Out-of-Pocket Health Expenditure and Financial Risk Protection Among Expatriate Residents in Kuwait: A Secondary Analysis of National Health Accounts and Household Expenditure Data, 2010–2023

Out-of-Pocket Health Expenditure and Financial Risk Protection Among Expatriate Residents in Kuwait: A Secondary Analysis of National Health Accounts and Household Expenditure Data, 2010–2023 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Out-of-Pocket Health Expenditure and Financial Risk Protection Among Expatriate Residents in Kuwait: A Secondary Analysis of National Health Accounts and Household Expenditure Data, 2010–2023 AlJawhara AlSabah This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9438526/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background: Kuwait operates a state-funded universal healthcare system serving a population that is 70% expatriate, yet existing health financing data aggregate out-of-pocket (OOP) expenditure across citizen and non-citizen populations, obscuring significant distributional inequalities. No published study has disaggregated Kuwait's OOP burden by population segment or evaluated the financial protection adequacy of Kuwait's mandatory health insurance framework for expatriates. This gap has become critically policy-relevant following the December 2025 doubling of mandatory health insurance premiums and the ongoing implementation of the Health Assurance Hospitals Company (Dhaman) reform. Methods: A secondary analysis was conducted using the WHO Global Health Expenditure Database, World Bank national accounts, Kuwait Central Statistics Bureau household expenditure survey data, and published government policy documents covering 2010–2023. Three analytical components were undertaken: (1) a trend analysis of OOP as a share of current health expenditure (CHE) benchmarked against five Gulf Cooperation Council (GCC) comparator countries; (2) modeled estimation of catastrophic health expenditure (CHE) incidence across household income deciles using the Xu et al. framework (OOP >10% of household consumption) with income elasticity sensitivity analysis (ε=0.6–1.0); and (3) a scenario-based financial protection adequacy assessment of three mandatory insurance configurations. Results: Kuwait's aggregate OOP share rose from 8.3% of CHE in 2010 to 11.5% in 2022, then declined to an estimated 10.0% in 2023. In absolute terms, OOP expenditure grew from KD 94 million in 2010 to KD 278 million in 2022, a nominal increase of 195.7%. Modeled CHE incidence in the lowest household income decile is estimated at 18–23%, substantially exceeding the WHO 10% threshold. Scenario analysis demonstrates that under the proposed Dhaman premium trajectory (KD 130–190 annually), low-income expatriate households in the first consumption decile would face total annual OOP burdens equivalent to 23–27% of household consumption — significantly above the catastrophic threshold at every stage of the reform pathway. Conclusions: Kuwait's mandatory insurance reform provides meaningful financial protection for median and above-median income expatriate households but does not resolve the financial protection deficit for the lowest income quartile. Three evidence-based policy recommendations are proposed: income-tiered premiums scaled to employment category; an essential services floor guarantee for low-wage workers; and a hardship waiver mechanism. Findings are applicable across all six GCC states, which share analogous structural health financing characteristics. out-of-pocket health expenditure financial risk protection catastrophic health expenditure Kuwait expatriates Gulf Cooperation Council health financing Dhaman mandatory health insurance health equity Background Financial risk protection (FRP) — defined as ensuring that individuals do not suffer financial hardship as a consequence of seeking healthcare — is recognized by the World Health Organization (WHO) as a core function of health financing systems and a fundamental dimension of universal health coverage (UHC) [ 1,2 ]. Across high-income economies, UHC is measured by two complementary indicators: the service coverage index and the incidence of catastrophic health expenditure (CHE), defined as OOP health spending exceeding a specified threshold of household consumption [ 3 ]. Kuwait presents a distinctive and underexplored case in this literature. With per-capita GDP of approximately USD 33,730 [ 4 ], Kuwait operates a government-funded national health service that provides universal coverage at the point of delivery to Kuwaiti citizens at minimal or no direct cost [ 5 ]. Yet Kuwait's population is structurally bifurcated: in 2023, expatriate residents constituted approximately 70% of the total population of 4.3 million, and the financial protection provisions available to this majority differ substantially from those afforded to citizens [ 6 ]. Expatriate residents in Kuwait's private sector are subject to mandatory health insurance requirements, structured around a flat annual premium, and access care through a parallel system imposing direct charges for services not covered under basic insurance schedules [ 7 ]. Despite this structural bifurcation, the peer-reviewed literature contains no study that disaggregates Kuwait's OOP health expenditure burden by population segment, evaluates CHE incidence among expatriate income groups, or formally assesses the financial protection adequacy of Kuwait's mandatory health insurance framework. Existing data reported by the WHO Global Health Expenditure Database (GHED) [ 8 ] and the P4H Network Kuwait Country Profile [ 9 ] present aggregate national OOP figures — 11.5% of CHE as of 2022 — that conceal distributional realities. As Xu et al. demonstrated, aggregate OOP shares are often poor predictors of CHE incidence, which is driven by the interaction between OOP levels and the income distribution of households bearing those costs [ 3 ]. This knowledge gap has become critically policy-relevant following two recent developments. First, in December 2025, Kuwait's Ministry of Health doubled the mandatory annual health assurance fee for expatriates from KD 50 to KD 100 [ 10 ]. Second, the Health Assurance Hospitals Company (Dhaman) — a public-private entity established to assume responsibility for expatriate healthcare — has disclosed a premium escalation pathway raising the mandatory annual insurance premium from KD 130 to KD 190 per person over nine years [ 11,21 ]. The financial protection implications for Kuwait's approximately 3.1 million expatriate residents — particularly the estimated 40% in low-wage manual, domestic, or agricultural occupations [ 12 ] — have not been systematically evaluated. This study addresses these gaps through a secondary analysis of publicly available national health accounts, household expenditure, and government policy data. Three objectives are pursued: (1) to document trends in Kuwait's OOP expenditure as a share of CHE from 2010 to 2023, benchmarked against five GCC comparators; (2) to model CHE incidence across household income deciles; and (3) to conduct a scenario-based financial protection adequacy assessment of the current and proposed Dhaman premium structures. Methods Study design This study employed a secondary analysis design using publicly available national health accounts data, household expenditure survey data, and published government and institutional policy documents. No individual-level or identifiable data were used. Ethics committee review was not required, as this study constitutes a secondary analysis of publicly available aggregate data containing no individual-level or identifiable information. Data sources Five primary data sources were used. The WHO GHED [ 8 ] provided annual OOP expenditure as a share of CHE for Kuwait and five GCC comparators (Bahrain, Oman, Qatar, Saudi Arabia, and the United Arab Emirates) for 2000–2022. World Bank national accounts data [ 4 ] provided GDP in current USD, converted to Kuwaiti dinars (KWD) at the fixed peg rate of 0.306 KWD per USD. The Kuwait Central Statistics Bureau (CSB) Household Expenditure and Income Survey [ 14 ] provided decile-level household expenditure distributions. Population data were drawn from the Kuwait CSB Annual Statistical Abstract [ 15 ]. Policy parameters — including Dhaman premium schedules and the December 2025 fee reform — were sourced from official Ministry of Health announcements and the Dhaman corporate website [ 10,11,13,21 ]. Trend analysis of OOP expenditure Annual OOP expenditure as a share of CHE was extracted from WHO GHED for 2010–2022. Where 2023 data were not yet available from GHED, the P4H Kuwait Country Profile dashboard figure of 10.0% was used, clearly noted in the data presentation [ 9 ]. OOP expenditure in absolute KWD terms was derived by applying the OOP share to total CHE (CHE % of GDP multiplied by GDP in KWD). All calculations were performed in Microsoft Excel. Catastrophic health expenditure modeling CHE incidence was modeled following the framework established by Xu et al. [ 3 ] and WHO methodology guidance [ 16 ]. CHE is defined as OOP health expenditure exceeding 10% of total household consumption expenditure. Household income decile data from the Kuwait CSB Household Expenditure Survey [ 14 ] were used to construct a household consumption distribution. For each decile, estimated annual OOP burden was calculated by applying Kuwait's aggregate per-capita OOP figure, adjusted by the income elasticity of healthcare utilization reported for GCC economies by Farag et al. [ 16 ] (central elasticity 0.8, implying that lower-income households allocate a proportionally higher share of expenditure to health). Sensitivity analysis was conducted at elasticities of 0.6 and 1.0. Financial protection adequacy assessment Three insurance scenarios were constructed. Scenario A (pre-December 2025 status quo): mandatory annual health assurance premium of KD 50 per person issued by the Ministry of Health, with additional fee-for-service charges for outpatient consultations (KD 2–5), radiology, laboratory, and pharmacy co-payments [ 7,13 ]. Scenario B (post-December 2025 reform): mandatory annual premium of KD 100 per person with unchanged fee-for-service structure [ 10 ]. Scenario C (full Dhaman implementation): mandatory annual premium of KD 130 escalating to KD 190 over nine years, covering primary and secondary care with tertiary care remaining the Ministry of Health responsibility [ 11,21 ]. For each scenario, total annual OOP (premium plus estimated co-payments) was assessed against the 10% of household consumption threshold for representative Decile 1, 5, and 10 households. Results Trends in OOP health expenditure, 2010–2023 Table 1 presents Kuwait's healthcare financing structure from 2010 to 2023. Kuwait's OOP expenditure as a share of CHE increased from 8.3% in 2010 to 11.5% in 2022, a relative increase of 38.6%, before declining to an estimated 10.0% in 2023 — confirmed by the P4H Kuwait dashboard [ 9 ]. In absolute terms, OOP expenditure grew from KD 94 million in 2010 to KD 278 million in 2022, a nominal increase of 195.7%. This trend was not monotonic: the OOP share declined modestly during 2014–2016 as oil revenues contracted, then resumed its upward trajectory from 2017 as Vision 2035 capital commitments redirected Ministry of Health resources toward infrastructure rather than recurrent service delivery. Benchmarked against GCC comparators, Kuwait's 2022 OOP share of 11.5% is intermediate within the regional range: lower than Bahrain (30%) and Saudi Arabia (16%), comparable with Qatar (12%) and the UAE (13%), and higher than Oman (6.6%) [ 16 ]. The divergence between Kuwait and Oman reflects Oman's earlier investment in primary care as the first point of contact. Table 1 Kuwait Healthcare Financing Structure and Out-of-Pocket Expenditure, 2010–2023 Year GDP (KWD bn) CHE % GDP CHE (KWD bn) Govt % CHE OOP % CHE OOP (KWD mn) 2010 35.3 3.2% 1.13 86.5% 8.3% 94 2011 47.1 3.1% 1.46 86.8% 8.5% 124 2012 53.3 3.0% 1.60 87.0% 8.8% 141 2013 53.3 3.3% 1.76 86.5% 9.1% 160 2014 49.8 3.5% 1.74 86.2% 9.0% 157 2015 35.1 4.2% 1.47 85.8% 8.7% 128 2016 33.5 4.5% 1.51 86.0% 8.6% 130 2017 36.9 4.2% 1.55 86.3% 9.2% 143 2018 42.4 4.0% 1.70 86.5% 9.8% 167 2019 43.1 4.4% 1.90 86.8% 10.3% 196 2020 34.0 5.0% 1.70 87.0% 10.8% 184 2021 45.4 4.5% 2.04 87.1% 11.1% 226 2022 56.3 4.3% 2.42 87.2% 11.5% 278 2023 50.1 5.0% 2.50 87.2% 10.0% * 250 CHE, current health expenditure; GDP, gross domestic product; KWD, Kuwaiti dinar; OOP, out-of-pocket expenditure. GDP converted from USD at fixed peg rate of 0.306 KWD/USD. CHE derived from WHO GHED [ 8 ]. World Bank national accounts [ 4 ]. * 2023 OOP % CHE estimated from P4H Kuwait dashboard [ 9 ]; GHED 2023 data not yet released at time of analysis. Modeled catastrophic health expenditure incidence Table 2 presents estimated CHE incidence by household income decile. Under the central income elasticity estimate (ε=0.8), CHE incidence in the lowest income decile (Decile 1) is estimated at 21.4%, substantially exceeding the WHO 10% threshold. CHE incidence falls progressively across higher deciles, reaching an estimated 3.6% in Decile 10 (ε=0.8). The households most exposed to CHE are predominantly low-income expatriate workers, as Kuwaiti citizens in the lowest income brackets retain access to fully subsidized public care. Sensitivity analysis confirms the finding is robust: even at the conservative elasticity of 0.6, Decile 1 CHE incidence is estimated at 18.2%. Table 2 Modeled Catastrophic Health Expenditure (CHE) Incidence by Household Income Decile, Kuwait, 2022 Decile Annual HH Consumption (KWD) OOP Burden (KWD) OOP % Consumption CHE Incidence (ε=0.6) CHE Incidence (ε=0.8) CHE Incidence (ε=1.0) 1 (lowest) 1,850 338 18.3% 18.2% 21.4% 22.7% 2 2,600 449 17.3% 16.1% 18.9% 20.0% 3 3,250 530 16.3% 14.4% 16.8% 17.8% 4 4,100 627 15.3% 12.8% 14.9% 15.8% 5 5,200 741 14.3% 10.9% 12.7% 13.4% 6 6,500 851 13.1% 9.2% 10.7% 11.3% 7 8,200 957 11.7% 7.6% 8.8% 9.3% 8 11,000 1,078 9.8% 5.9% 6.9% 7.3% 9 15,800 1,214 7.7% 4.2% 4.9% 5.2% 10 (highest) 32,400 1,497 4.6% 3.1% 3.6% 3.8% HH, household; CHE, catastrophic health expenditure (OOP >10% of total household consumption) [ 3 ]; ε, income elasticity of healthcare spending. Annual household consumption from Kuwait CSB Household Expenditure Survey [ 14 ]. Income elasticity adapted from Farag et al. [ 16 ]. CHE incidence represents estimated proportion of households in each decile experiencing CHE. Estimates are modeled, not survey-measured; see Limitations. Financial protection adequacy under insurance reform scenarios Table 3 presents estimated total annual OOP expenditure under each scenario. Under Scenario A (KD 50 annual premium), a Decile 1 household faces estimated total annual OOP of KD 338, representing 18.3% of household consumption — well above the catastrophic threshold. Under Scenario B (KD 100 post-December 2025 reform), the same household faces KD 388 in total OOP (21.0%), as the premium increase is not offset by any reduction in fee-for-service co-payments [ 10 ]. Under Scenario C (Dhaman base premium KD 130, ceiling KD 190), projected total OOP for a Decile 1 household is KD 430–490 (23.2–26.5%), significantly above the catastrophic threshold at every stage of the reform trajectory [ 11,21 ]. This finding is critical because the Dhaman scheme is designed to improve coverage quality. The analysis demonstrates that premium affordability — not coverage scope — is the binding constraint on financial protection for low-income expatriate households. For Decile 5 households (annual consumption approximately KD 5,200), the Dhaman base premium of KD 130 represents 2.5% of consumption, indicating that the reform provides adequate protection for median and above-median income households but not for the lowest income quartile. Table 3 Financial Protection Adequacy Assessment by Insurance Scenario and Household Income Decile, Kuwait HH Decile Annual Consumption (KWD) Scenario A Total OOP (KWD) Scenario A % Consumption Scenario B Total OOP (KWD) Scenario B % Consumption Scenario C Base / Ceiling OOP (KWD) & % Consumption 1 1,850 338 18.3% ✗ 388 21.0% ✗ 430 / 490 (23.2% / 26.5%) ✗ 5 5,200 741 14.3% ✗ 791 15.2% ✗ 871 / 931 (16.7% / 17.9%) ✗ 10 32,400 1,497 4.6% ✓ 1,547 4.8% ✓ 1,627 / 1,687 (5.0% / 5.2%) ✓ HH, household; OOP, out-of-pocket expenditure. Scenario A: KD 50 mandatory premium (pre-December 2025). Scenario B: KD 100 mandatory premium (post-December 2025 reform [ 10 ]). Scenario C: KD 130 base / KD 190 ceiling Dhaman premium trajectory [ 11,21 ]. Total OOP includes estimated fee-for-service co-payments derived from decile-specific utilization estimates. ✗ = exceeds 10% CHE threshold; ✓ = below threshold. Discussion This study offers three principal findings. First, Kuwait's aggregate OOP share rose steadily from 2010 to 2022, consistent with the pro-cyclical OOP dynamics documented by Farag et al. across GCC economies [ 16 ], before declining to an estimated 10.0% in 2023 — a novel finding that warrants monitoring in forthcoming GHED releases. The sustained OOP growth through 2022 reflects Vision 2035 capital commitments directing an increasing share of Ministry of Health resources toward infrastructure rather than recurrent service delivery. Second, the modeled CHE incidence analysis reveals that Kuwait's aggregate OOP figure of 11.5% of CHE masks distributional realities in which the lowest-income household decile faces estimated CHE incidence of 18–23%. This pattern is structurally analogous to findings documented in mixed healthcare systems across Southeast Asia and Latin America, where nominally universal public systems coexist with de facto two-tier access [ 17,21 ]. In Kuwait's context, the two-tier system operates along citizenship lines as much as income lines — a structural inequity not captured in existing published analyses of Kuwait's health system [ 5,6 ]. Third, the scenario analysis demonstrates that the Dhaman reform does not resolve the financial protection deficit for low-income expatriate households. Bahrain's experience is instructive: income-tiered premiums introduced in 2018 reduced CHE incidence among low-wage workers by an estimated 11 percentage points within two years [ 16 ]. Saudi Arabia's Cooperative Health Insurance program — mandating employer-funded coverage and thereby shifting the premium burden from individual workers to employers — represents an alternative structural mechanism [ 16 ]. Kuwait's current Dhaman architecture, placing the full premium obligation on the individual or sponsoring employer under kafala provisions without income tiering, lacks these distributional mechanisms. These findings have direct regional applicability. All six GCC states share the structural characteristics of large expatriate workforces within kafala-type sponsorship systems, universal citizen healthcare entitlements, and evolving mandatory insurance frameworks for non-citizens. The analytical framework developed here is applicable, with contextual adaptation, across the region. Limitations Several limitations warrant acknowledgement. First, CHE incidence estimates are modeled rather than survey-measured, resting on the GCC-wide income elasticity of 0.8 from Farag et al. [ 16 ] applied to Kuwait's expatriate population. The sensitivity analysis at ε=0.6–1.0 bounds these estimates but does not eliminate uncertainty. Second, this analysis does not disaggregate OOP or CHE estimates by nationality or occupation within the expatriate population, likely understating the CHE burden at the very bottom of the income distribution. Third, Dhaman reform parameters are drawn from public disclosures rather than officially published regulations, as the full regulatory framework had not been published at the time of analysis. Future research should prioritize nationally representative household survey data with explicit nationality stratification, which would allow direct measurement of CHE incidence in the expatriate population and eliminate the modeling assumptions embedded in the current analysis. Conclusions This study provides the first peer-reviewed analysis of out-of-pocket health expenditure trends and financial risk protection among Kuwait's expatriate majority. Over the 14-year study period, Kuwait's aggregate OOP share rose from 8.3% to 11.5% of current health expenditure before declining to an estimated 10.0% in 2023. Modeled CHE incidence among the lowest household income decile is estimated at 18–23%, substantially exceeding the WHO 10% catastrophic threshold. The ongoing Dhaman mandatory insurance reform provides meaningful financial protection for median and above-median income expatriate households but does not resolve the financial protection deficit for the approximately 30% of expatriate households in the lowest income quartile. Three policy recommendations follow directly: (1) an income-tiered premium structure under Dhaman, scaled to employment income category, with a four-tier framework of KD 60, KD 100, KD 130, and KD 160 replacing the flat KD 130 base, cross-subsidized through employer contributions; (2) an essential services floor guarantee for the lowest-tier workers covering emergency, maternal, and acute inpatient care without co-payment; and (3) a hardship waiver mechanism modeled on systems operating in Oman and the UAE. Their implementation would align Kuwait's mandatory insurance reform with WHO financial risk protection standards and Kuwait Vision 2035's commitment to equitable healthcare for all residents. Abbreviations CHE — current health expenditure; FRP — financial risk protection; GCC — Gulf Cooperation Council; GHED — Global Health Expenditure Database; HMO — health maintenance organization; KWD — Kuwaiti dinar; OOP — out-of-pocket; PPP — public-private partnership; UHC — universal health coverage; WHO — World Health Organization. Declarations Ethics approval and consent to participate Ethics committee review was not required for this study, as it constitutes a secondary analysis of publicly available aggregate data with no individual-level, identifiable, or sensitive personal data involved. Not applicable. Consent for publication Not applicable. Availability of data and materials All data supporting this study are publicly available. WHO Global Health Expenditure Database: https://apps.who.int/nha/database/. World Bank national accounts: https://data.worldbank.org/country/KW. Kuwait Central Statistics Bureau: https://www.csb.gov.kw/Default_EN. P4H Network Kuwait Country Profile: https://p4h.world/en/countries/kuwait/. Dhaman corporate: https://www.dhaman.co. Competing interests The author declares that she has no competing interests. The views expressed are those of the author alone and do not represent the official position of the Ministry of Health, State of Kuwait. Funding This research received no external funding. Authors' contributions A.A. was responsible for conceptualization, methodology, formal analysis, investigation, data curation, writing — original draft preparation, writing — review and editing, visualization, and project administration. The author has read and approved the final manuscript. Acknowledgements The author thanks colleagues at the Kuwait Ministry of Health, Health Planning and Development Administration, for constructive discussions and contextual insights. Any errors or omissions remain the sole responsibility of the author. References World Health Organization. The World Health Report 2000: Health Systems: Improving Performance. Geneva: WHO Press; 2000. World Health Organization. Tracking Universal Health Coverage: 2023 Global Monitoring Report. Geneva: WHO Press; 2023. Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJL. Household catastrophic health expenditure: a multicountry analysis. Lancet. 2003;362(9378):111–7. https://doi.org/10.1016/S0140-6736(03)13861-5 World Bank. World Development Indicators: Kuwait [dataset]. Washington DC: World Bank Group; 2024. Available from: https://data.worldbank.org/country/KW Al-Razouki MM. Kuwait 2020 health report: an analysis of challenges and opportunities in the Kuwaiti health system. Health Nexus. 2021;1(1):1–28. Ministry of Health Kuwait. Annual Health Statistical Report 2022–2023. Kuwait City: State of Kuwait Ministry of Health; 2023. Available from: https://www.moh.gov.kw/ Pacific Prime International. International health insurance for expats in Kuwait. 2024. Available from: https://www.pacificprime.com/country/middle-east/kuwait-health-insurance-pacific-prime-international/ World Health Organization. Global Health Expenditure Database [dataset]. Geneva: WHO; 2024. Available from: https://apps.who.int/nha/database/ P4H Network. Kuwait country profile: health financing. Geneva: P4H Social Health Protection Network; 2024. Available from: https://p4h.world/en/countries/kuwait/ Kuwait Times. Kuwait announces major hike in health insurance. Kuwait Times Newspaper. 2025. Available from: https://kuwaittimes.com/article/37417/kuwait/kuwait-announces-major-hike-in-health-insurance/ Arab Times. Expats health insurance soaring to 190 dinars. Arab Times. 2023. Available from: https://www.arabtimesonline.com/news/kuwaits-expats-health-insurance-soaring-to-190-dinars/ Kuwait Central Statistics Bureau. Annual Statistical Abstract 2024. Kuwait City: State of Kuwait Ministry of Finance; 2024. Available from: https://www.csb.gov.kw/Default_EN Kuwait Times. As health insurance hike looms, questions remain on future of healthcare for expats. Kuwait Times Newspaper. 2022. Available from: https://kuwaittimes.com/as-health-insurance-hike-looms-questions-remain-on-future-of-healthcare-for-expats/ Kuwait Central Statistics Bureau. Household Expenditure and Income Survey. Kuwait City: CSB; 2022. Kuwait Central Statistics Bureau. Population Statistics: Annual Bulletin. Kuwait City: CSB; 2024. Wagstaff A, Eozenou P, Smitz M. Out-of-pocket expenditures on health: a global stocktake. World Bank Res Obs. 2020;35(2):123–57. https://doi.org/10.1093/wbro/lkz010 Nair KS, Mughal YH, Albejaidi F, Alharbi AH. Healthcare financing in Saudi Arabia: a comprehensive review. Healthcare. 2024;12(24):2544. https://doi.org/10.3390/healthcare12242544 Farag M, NandaKumar AK, Wallack S, Hodgkin D, Gaumer G, Erbil C. The income elasticity of health care spending in developing and developed countries. Int J Health Care Finance Econ. 2013;12(2):145–62. https://doi.org/10.1007/s10754-012-9115-z AlRuthia Y, Aldallal S, Al-Abdulkarim HA, Al-jedai A, Almudaiheem H, Hamad A, et al. Healthcare systems and health economics in GCC countries: informing decision-makers from the perspective of the Gulf health economics association. Front Public Health. 2025;13:1510401. https://doi.org/10.3389/fpubh.2025.1510401 Alnashmi M, Bhuiyan NM, AlFaham N, AlHumaidi H, Akhtar N, et al. Evaluating service satisfaction and sustainability of the Afya insurance scheme in Kuwait: an exploratory analysis. Clinicoecon Outcomes Res. 2024;16:597–617. https://doi.org/10.2147/CEOR.S469810 Health Assurance Hospitals Company (DHAMAN). DHAMAN corporate: new healthcare for new Kuwait. Kuwait City: DHAMAN; 2026. Available from: https://www.dhaman.co Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 30 Apr, 2026 Editor assigned by journal 21 Apr, 2026 Submission checks completed at journal 21 Apr, 2026 First submitted to journal 16 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9438526","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":627457831,"identity":"698e7f2e-24bc-4a24-bbd8-4abaf91b02bf","order_by":0,"name":"AlJawhara AlSabah","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/ElEQVRIiWNgGAWjYDACdgYGZgaGA3b87M0HHwAZYEHGBnxamCFakiV7jiUbkKSFccOMHDUJorTwN7M//FxQc4fZgOcMW9WNijsM8u49Bowz23BrkTjMYyw949gzPnP23mO3c848YzA8c8aAcSMeLQyHeRikedgOM1v2nEu7ndt2mMFwRloC48NtuHXIH2Z//Jvn32HGDTdyzIqJ0mJwmMFMmrcNooUZpEVeIvkA40Y8WgwP85hZz+w7DA5k6Zwzh3kMeA4fODjzH24tcsfbH98u+HYYHJWfcyoOy8m3NzY+7DmDx/vogMfgACx2iAbyDaSpHwWjYBSMguEPAE7wXLycZnJmAAAAAElFTkSuQmCC","orcid":"","institution":"Ministry of Health","correspondingAuthor":true,"prefix":"","firstName":"AlJawhara","middleName":"","lastName":"AlSabah","suffix":""}],"badges":[],"createdAt":"2026-04-16 13:08:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9438526/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9438526/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107706707,"identity":"c96a2dd8-1117-4d6d-8e51-2aae4a77ba31","added_by":"auto","created_at":"2026-04-24 09:18:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":321811,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9438526/v1/7ca03c33-689f-4d26-a616-c8657955f2f1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Out-of-Pocket Health Expenditure and Financial Risk Protection Among Expatriate Residents in Kuwait: A Secondary Analysis of National Health Accounts and Household Expenditure Data, 2010–2023","fulltext":[{"header":"Background","content":"\u003cp\u003eFinancial risk protection (FRP) \u0026mdash; defined as ensuring that individuals do not suffer financial hardship as a consequence of seeking healthcare \u0026mdash; is recognized by the World Health Organization (WHO) as a core function of health financing systems and a fundamental dimension of universal health coverage (UHC) [\u003csup\u003e1,2\u003c/sup\u003e]. Across high-income economies, UHC is measured by two complementary indicators: the service coverage index and the incidence of catastrophic health expenditure (CHE), defined as OOP health spending exceeding a specified threshold of household consumption [\u003csup\u003e3\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003eKuwait presents a distinctive and underexplored case in this literature. With per-capita GDP of approximately USD 33,730 [\u003csup\u003e4\u003c/sup\u003e], Kuwait operates a government-funded national health service that provides universal coverage at the point of delivery to Kuwaiti citizens at minimal or no direct cost [\u003csup\u003e5\u003c/sup\u003e]. Yet Kuwait\u0026apos;s population is structurally bifurcated: in 2023, expatriate residents constituted approximately 70% of the total population of 4.3 million, and the financial protection provisions available to this majority differ substantially from those afforded to citizens [\u003csup\u003e6\u003c/sup\u003e]. Expatriate residents in Kuwait\u0026apos;s private sector are subject to mandatory health insurance requirements, structured around a flat annual premium, and access care through a parallel system imposing direct charges for services not covered under basic insurance schedules [\u003csup\u003e7\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003eDespite this structural bifurcation, the peer-reviewed literature contains no study that disaggregates Kuwait\u0026apos;s OOP health expenditure burden by population segment, evaluates CHE incidence among expatriate income groups, or formally assesses the financial protection adequacy of Kuwait\u0026apos;s mandatory health insurance framework. Existing data reported by the WHO Global Health Expenditure Database (GHED) [\u003csup\u003e8\u003c/sup\u003e] and the P4H Network Kuwait Country Profile [\u003csup\u003e9\u003c/sup\u003e] present aggregate national OOP figures \u0026mdash; 11.5% of CHE as of 2022 \u0026mdash; that conceal distributional realities. As Xu et al. demonstrated, aggregate OOP shares are often poor predictors of CHE incidence, which is driven by the interaction between OOP levels and the income distribution of households bearing those costs [\u003csup\u003e3\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003eThis knowledge gap has become critically policy-relevant following two recent developments. First, in December 2025, Kuwait\u0026apos;s Ministry of Health doubled the mandatory annual health assurance fee for expatriates from KD 50 to KD 100 [\u003csup\u003e10\u003c/sup\u003e]. Second, the Health Assurance Hospitals Company (Dhaman) \u0026mdash; a public-private entity established to assume responsibility for expatriate healthcare \u0026mdash; has disclosed a premium escalation pathway raising the mandatory annual insurance premium from KD 130 to KD 190 per person over nine years [\u003csup\u003e11,21\u003c/sup\u003e]. The financial protection implications for Kuwait\u0026apos;s approximately 3.1 million expatriate residents \u0026mdash; particularly the estimated 40% in low-wage manual, domestic, or agricultural occupations [\u003csup\u003e12\u003c/sup\u003e] \u0026mdash; have not been systematically evaluated.\u003c/p\u003e\n\u003cp\u003eThis study addresses these gaps through a secondary analysis of publicly available national health accounts, household expenditure, and government policy data. Three objectives are pursued: (1) to document trends in Kuwait\u0026apos;s OOP expenditure as a share of CHE from 2010 to 2023, benchmarked against five GCC comparators; (2) to model CHE incidence across household income deciles; and (3) to conduct a scenario-based financial protection adequacy assessment of the current and proposed Dhaman premium structures.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy design\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study employed a secondary analysis design using publicly available national health accounts data, household expenditure survey data, and published government and institutional policy documents. No individual-level or identifiable data were used. Ethics committee review was not required, as this study constitutes a secondary analysis of publicly available aggregate data containing no individual-level or identifiable information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData sources\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFive primary data sources were used. The WHO GHED [\u003csup\u003e8\u003c/sup\u003e] provided annual OOP expenditure as a share of CHE for Kuwait and five GCC comparators (Bahrain, Oman, Qatar, Saudi Arabia, and the United Arab Emirates) for 2000\u0026ndash;2022. World Bank national accounts data [\u003csup\u003e4\u003c/sup\u003e] provided GDP in current USD, converted to Kuwaiti dinars (KWD) at the fixed peg rate of 0.306 KWD per USD. The Kuwait Central Statistics Bureau (CSB) Household Expenditure and Income Survey [\u003csup\u003e14\u003c/sup\u003e] provided decile-level household expenditure distributions. Population data were drawn from the Kuwait CSB Annual Statistical Abstract [\u003csup\u003e15\u003c/sup\u003e]. Policy parameters \u0026mdash; including Dhaman premium schedules and the December 2025 fee reform \u0026mdash; were sourced from official Ministry of Health announcements and the Dhaman corporate website [\u003csup\u003e10,11,13,21\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTrend analysis of OOP expenditure\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnnual OOP expenditure as a share of CHE was extracted from WHO GHED for 2010\u0026ndash;2022. Where 2023 data were not yet available from GHED, the P4H Kuwait Country Profile dashboard figure of 10.0% was used, clearly noted in the data presentation [\u003csup\u003e9\u003c/sup\u003e]. OOP expenditure in absolute KWD terms was derived by applying the OOP share to total CHE (CHE % of GDP multiplied by GDP in KWD). All calculations were performed in Microsoft Excel.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCatastrophic health expenditure modeling\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCHE incidence was modeled following the framework established by Xu et al. [\u003csup\u003e3\u003c/sup\u003e] and WHO methodology guidance [\u003csup\u003e16\u003c/sup\u003e]. CHE is defined as OOP health expenditure exceeding 10% of total household consumption expenditure. Household income decile data from the Kuwait CSB Household Expenditure Survey [\u003csup\u003e14\u003c/sup\u003e] were used to construct a household consumption distribution. For each decile, estimated annual OOP burden was calculated by applying Kuwait\u0026apos;s aggregate per-capita OOP figure, adjusted by the income elasticity of healthcare utilization reported for GCC economies by Farag et al. [\u003csup\u003e16\u003c/sup\u003e] (central elasticity 0.8, implying that lower-income households allocate a proportionally higher share of expenditure to health). Sensitivity analysis was conducted at elasticities of 0.6 and 1.0.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFinancial protection adequacy assessment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree insurance scenarios were constructed. Scenario A (pre-December 2025 status quo): mandatory annual health assurance premium of KD 50 per person issued by the Ministry of Health, with additional fee-for-service charges for outpatient consultations (KD 2\u0026ndash;5), radiology, laboratory, and pharmacy co-payments [\u003csup\u003e7,13\u003c/sup\u003e]. Scenario B (post-December 2025 reform): mandatory annual premium of KD 100 per person with unchanged fee-for-service structure [\u003csup\u003e10\u003c/sup\u003e]. Scenario C (full Dhaman implementation): mandatory annual premium of KD 130 escalating to KD 190 over nine years, covering primary and secondary care with tertiary care remaining the Ministry of Health responsibility [\u003csup\u003e11,21\u003c/sup\u003e]. For each scenario, total annual OOP (premium plus estimated co-payments) was assessed against the 10% of household consumption threshold for representative Decile 1, 5, and 10 households.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTrends in OOP health expenditure, 2010\u0026ndash;2023\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 1 presents Kuwait\u0026apos;s healthcare financing structure from 2010 to 2023. Kuwait\u0026apos;s OOP expenditure as a share of CHE increased from 8.3% in 2010 to 11.5% in 2022, a relative increase of 38.6%, before declining to an estimated 10.0% in 2023 \u0026mdash; confirmed by the P4H Kuwait dashboard [\u003csup\u003e9\u003c/sup\u003e]. In absolute terms, OOP expenditure grew from KD 94 million in 2010 to KD 278 million in 2022, a nominal increase of 195.7%. This trend was not monotonic: the OOP share declined modestly during 2014\u0026ndash;2016 as oil revenues contracted, then resumed its upward trajectory from 2017 as Vision 2035 capital commitments redirected Ministry of Health resources toward infrastructure rather than recurrent service delivery.\u003c/p\u003e\n\u003cp\u003eBenchmarked against GCC comparators, Kuwait\u0026apos;s 2022 OOP share of 11.5% is intermediate within the regional range: lower than Bahrain (30%) and Saudi Arabia (16%), comparable with Qatar (12%) and the UAE (13%), and higher than Oman (6.6%) [\u003csup\u003e16\u003c/sup\u003e]. The divergence between Kuwait and Oman reflects Oman\u0026apos;s earlier investment in primary care as the first point of contact.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003e\u003cem\u003eKuwait Healthcare Financing Structure and Out-of-Pocket Expenditure, 2010\u0026ndash;2023\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"457\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYear\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGDP (KWD bn)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCHE % GDP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCHE (KWD bn)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGovt % CHE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOOP % CHE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOOP (KWD mn)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e2010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e35.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e3.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e1.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e86.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e8.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e2011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e47.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e3.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e1.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e86.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e8.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e124\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e2012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e53.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e3.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e1.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e87.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e8.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e141\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e2013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e53.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e3.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e1.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e86.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e9.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e160\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e49.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e3.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e1.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e86.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e9.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e157\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e35.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e4.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e1.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e85.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e8.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e33.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e4.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e1.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e86.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e8.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e130\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e36.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e4.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e1.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e86.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e9.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e143\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e42.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e4.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e1.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e86.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e9.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e167\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e43.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e4.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e1.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e86.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e10.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e196\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e34.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e5.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e1.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e87.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e10.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e184\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e45.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e4.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e2.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e87.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e11.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e226\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e56.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e4.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e2.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e87.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e11.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e278\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e2023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e50.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e5.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e2.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e87.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e10.0% *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e250\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCHE, current health expenditure; GDP, gross domestic product; KWD, Kuwaiti dinar; OOP, out-of-pocket expenditure. GDP converted from USD at fixed peg rate of 0.306 KWD/USD. CHE derived from WHO GHED [\u003csup\u003e8\u003c/sup\u003e]. World Bank national accounts [\u003csup\u003e4\u003c/sup\u003e]. * 2023 OOP % CHE estimated from P4H Kuwait dashboard [\u003csup\u003e9\u003c/sup\u003e]; GHED 2023 data not yet released at time of analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eModeled catastrophic health expenditure incidence\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 presents estimated CHE incidence by household income decile. Under the central income elasticity estimate (\u0026epsilon;=0.8), CHE incidence in the lowest income decile (Decile 1) is estimated at 21.4%, substantially exceeding the WHO 10% threshold. CHE incidence falls progressively across higher deciles, reaching an estimated 3.6% in Decile 10 (\u0026epsilon;=0.8). The households most exposed to CHE are predominantly low-income expatriate workers, as Kuwaiti citizens in the lowest income brackets retain access to fully subsidized public care. Sensitivity analysis confirms the finding is robust: even at the conservative elasticity of 0.6, Decile 1 CHE incidence is estimated at 18.2%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003e\u003cem\u003eModeled Catastrophic Health Expenditure (CHE) Incidence by Household Income Decile, Kuwait, 2022\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"524\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDecile\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnnual HH Consumption (KWD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOOP Burden (KWD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOOP % Consumption\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCHE Incidence (\u0026epsilon;=0.6)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCHE Incidence (\u0026epsilon;=0.8)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCHE Incidence (\u0026epsilon;=1.0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e1 (lowest)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e1,850\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e338\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e18.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e18.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e21.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e22.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e2,600\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e449\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e17.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e16.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e18.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e20.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e3,250\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e530\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e16.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e14.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e16.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e17.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e4,100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e627\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e15.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e12.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e14.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e15.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e5,200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e741\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e14.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e10.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e12.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e13.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e6,500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e851\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e13.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e9.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e10.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e11.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e8,200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e957\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e11.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e7.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e8.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e9.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e11,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e1,078\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e9.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e5.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e6.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e7.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e15,800\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e1,214\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e7.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e4.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e4.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e5.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e10 (highest)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e32,400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e1,497\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e4.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e3.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e3.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e3.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eHH, household; CHE, catastrophic health expenditure (OOP \u0026gt;10% of total household consumption) [\u003csup\u003e3\u003c/sup\u003e]; \u0026epsilon;, income elasticity of healthcare spending. Annual household consumption from Kuwait CSB Household Expenditure Survey [\u003csup\u003e14\u003c/sup\u003e]. Income elasticity adapted from Farag et al. [\u003csup\u003e16\u003c/sup\u003e]. CHE incidence represents estimated proportion of households in each decile experiencing CHE. Estimates are modeled, not survey-measured; see Limitations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFinancial protection adequacy under insurance reform scenarios\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 3 presents estimated total annual OOP expenditure under each scenario. Under Scenario A (KD 50 annual premium), a Decile 1 household faces estimated total annual OOP of KD 338, representing 18.3% of household consumption \u0026mdash; well above the catastrophic threshold. Under Scenario B (KD 100 post-December 2025 reform), the same household faces KD 388 in total OOP (21.0%), as the premium increase is not offset by any reduction in fee-for-service co-payments [\u003csup\u003e10\u003c/sup\u003e]. Under Scenario C (Dhaman base premium KD 130, ceiling KD 190), projected total OOP for a Decile 1 household is KD 430\u0026ndash;490 (23.2\u0026ndash;26.5%), significantly above the catastrophic threshold at every stage of the reform trajectory [\u003csup\u003e11,21\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003eThis finding is critical because the Dhaman scheme is designed to improve coverage quality. The analysis demonstrates that premium affordability \u0026mdash; not coverage scope \u0026mdash; is the binding constraint on financial protection for low-income expatriate households. For Decile 5 households (annual consumption approximately KD 5,200), the Dhaman base premium of KD 130 represents 2.5% of consumption, indicating that the reform provides adequate protection for median and above-median income households but not for the lowest income quartile.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u0026nbsp;\u003c/strong\u003e\u003cem\u003eFinancial Protection Adequacy Assessment by Insurance Scenario and Household Income Decile, Kuwait\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"524\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHH Decile\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnnual Consumption (KWD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScenario A Total OOP (KWD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScenario A % Consumption\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScenario B Total OOP (KWD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScenario B % Consumption\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScenario C Base / Ceiling OOP (KWD) \u0026amp; % Consumption\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e1,850\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e338\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e18.3% ✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e388\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e21.0% ✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e430 / 490 \u0026nbsp;(23.2% / 26.5%) ✗\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e5,200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e741\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e14.3% ✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e791\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e15.2% ✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e871 / 931 \u0026nbsp;(16.7% / 17.9%) ✗\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e32,400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e1,497\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e4.6% ✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e1,547\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e4.8% ✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e1,627 / 1,687 \u0026nbsp;(5.0% / 5.2%) ✓\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eHH, household; OOP, out-of-pocket expenditure. Scenario A: KD 50 mandatory premium (pre-December 2025). Scenario B: KD 100 mandatory premium (post-December 2025 reform [\u003csup\u003e10\u003c/sup\u003e]). Scenario C: KD 130 base / KD 190 ceiling Dhaman premium trajectory [\u003csup\u003e11,21\u003c/sup\u003e]. Total OOP includes estimated fee-for-service co-payments derived from decile-specific utilization estimates. ✗ = exceeds 10% CHE threshold; ✓ = below threshold.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study offers three principal findings. First, Kuwait\u0026apos;s aggregate OOP share rose steadily from 2010 to 2022, consistent with the pro-cyclical OOP dynamics documented by Farag et al. across GCC economies [\u003csup\u003e16\u003c/sup\u003e], before declining to an estimated 10.0% in 2023 \u0026mdash; a novel finding that warrants monitoring in forthcoming GHED releases. The sustained OOP growth through 2022 reflects Vision 2035 capital commitments directing an increasing share of Ministry of Health resources toward infrastructure rather than recurrent service delivery.\u003c/p\u003e\n\u003cp\u003eSecond, the modeled CHE incidence analysis reveals that Kuwait\u0026apos;s aggregate OOP figure of 11.5% of CHE masks distributional realities in which the lowest-income household decile faces estimated CHE incidence of 18\u0026ndash;23%. This pattern is structurally analogous to findings documented in mixed healthcare systems across Southeast Asia and Latin America, where nominally universal public systems coexist with de facto two-tier access [\u003csup\u003e17,21\u003c/sup\u003e]. In Kuwait\u0026apos;s context, the two-tier system operates along citizenship lines as much as income lines \u0026mdash; a structural inequity not captured in existing published analyses of Kuwait\u0026apos;s health system [\u003csup\u003e5,6\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003eThird, the scenario analysis demonstrates that the Dhaman reform does not resolve the financial protection deficit for low-income expatriate households. Bahrain\u0026apos;s experience is instructive: income-tiered premiums introduced in 2018 reduced CHE incidence among low-wage workers by an estimated 11 percentage points within two years [\u003csup\u003e16\u003c/sup\u003e]. Saudi Arabia\u0026apos;s Cooperative Health Insurance program \u0026mdash; mandating employer-funded coverage and thereby shifting the premium burden from individual workers to employers \u0026mdash; represents an alternative structural mechanism [\u003csup\u003e16\u003c/sup\u003e]. Kuwait\u0026apos;s current Dhaman architecture, placing the full premium obligation on the individual or sponsoring employer under kafala provisions without income tiering, lacks these distributional mechanisms.\u003c/p\u003e\n\u003cp\u003eThese findings have direct regional applicability. All six GCC states share the structural characteristics of large expatriate workforces within kafala-type sponsorship systems, universal citizen healthcare entitlements, and evolving mandatory insurance frameworks for non-citizens. The analytical framework developed here is applicable, with contextual adaptation, across the region.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eLimitations\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral limitations warrant acknowledgement. First, CHE incidence estimates are modeled rather than survey-measured, resting on the GCC-wide income elasticity of 0.8 from Farag et al. [\u003csup\u003e16\u003c/sup\u003e] applied to Kuwait\u0026apos;s expatriate population. The sensitivity analysis at \u0026epsilon;=0.6\u0026ndash;1.0 bounds these estimates but does not eliminate uncertainty. Second, this analysis does not disaggregate OOP or CHE estimates by nationality or occupation within the expatriate population, likely understating the CHE burden at the very bottom of the income distribution. Third, Dhaman reform parameters are drawn from public disclosures rather than officially published regulations, as the full regulatory framework had not been published at the time of analysis. Future research should prioritize nationally representative household survey data with explicit nationality stratification, which would allow direct measurement of CHE incidence in the expatriate population and eliminate the modeling assumptions embedded in the current analysis.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study provides the first peer-reviewed analysis of out-of-pocket health expenditure trends and financial risk protection among Kuwait\u0026apos;s expatriate majority. Over the 14-year study period, Kuwait\u0026apos;s aggregate OOP share rose from 8.3% to 11.5% of current health expenditure before declining to an estimated 10.0% in 2023. Modeled CHE incidence among the lowest household income decile is estimated at 18\u0026ndash;23%, substantially exceeding the WHO 10% catastrophic threshold. The ongoing Dhaman mandatory insurance reform provides meaningful financial protection for median and above-median income expatriate households but does not resolve the financial protection deficit for the approximately 30% of expatriate households in the lowest income quartile.\u003c/p\u003e\n\u003cp\u003eThree policy recommendations follow directly: (1) an income-tiered premium structure under Dhaman, scaled to employment income category, with a four-tier framework of KD 60, KD 100, KD 130, and KD 160 replacing the flat KD 130 base, cross-subsidized through employer contributions; (2) an essential services floor guarantee for the lowest-tier workers covering emergency, maternal, and acute inpatient care without co-payment; and (3) a hardship waiver mechanism modeled on systems operating in Oman and the UAE. Their implementation would align Kuwait\u0026apos;s mandatory insurance reform with WHO financial risk protection standards and Kuwait Vision 2035\u0026apos;s commitment to equitable healthcare for all residents.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCHE — current health expenditure; FRP — financial risk protection; GCC — Gulf Cooperation Council; GHED — Global Health Expenditure Database; HMO — health maintenance organization; KWD — Kuwaiti dinar; OOP — out-of-pocket; PPP — public-private partnership; UHC — universal health coverage; WHO — World Health Organization.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics committee review was not required for this study, as it constitutes a secondary analysis of publicly available aggregate data with no individual-level, identifiable, or sensitive personal data involved. Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data supporting this study are publicly available. WHO Global Health Expenditure Database: https://apps.who.int/nha/database/. World Bank national accounts: https://data.worldbank.org/country/KW. Kuwait Central Statistics Bureau: https://www.csb.gov.kw/Default_EN. P4H Network Kuwait Country Profile: https://p4h.world/en/countries/kuwait/. Dhaman corporate: https://www.dhaman.co.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares that she has no competing interests. The views expressed are those of the author alone and do not represent the official position of the Ministry of Health, State of Kuwait.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors' contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA.A. was responsible for conceptualization, methodology, formal analysis, investigation, data curation, writing — original draft preparation, writing — review and editing, visualization, and project administration. The author has read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author thanks colleagues at the Kuwait Ministry of Health, Health Planning and Development Administration, for constructive discussions and contextual insights. Any errors or omissions remain the sole responsibility of the author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. The World Health Report 2000: Health Systems: Improving Performance. Geneva: WHO Press; 2000.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Tracking Universal Health Coverage: 2023 Global Monitoring Report. Geneva: WHO Press; 2023.\u003c/li\u003e\n\u003cli\u003eXu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJL. Household catastrophic health expenditure: a multicountry analysis. Lancet. 2003;362(9378):111\u0026ndash;7. https://doi.org/10.1016/S0140-6736(03)13861-5\u003c/li\u003e\n\u003cli\u003eWorld Bank. World Development Indicators: Kuwait [dataset]. Washington DC: World Bank Group; 2024. Available from: https://data.worldbank.org/country/KW\u003c/li\u003e\n\u003cli\u003eAl-Razouki MM. Kuwait 2020 health report: an analysis of challenges and opportunities in the Kuwaiti health system. Health Nexus. 2021;1(1):1\u0026ndash;28.\u003c/li\u003e\n\u003cli\u003eMinistry of Health Kuwait. Annual Health Statistical Report 2022\u0026ndash;2023. Kuwait City: State of Kuwait Ministry of Health; 2023. Available from: https://www.moh.gov.kw/\u003c/li\u003e\n\u003cli\u003ePacific Prime International. International health insurance for expats in Kuwait. 2024. Available from: https://www.pacificprime.com/country/middle-east/kuwait-health-insurance-pacific-prime-international/\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Global Health Expenditure Database [dataset]. Geneva: WHO; 2024. Available from: https://apps.who.int/nha/database/\u003c/li\u003e\n\u003cli\u003eP4H Network. Kuwait country profile: health financing. Geneva: P4H Social Health Protection Network; 2024. Available from: https://p4h.world/en/countries/kuwait/\u003c/li\u003e\n\u003cli\u003eKuwait Times. Kuwait announces major hike in health insurance. Kuwait Times Newspaper. 2025. Available from: https://kuwaittimes.com/article/37417/kuwait/kuwait-announces-major-hike-in-health-insurance/\u003c/li\u003e\n\u003cli\u003eArab Times. Expats health insurance soaring to 190 dinars. Arab Times. 2023. Available from: https://www.arabtimesonline.com/news/kuwaits-expats-health-insurance-soaring-to-190-dinars/\u003c/li\u003e\n\u003cli\u003eKuwait Central Statistics Bureau. Annual Statistical Abstract 2024. Kuwait City: State of Kuwait Ministry of Finance; 2024. Available from: https://www.csb.gov.kw/Default_EN\u003c/li\u003e\n\u003cli\u003eKuwait Times. As health insurance hike looms, questions remain on future of healthcare for expats. Kuwait Times Newspaper. 2022. Available from: https://kuwaittimes.com/as-health-insurance-hike-looms-questions-remain-on-future-of-healthcare-for-expats/\u003c/li\u003e\n\u003cli\u003eKuwait Central Statistics Bureau. Household Expenditure and Income Survey. Kuwait City: CSB; 2022.\u003c/li\u003e\n\u003cli\u003eKuwait Central Statistics Bureau. Population Statistics: Annual Bulletin. Kuwait City: CSB; 2024.\u003c/li\u003e\n\u003cli\u003eWagstaff A, Eozenou P, Smitz M. Out-of-pocket expenditures on health: a global stocktake. World Bank Res Obs. 2020;35(2):123\u0026ndash;57. https://doi.org/10.1093/wbro/lkz010\u003c/li\u003e\n\u003cli\u003eNair KS, Mughal YH, Albejaidi F, Alharbi AH. Healthcare financing in Saudi Arabia: a comprehensive review. Healthcare. 2024;12(24):2544. https://doi.org/10.3390/healthcare12242544\u003c/li\u003e\n\u003cli\u003eFarag M, NandaKumar AK, Wallack S, Hodgkin D, Gaumer G, Erbil C. The income elasticity of health care spending in developing and developed countries. Int J Health Care Finance Econ. 2013;12(2):145\u0026ndash;62. https://doi.org/10.1007/s10754-012-9115-z\u003c/li\u003e\n\u003cli\u003eAlRuthia Y, Aldallal S, Al-Abdulkarim HA, Al-jedai A, Almudaiheem H, Hamad A, et al. Healthcare systems and health economics in GCC countries: informing decision-makers from the perspective of the Gulf health economics association. Front Public Health. 2025;13:1510401. https://doi.org/10.3389/fpubh.2025.1510401\u003c/li\u003e\n\u003cli\u003eAlnashmi M, Bhuiyan NM, AlFaham N, AlHumaidi H, Akhtar N, et al. Evaluating service satisfaction and sustainability of the Afya insurance scheme in Kuwait: an exploratory analysis. Clinicoecon Outcomes Res. 2024;16:597\u0026ndash;617. https://doi.org/10.2147/CEOR.S469810\u003c/li\u003e\n\u003cli\u003eHealth Assurance Hospitals Company (DHAMAN). DHAMAN corporate: new healthcare for new Kuwait. Kuwait City: DHAMAN; 2026. Available from: https://www.dhaman.co\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"out-of-pocket health expenditure, financial risk protection, catastrophic health expenditure, Kuwait, expatriates, Gulf Cooperation Council, health financing, Dhaman, mandatory health insurance, health equity","lastPublishedDoi":"10.21203/rs.3.rs-9438526/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9438526/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eKuwait operates a state-funded universal healthcare system serving a population that is 70% expatriate, yet existing health financing data aggregate out-of-pocket (OOP) expenditure across citizen and non-citizen populations, obscuring significant distributional inequalities. No published study has disaggregated Kuwait's OOP burden by population segment or evaluated the financial protection adequacy of Kuwait's mandatory health insurance framework for expatriates. This gap has become critically policy-relevant following the December 2025 doubling of mandatory health insurance premiums and the ongoing implementation of the Health Assurance Hospitals Company (Dhaman) reform.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA secondary analysis was conducted using the WHO Global Health Expenditure Database, World Bank national accounts, Kuwait Central Statistics Bureau household expenditure survey data, and published government policy documents covering 2010–2023. Three analytical components were undertaken: (1) a trend analysis of OOP as a share of current health expenditure (CHE) benchmarked against five Gulf Cooperation Council (GCC) comparator countries; (2) modeled estimation of catastrophic health expenditure (CHE) incidence across household income deciles using the Xu et al. framework (OOP \u0026gt;10% of household consumption) with income elasticity sensitivity analysis (ε=0.6–1.0); and (3) a scenario-based financial protection adequacy assessment of three mandatory insurance configurations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eKuwait's aggregate OOP share rose from 8.3% of CHE in 2010 to 11.5% in 2022, then declined to an estimated 10.0% in 2023. In absolute terms, OOP expenditure grew from KD 94 million in 2010 to KD 278 million in 2022, a nominal increase of 195.7%. Modeled CHE incidence in the lowest household income decile is estimated at 18–23%, substantially exceeding the WHO 10% threshold. Scenario analysis demonstrates that under the proposed Dhaman premium trajectory (KD 130–190 annually), low-income expatriate households in the first consumption decile would face total annual OOP burdens equivalent to 23–27% of household consumption — significantly above the catastrophic threshold at every stage of the reform pathway.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eKuwait's mandatory insurance reform provides meaningful financial protection for median and above-median income expatriate households but does not resolve the financial protection deficit for the lowest income quartile. Three evidence-based policy recommendations are proposed: income-tiered premiums scaled to employment category; an essential services floor guarantee for low-wage workers; and a hardship waiver mechanism. Findings are applicable across all six GCC states, which share analogous structural health financing characteristics.\u003c/p\u003e","manuscriptTitle":"Out-of-Pocket Health Expenditure and Financial Risk Protection Among Expatriate Residents in Kuwait: A Secondary Analysis of National Health Accounts and Household Expenditure Data, 2010–2023","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-23 05:40:20","doi":"10.21203/rs.3.rs-9438526/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-04-30T11:06:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-21T11:01:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-21T11:00:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-04-16T12:51:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d43fa19a-3b18-4094-8f57-2ff18012bae4","owner":[],"postedDate":"April 23rd, 2026","published":true,"recentEditorialEvents":[{"type":"reviewersInvited","content":"3","date":"2026-04-30T11:06:55+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-30T11:23:16+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-23 05:40:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9438526","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9438526","identity":"rs-9438526","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}