Low catastrophic expenditure, high unmet need in Lesotho: Rethinking financial protection indicators for universal health coverage

Abstract Introduction Achieving universal health coverage (UHC) requires both, service access and financial risk protection. This study provides the first comprehensive UHC assessment for Lesotho, highlighting a critical measurement challenge relevant to many LMICs. Methods We constructed a UHC index using data from the 2023-24 Demographic and Health Survey and 2017-18 Household Budget Survey. We applied concentration index analysis for equity assessment, logistic regression for catastrophic health expenditure (CHE) determinants, and a selection model to account for forgone healthcare. Results Lesotho’s UHC index (74.1) is comparable to other lower-middle-income countries. Equity analysis reveals pro-rich inequity in maternal and child health services, driven by household socioeconomic status and maternal education. Critically, extremely low CHE prevalence (0.9% at 10% threshold, 0.2% at 25% threshold) coexists with 28.1% of households reporting at least one member forgoing needed care, suggesting that low CHE may reflect healthcare avoidance rather than effective financial protection. A selection model further indicates that poorer households are significantly less likely to seek care when needed. Implications In resource-constrained settings, low CHE can mask system failure where households forgo needed care due to anticipated costs. UHC monitoring frameworks must complement financial protection indicators with unmet need measures. For Lesotho, progress requires addressing affordability barriers, strengthening maternal education, expanding community health workers, and increasing primary healthcare investment for rural and vulnerable populations.