Out-of-pocket expenditures (OOPE) continue to be the main source of financing for health care in many low- and middle-income countries (LMICs), in particular countries in Asia and Africa [1–4]. In these countries OOPE represent more than 50 % of health care spending [1]. OOPE has been found to be a financial barrier to accessing essential care, to increase the risk of more severe or longer term ill-health, to place households at increased risk of poverty and to exacerbate inequity [1, 5].

Recent evidence from Africa and Asia shows that high OOPE discourages individuals from poor and disadvantaged groups from seeking health care [1, 2, 6]. Even relatively modest levels of absolute spending can be catastrophic for poorer households, forcing them to reduce spending on other essential items such as food or to rely on high-risk coping strategies (e.g., selling productive assets) [7–9]. Based on World Health Organization (WHO) estimates, every year approximately 44 million households worldwide (or more than 150 million individuals) face catastrophic health expenditure, and about 25 million households (or more than 100 million individuals) are pushed into poverty by the need to pay for health services [10].

The financial burden of sexual and reproductive health (SRH) care seeking in LMICs has not been widely explored in the literature. Few studies have measured OOPE or the equity impact of payments for SRH in LMICs. Among available studies, most have focused on maternal care [11–15]. The evidence from these studies suggests that costs of seeking SRH services could be significant and catastrophic, and affect more individuals from low socio-economic groups.

Poor sexual and reproductive health accounts for a large share of the global burden of disease, disproportionally affecting LMICs [16–19]. Addressing the financial barriers to SRH care access is also critical to improving progress towards Millennium Development Goal 5 (MDG 5: Reduce Maternal Mortality & Achieve Universal Access to Reproductive Health), MDG 6 (Combat HIV/AIDS) and to some extent MDG 3 (Promote gender equality and empower women) and MDG 4 (Reduce Child Mortality). However, addressing financial barriers to essential health care access will be challenging for many low- and middle-income countries, particularly those such as India and Kenya, which lack universal pre-payment mechanisms for health care, have high degrees of relative poverty (inequality) and high levels of absolute poverty [2, 7, 20, 21].

This study aims to explore three main characteristics of inequality in spending on SRH care services in Mysore, India and Mombasa, Kenya; 1) the extent to which payments are regressive, 2) the extent to which payments are catastrophic, and 3) explore coping mechanisms used to finance health spending.

This study aimed to assess inequity in spending on SRH services in India and Kenya. Specifically, this study assessed: 1) progressivity of payments, 2) the extent to which payments are catastrophic, and 3) the coping mechanisms adopted by the respondents to finance the payments. The findings showed that the spending on SRH services was highly regressive in both sites, with the lower income households spending a significantly higher percentage of their income on seeking care compared to households with a higher income. In India, the poorest households spent two times and in Kenya ten times more on seeking care than the least poor households. However, expenditure on this single care-seeking event was not catastrophic or likely to be impoverishing. The findings also indicated that the common coping mechanisms adopted by respondents in India and Kenya were “received from partner or household members” and “own saving or regular income”, respectively.

The finding that spending was highly regressive is in line with findings from national studies describing the regressive nature of total health care financing/payments in these two countries [30, 31]. India and Kenya have different health systems structures in that India has a decentralised public health system, while Kenya’s system is highly centralized [30, 31]. However, both settings are pluralistic, with a significant proportion of services offered either by private providers or by public providers charging users fees at the point of use. In both settings, out of pocket spending constitutes a high proportion of total health expenditure; approximately 60 % in India and 50 % in Kenya [32, 33]. The government contribution to total health spending is similarly low in both contexts; approximately 32 % in India and 42 % in Kenya [34]. Considering the high proportion of OOPE in both countries, the findings of these analyses are perhaps unsurprising.

Although the findings of this study don’t suggest that the cost of a single care seeking event was catastrophic or likely to be impoverishing, this may not be the case if multiple visits are required. For some services, patients or service users are required to have repeated visits to the facilities (for example, repeated visits for family planning, or HIV care and treatment services). Relatively small repeated payments can result in financial catastrophe forcing households into poverty. Evidence from previous studies has shown that patients may delay seeking care or fail to seek care because of the high cost of services or high opportunity costs of care seeking [29, 35, 36]. Moreover, other studies in India and Kenya have shown the negative impact of user fees on utilization of healthcare services and incidence of catastrophic spending, including SRH [30, 33, 37]. The high rate of transport spending, in particular in the Indian site, suggests that, while user fee exemption may offer some protection from catastrophic health expenditure, a significant and regressive financial barrier to service access remains. Moreover, the opportunity cost of travelling and time spent at the facility can act as a barrier to accessing services. The findings show that in India, median time taken to reach the facility and time from arriving until completing a visit at the facility was 60 and 120 min, respectively. In Kenya, respondents took an median of 20 min to reach the facility and 60 min to complete their visit.

The literature suggests that households use various strategies to cope with health shocks, which can differ in different contexts [7–9, 38, 39]. Generally, coping strategies are categorised into two broad categories; detrimental and non-detrimental. Detrimental or harmful strategies include strategies such as borrowing money/taking out loans or selling productive assets. Non-detrimental strategies commonly include the use of income and savings, labour substitution or social networks [7–9, 38, 39]. Detrimental coping strategies can have a dramatic impact on future earnings and may leave households at higher risk of increased economic vulnerability and poverty in the long run [7–9, 38]. Non-detrimental strategies, such as income and savings, are generally used when health spending is small or moderate. Although these funding sources are commonly referred to as non-detrimental in the literature, it should be noted that this spending can have a temporary, negative impact on household finances and consumption [7]. In poorer households this negative effect may be significant and this warrants further exploration in future empirical work.

The findings of this study indicated that the most common coping mechanisms adopted by respondents in India was “receiving money from partner or household members” and in Kenya was “using own saving or regular income”. This finding can be explained by the unemployment rate of the respondents in both sites. If the money from partners or household members does not need to be repaid, then these would generally be considered non-detrimental strategies. Using detrimental coping strategies was rare among respondents in both sites, where very few borrowed money and no one sold productive assets.

Furthermore, previous studies have shown that lack of financial control can limit women’s access to SRH services [40, 41]. Based on the results of this study, a significant proportion of respondents (particularly in India with more than 70 %) were unemployed. This means that they depend on their spouses or other household members to pay for health expenditure. This may discourage them from seeking SRH-related care on time or at all. Further, the large proportion of service users relying on borrowing to finance care seeking suggests that care access would be more difficult for those with weak social ties, small social networks or weak bargaining positions within the family - although this requires further investigation. It is well documented that in LMICs countries, social networks are one of the most important resources mobilized by households to obtain money to seek treatment [9, 29, 42, 43], although some evidence suggests that the poorest have the weakest social resources [29, 42, 43].

The results from this study should be interpreted in light of a number of limitations. Firstly, this study only included women who sought out and accessed health services. As such, the results might not be generalizable to the wider population of the countries under study. In addition, although the facilities from which respondents were recruited, are considered to be representative of urban facilities in both countries, the composition of patients visiting the facilities may differ from other urban facilities. Secondly, due to the small sample size, it was not possible to conduct robust sub-sample analyses and the results of the analyses presented (i.e. association of the coping strategies and socio-economic status), should be interpreted with caution. Thirdly, monthly household income is not adjusted for household size, as we didn’t have an appropriate measure of household size. Fourthly, expenditure for Kenya included only payments to the providers of SRH services and for India, it is only included non-medical direct costs such as transportation costs. In India, 18 respondents (12 %) stated that they were asked to pay for services however, they did not report the amount paid. Although the effect on the magnitude of inequality or degree of regressiveness of spending (i.e. the main focus of this study) is not clear, if full costs had been measured, total expenditure had been higher, so we had achieved a better picture of the likelihood of catastrophic payments. Finally, this study did not measure the opportunity costs of seeking care (i.e. lost earning opportunities due to time spent seeking care). Opportunity costs are widely considered to be a sizeable component of the overall costs of health care in contexts such as these. However, due to difficulties quantifying these costs, in common with many other studies, they were not included in this study. As such, our estimates of spending are highly conservative in nature.

These findings demonstrate that spending on SRH services are highly regressive in India and Kenya. Highly regressive spending on SRH services highlights a heavier burden borne by the most poor when seeking care in these resource-constrained settings. The findings can provide useful information for policy makers and programme managers in designing appropriate policies to improve access to care, reduce socio-economic inequality, and promote progress towards the MDGs in these settings.