An Empirical Assessment of Out-of-Pocket Healthcare Expenditure and Financial Vulnerability in Southern India: A Cross-Sectional Survey Study

Background Out-of-pocket (OOP) expenditure remains the dominant mode of healthcare financing in India, frequently resulting in financial distress among low- and middle-income households. Despite public health insurance programs such as Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (PM-JAY) and state-level schemes like the Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS), large gaps in financial protection persist, especially in rural settings. Objective This study aimed to quantify OOP healthcare expenditure in Southern India and assess the role of insurance schemes and awareness of government programs in mitigating financial vulnerability. Methods A descriptive cross-sectional survey was conducted in December 2022 among 110 respondents from Tamil Nadu, Kerala, and Puducherry. Data on demographics, income, insurance coverage, healthcare utilization, and OOP spending were collected using a structured questionnaire. Descriptive statistics, t-tests, and correlation analysis were performed using SPSS v26. Results Of the 110 participants, 52 provided complete OOP data. The mean annual OOP expenditure was ₹22,856 (maximum ₹2,00,000). Although 55% reported health insurance coverage, significant OOP costs persisted. Urban respondents incurred higher absolute expenditures, while rural households bore a relatively greater financial burden compared to income. A weak negative correlation (r = –0.14) between income and OOP spending reflected the regressive nature of healthcare financing. Awareness and utilization of Janani Suraksha Yojana (JSY) were notably low. Conclusion OOP spending continues to impose disproportionate financial hardship in Southern India despite the presence of insurance schemes. Policy reforms must expand coverage to outpatient care, enhance rural health infrastructure, and strengthen awareness of government programs to ensure equitable financial protection. Keywords: Out-of-pocket expenditure, Catastrophic health spending, Financial risk protection, PM-JAY, CMCHIS, JSY, Southern India