Heart Failure Drives High Out-of-Pocket Spending and Financial Burden in India: Latest 2026 Published Multicentric ICMR Study

New findings from a large multicentre study conducted across India highlights the substantial financial burden associated with Heart Failure (HF), with Out-Of-Pocket (OOP) expenditure accounting for over 90% of total healthcare spending, placing significant economic strain on patients and households.

The study, titled ‘Financial Burden, Out-of-Pocket Health Spending, and Household Economic Well-Being in Heart Failure Patients in India,’ published in Global Heart (2026), offers thorough empirical data on the financial effects of Heart Failure (HF) in India.

Heart Failure (HF) remains a resource-intensive chronic condition requiring repeated hospitalizations, long-term pharmacotherapy, and ongoing follow-up care. In low and middle-income countries like India, these demands translate into substantial direct and indirect costs, often leading to financial distress and compromised care.

About the Study

This multicentre, cross-sectional survey included 1,859 heart failure patients recruited from 21 hospitals across India, representing diverse geographic regions and epidemiological transition levels. The study population had a mean age of 55.9 years, included 30.2% women, nearly half resided in rural areas, and only about one-third (32.2%) had health insurance coverage. Data were collected using validated structured questionnaires capturing clinical characteristics, healthcare utilisation, and detailed economic parameters, including out-of-pocket expenditure, catastrophic health spending (CHS), and distress financing (DF).

Insurance Status Significantly Influences Heart Failure Treatment Costs in India

Heart failure impacts individuals in their productive years, increasing socioeconomic strain. High treatment costs, recurrent hospitalisations, and income loss drive financial vulnerability, with one-third reporting reduced income. Expenditure is dominated by hospitalisation and OOP costs, alongside significant catastrophic spending and distress financing. The figure illustrates the healthcare expenditure among heart failure patients varies by insurance status, with uninsured individuals facing the highest financial burden and out-of-pocket (OOP) costs. Among insured groups, social insurance schemes (PMJAY & SHI) show lower expenses, while private and government schemes remain costlier. In-patient care dominates spending across all groups. OOP accounts for 97.9% of costs in uninsured patients, compared to 73.8% (social insurance) and 58.5% (private insurance). Catastrophic health spending is also higher among the uninsured (40.3% vs 30.8%).

Despite some protection, existing insurance schemes remain largely focused on inpatient care, leaving outpatient costs and long-term medication expenses inadequately covered.

Figure 1: Expenditure breakdown, Insured v/s Uninsured: High OOP Expenditure

Key Findings: Financial Burden Associated with Heart Failure in India

• The average annual out-of-pocket expenditure was ₹1,06,566, accounting for 92.6% of total health spending.

• Average cost of the most recent heart failure-related hospitalisation per patient was ₹1,18,954.21 (INT$5,256.5), based on self-reported expenditure for the last hospital stay.

• Nearly one-third of individuals (32.3%) and households (36.2%) reported a decline in income following HF diagnosis

• Catastrophic health spending (CHS) was observed in 37.7% of patients. Distress financing (DF), including borrowing or selling assets, was reported in 17.7% of households.

• Financial burden was disproportionately higher among rural residents, unemployed individuals, and those from lower socioeconomic groups

• Among uninsured patients, OOP expenditure constituted 97.9% of total spending, compared to lower proportions among those with social or private insurance

The data underscore that HF care in India is predominantly financed through household resources, with limited financial protection mechanisms in place.

Improving Affordability: Emerging Access to GDMT for HF, including Sacubitril Valsartan, available at ~INR. 8/- per Tablet

The study also highlights a critical gap in financial protection, particularly for long-term outpatient care and medications, which remain largely uncovered under most existing insurance frameworks. However, the heart failure treatment landscape in India is gradually evolving, with increasing availability of cost-effective therapeutic options, including GDMT drug classes such as angiotensin receptor–neprilysin inhibitors (ARNIs). The availability of more affordable high-quality formulations—reported to be accessible at approximately ₹8 per tablet in Indian settings—marks an important step toward improving access to guideline-directed medical therapy (GDMT).

These medications are proven to reduce heart failure hospitalisations and improve cardiovascular outcomes. Access to such cost-effective interventions is very pragmatic in Indian healthcare settings. They have the potential to lower out-of-pocket expenses, increase drug adherence, and improve long-term outcomes, especially in a country where OOP spending accounts for more than 90% of total healthcare cost in HF. Expanding access to cost-effective evidence-based medicines, as well as expanded insurance coverage, would be critical in alleviating the dual burden of disease and financial toxicity in heart failure care in India.

 Expert reactions to the ICMR study

Given the high OOP expenditure (> 90%) of total HF-related spending among Indian HF patients, what practical steps can a clinician recommend their heart failure patients to lead a complication-free life, reduce hospitalisation and emergency healthcare costs? 

Responding to this, Dr. Dhiman Kahali, Director, Interventional Cardiology, B.M. Birla Heart Hospital, Kolkata, said that in our current practice, the focus in Heart Failure management must shift towards prevention of decompensation. Early optimization of Guideline-Directed Medical Therapy (GDMT), along with strict patient adherence and regular follow-ups, is essential for improving long-term outcomes.

Simple lifestyle modifications such as salt restriction, weight management, and early reporting of symptoms can significantly reduce the risk of hospitalizations.

At the same time, we must be mindful of the cost burden on patients. There is a significant price difference between high-cost multinational brands and more affordable indigenous alternatives of the same quality, many of which are exported to advanced countries. Choosing cost-effective options can improve adherence and ensure continuity of treatment.

Key therapies like Empagliflozin and Sacubitril–Valsartan have strong clinical evidence in reducing mortality and recurrent hospitalizations. However, price variations among brands of the same molecule provide an opportunity to position more economical options for long-term patient benefit.

Let us align our approach towards early intervention, affordability, and sustained therapy to improve outcomes in Heart Failure patients.

What is the role of cost-effective medications to improve outcomes in heart failure patients? 

In reply, Dr. S. Manoj, Senior Consultant & Interventional Cardiologist, Kauvery Hospital, Chennai, said that cost-effective, evidence-based therapies constitute the backbone of heart failure management in our country. Affordable therapies expand access and help patients endure long-term treatment, which is the practical need in the real world. The rational use of cost-effective GDMT, including ARNI, SGLT2i, BB, and MRA, improves survival, minimizes rehospitalization, and increases patient adherence. Remember, affordability directly influences whether patients stick to their treatment in our country. Approving out patient chronic therapy care under various health insurance means, can enhance greater access and sustain long term adherence with optimal clinical outcomes for critical illness like heart failure. We now have access to sacubitril-valsartan and dapagliflozin FDC in our country; they can be good, practical, cost-effective considerations when indicated. Selecting cost-effective regimens is not only financial; it is also therapeutically important and practically relevant for long-term HF care.

These findings underscore the need for physicians to prioritise cost-conscious, guideline-directed therapies, promote adherence, and minimise preventable hospitalisations, while policymakers must expand comprehensive insurance coverage beyond inpatient care to include outpatient management and essential medications.

Abbreviations

HF- Heart Failure; ICMR-Indian Counsil of Medical Research; OOP- Out-Of-Pocket; CHS- Catastrophic Health Spending; DF- Distress Financing; ARNI- Angiotensin Receptor–Neprilysin Inhibitor; GDMT- Guideline-Directed Medical Therapy