms experienced by patients at private hospitals financed by these institutions.

Paper long abstract

In the name of Universal Health Coverage (UHC), Development Finance Institutions (DFIs) invest in private for-profit healthcare in the Global South. Limited information is available about how and what they finance and whether UHC objectives are achieved. This paper presents findings from the first known systematic mapping of healthcare investments by four European DFIs together with the World Bank’s International Finance Corporation (2010 to 2022), together with primary research on patient healthcare seeking experiences in sample hospitals, and desk-based research on the affordability and accessibility of all identified funded hospitals.

The paper evidences the role played by five DFIs in the financialisation of healthcare in low- and middle-income countries by investing hundreds of millions of dollars in expensive private hospitals via a complex web of financial intermediaries, mostly private equity funds. Purposefully selected patient case studies reveal that at least some of the revenue generated by investee hospitals is derived from alleged exploitative and extractive practices, in addition to high fees, leading to catastrophic health expenditure and other related harms, such as patient detentions. Cases include low-income government-insured patients denied the cashless healthcare they were entitled to. The data gives insight into coping mechanisms including emergency sales of land, and loans from extended family and friends and/or commercial and financialised lending facilities.

Significant transparency, governance and accountability shortfalls are evidenced, many of which appear inherent to the commercial and financialised character of the DFI investee intermediaries and healthcare companies. The paper stresses the urgency of further independent research and investigations.

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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.