The burden of healthcare on informal workers in Assam

Healthcare in India is largely financed through private spending, with out-of-pocket health expenditure (OOPHE) exceeding 60% of total costs. Informal sector workers, who constitute the majority of the workforce, are particularly vulnerable due to their lack of formal insurance and limited access to affordable public healthcare. This study addresses the extent and implications of the healthcare burden faced by informal workers in Assam, with emphasis on OOPHE and catastrophic health shocks. The study employed a mixed-methods approach using both primary and secondary data. A multi-stage sampling framework was applied across three districts in Assam, covering 600 informal workers. Quantitative analysis was conducted using measures of catastrophic expenditure, OOPHE, and logistic regression, while qualitative interviews were carried out to capture household coping strategies and gendered impacts of healthcare expenses. Findings indicate that informal workers incur an average annual healthcare cost of ₹3,266, equivalent to 8.33% of their income. Approximately 43.1% of households spend more than 10% of their total expenditure on healthcare, reflecting significant financial vulnerability. Health shocks frequently result in catastrophic expenditure, forcing households into debt, distress asset sales, and educational disruptions for children, with women bearing a disproportionate share of these impacts. The study underscores systemic gaps in India’s public healthcare provisioning and inadequate financial protection for informal workers. Policy interventions should focus on strengthening rural healthcare infrastructure, expanding insurance coverage, providing income support during illness, and implementing equity-focused reforms aligned with Universal Health Coverage. These measures are essential to reduce financial vulnerability and promote inclusive, sustainable health security.