This narrative review investigates the implications of out-of-pocket (OOP) payments for malaria treatment in developing countries by synthesizing evidence from peer-reviewed articles, reports, and policy documents. A thematic approach was employed to analyze key areas, including economic impacts on households, barriers to accessing care, and the overall effectiveness of malaria control interventions. The review also evaluated alternative financing mechanisms and their potential to mitigate the financial burden on vulnerable populations. The findings reveal that OOP payments significantly hinder timely access to malaria treatment, disproportionately affecting low-income and rural households. Delayed treatment-seeking behavior, underutilization of preventive measures such as insecticide-treated nets, and suboptimal use of diagnostics were identified as major challenges. Furthermore, the financial burden of OOP payments exacerbates health inequities, increasing morbidity and mortality among marginalized groups. Effective alternatives, such as government subsidies, community health insurance, and donor-funded programs, were highlighted as solutions to reduce these barriers. The review concludes that reducing OOP payments is critical to improving malaria control and ensuring equitable healthcare access in developing countries. It recommends scaling up subsidized care, strengthening public health systems, and engaging in public-private partnerships to enhance the availability and affordability of malaria interventions. Policymakers are urged to prioritize financial protection strategies to achieve sustainable progress in malaria eradication efforts.

Objective: To evaluate access to medicines and out-of-pocket expenses among patients treated at the Lima Este – Vitarte Hospital. Methods: A descriptive, cross-sectional study was conducted in 58 patients selected through non-probabilistic convenience sampling. Data were collected using a structured questionnaire administered via Google Forms and analyzed using IBM SPSS Statistics v.25. The instrument showed high reliability (Cronbach’s alpha = 0.89). Results: A total of 62.1% of participants reported incomes equal to or below the minimum wage, and 49.3% stated that medication prices limited their access to treatment. Only 8.6% reported that all prescribed medicines were available at the hospital pharmacy. Conclusions: Significant gaps in access to medicines and a high burden of out-of-pocket expenditure were identified, highlighting the need to strengthen public policies aimed at improving drug supply and financial protection within the public health system.

This article presents a comprehensive analysis of the health system of the Republic of Kazakhstan, its current state, key achievements and remaining challenges. Using the Harvard “Five Control Knobs” analytical framework (financing, payment, organization, regulation and behavior), as well as analysis of the dynamics of the main medical and demographic indicators and human resources for 2017-2023, the article seeks to fill the gap in the systemic understanding of the effectiveness of the ongoing reforms and their impact on the health of the population. Particular attention is paid to the relationship between the various components of the system and the identification of priority areas for further improvement.<br /> Our findings indicate a moderate improvement in population health, with average life expectancy increasing from 72.9 to 75.1 years and overall mortality returning to pre-pandemic levels. However, noncommunicable diseases continue to account for approximately 84% of all deaths. Total health expenditure remained low at 3.8% of GDP in 2023, while out-of-pocket spending accounted for 27.7% of current health expenditure, reflecting persistent gaps in financial protection. Although the introduction of mandatory social health insurance has expanded pooled financing, significant weaknesses persist in provider incentive structures, workforce distribution, and regulatory enforcement.<br /> Overall, the results suggest that while gradual progress has been achieved, chronic underfunding, system fragmentation, and governance challenges continue to constrain equity and efficiency, underscoring the need for coordinated, evidence-based reforms.

Universal Health Coverage places strong emphasis on health insurance as a strategy to ensure need-based care without financial hardship, yet its direct impact on healthcare utilisation and expenditure remains unclear. This scoping review maps recent evidence on how insurance influences both service use and out-of-pocket expenditure (OOPE), including catastrophic health expenditure(CHE) , by examining studies published between 2018 and early 2024. Using the Population, Concept, Context (PCC) framework and PRISMA-Scr checklist, the review included only studies that reported both utilisation and expenditure outcomes within the same context. Ten eligible studies were identified. Overall, the findings indicate that enrolment in health insurance schemes generally increases healthcare utilisation, although the effect varies by type of service and is not universal across all care categories. Evidence also shows that insurance contributes to reducing OOPE, but the magnitude of this effect depends heavily on the design and generosity of the insurance scheme. In contrast, CHE does not demonstrate a clear or consistent association with insurance coverage, suggesting gaps in financial protection. These results highlight the need for policy attention to benefit package design, depth of coverage, and inclusion of diverse service types to strengthen financial risk protection across different health system settings.

Nigeria's health reforms aim to accelerate progress toward Universal Health Coverage (UHC). In alignment with these efforts, Gombe State has leveraged national policy frameworks to implement health sector reforms that have improved maternal, newborn, and child health outcomes. To consolidate gains and define future priorities, the state convened the Maiden Gombe State Health Summit in October 2025. The Summit was a two-day hybrid event with over 500 participants from government, development partners, civil society, academia, and the private sector. Data were drawn from rapporteur reports, recordings, presentations, session transcripts, keynote speeches, and policy documents. A thematic analysis approach was used to synthesize key discussions and outcomes. The Summit highlighted strong political commitment, revitalization of 228 primary health centres, upgrades to secondary facilities, expanded immunization coverage, and strengthened disease surveillance. Health workforce reforms, including Human Resources for Health (HRH) governance structures, biometric attendance tracking, training programmes, and welfare improvements, enhanced accountability and productivity. Financial protection was strengthened through the Gombe State Contributory Health Insurance Scheme, covering over 380,000 residents. Implementation of the Sector Wide Approach (SWAp) improved coordination of partner investments. These reforms contributed to measurable reductions in under-five, infant, and child mortality between 2018 and 2023. Gombe State's experience demonstrates how subnational governments can advance UHC through political leadership, alignment with national reforms, primary healthcare strengthening, health workforce investment, sustainable financing, and inclusive stakeholder engagement. The lessons from the Summit provide actionable insights for sustaining reform momentum and strengthening health systems in similar settings.

Health care financing is essential for protecting populations from the financial risks of illness and for advancing universal health coverage. In many countries, limited public spending and rising health care costs have increased reliance on out-of-pocket payments, exposing households to financial hardship and poverty. This study analyzes the effects of guaranteed medical care packages and health financing mechanisms on population economic well-being, with a focus on financial risk protection. Evidence from different countries shows that insufficient coverage and inefficient financing can worsen income loss and deepen poverty, especially among vulnerable groups. The results indicate that supplementary or private insurance does not always reduce out-of-pocket spending and may even increase household health costs. By contrast, well-funded and effectively regulated guaranteed medical care packages improve access to essential services and reduce the impoverishing impact of health expenditures. The study highlights the importance of equitable coverage and strong financial protection in promoting long-term economic well-being and safeguarding household welfare.

Background In sub-Saharan Africa, the epidemiological transition has created a double burden of chronic disease and functional decline. While the relationship between non-communicable diseases (NCDs) and out-of-pocket (OOP) health expenditure is well-established, less is known about the financial burden of physical frailty and cognitive decline. This study investigates the “financial toxicity” of ageing, distinguishing between the costs of disease diagnosis and those of functional disability. Methods We analysed longitudinal data from the Health and Ageing in Africa: A Longitudinal Study (HAALSI) in rural South Africa (Waves 1–3, 2015–2022). The analytic sample included 4,371 adults aged ≥40 years (13,437 person-wave observations). We utilised Generalised Estimating Equations (GEE) to model two outcomes: the likelihood of incurring any OOP health expenditure (market entry) and the magnitude of spending among payers (financial toxicity). Predictors included chronic diagnoses (hypertension, diabetes, HIV), objective function (grip strength, gait speed), and cognitive/mental status (delayed recall, depression), adjusting for sociodemographic factors. Findings Socioeconomic status and NCD diagnoses were the primary drivers of market entry; hypertension was associated with a 26% increase in spending (AOR 1.26, 95% CI 1.14–1.40). Among those incurring costs, physical frailty (weaker grip strength) was associated with a greater magnitude of spending ( p = 0.012). However, severe vulnerability unexpectedly predicted lower spending: for every additional Activity of Daily Living (ADL) limitation, the odds of incurring costs decreased by 16% (AOR 0.84, p < 0.001), and depression was associated with significantly lower expenditure intensity ( p < 0.001). HIV-positive status was protective against high OOP costs. Conclusion The financial toxicity of ageing is characterised by a “dual burden of exclusion.” While NCD diagnoses drive households into the payment system, severe functional and mental decline appears to act as a barrier to access, effectively excluding the most vulnerable from the formal health economy. Financial risk protection mechanisms must be expanded beyond disease-specific models to cover geriatric frailty and disability explicitly.

Congenital anomalies represent a major cause of childhood morbidity and disability, imposing long-term health, social, and financial challenges. While medical expenditures are relatively well-documented, evidence on the broader financial and social impact on families-particularly in Central and Eastern Europe-remains limited. Accordingly, this study aimed to quantify the economic burden associated with congenital anomalies from a caregiver perspective. A cross-sectional, questionnaire-based study was conducted in Lithuania in 2023 among 160 caregivers of children aged 5-18 years diagnosed with congenital anomalies. Participants were grouped by the number of affected organ systems to reflect the increasing disease complexity. Using standardized cost-of-illness methodology and both the human capital and opportunity cost approaches, we estimated annual direct medical and non-medical, indirect, and informal care costs. Families experienced a substantial and multidimensional financial burden that intensified with disease severity. The annual indirect cost, mainly reflecting productivity losses, represented the largest component of the total economic burden, with a median of €7,566 overall and €12,965 in the most severely affected families. Out-of-pocket payments were also considerable, with a median of €2,040 per year; in the most severe group they exceeded 20% of monthly household income for 42% of families. The economic value of informal care represented a smaller yet meaningful portion of total costs (median €1,967), increasing more than fivefold between the mildest and most severe groups. Congenital anomalies place a substantial economic burden on families, extending far beyond healthcare expenses. These findings highlight the need for policies that improve financial protection, support caregivers' labor market participation, and acknowledge the economic value of informal care within health and welfare systems.

This research examines the legal standing and statutory authority of the Financial Services Authority (Otoritas Jasa Keuangan, OJK) to commence civil proceedings on behalf of consumers in Indonesia’s financial services sector, a mandate that has gained increasing relevance amid the expansion of complex financial products and digital delivery channels. Grounded in Law No. 21 of 2011 and its implementing regulations, OJK’s litigation power is conceptualised as a regulatory enforcement mechanism intended to address structural consumer disadvantages, strengthen institutional accountability, and promote compliance with market-conduct norms. The analysis situates this authority within broader doctrinal frameworks, including public interest litigation, administrative law principles, and regulatory enforcement theory. To provide comparative context, the article briefly contrasts OJK’s mandate with the enforcement powers of the United States Consumer Financial Protection Bureau (CFPB), a leading model in consumer-focused financial regulation. Using a normative juridical methodology, the article evaluates the practical effectiveness of OJK-initiated civil actions and compares them with alternative redress mechanisms, such as class actions. The findings indicate that despite a clear statutory foundation, OJK’s use of civil litigation remains limited by procedural uncertainties and institutional preferences for non-judicial approaches. Nevertheless, OJK-filed lawsuits hold significant potential to enhance remedial access, improve evidentiary processes, and create stronger deterrence against market misconduct. The study concludes that clearer procedural guidelines and strengthened institutional capacity are essential to optimise OJK’s role in consumer protection.

Epilepsy surgery remains underutilized in Latin America despite its proven effectiveness for drug-resistant epilepsy. Structural and socioeconomic barriers may contribute to limited access and delayed intervention.To systematically evaluate the clinical characteristics, surgical outcomes, and socioeconomic barriers to accessibility associated with epilepsy surgery in Latin America.A systematic review was conducted following PRISMA guidelines. Searches were performed in PubMed, Scopus, ScienceDirect, Web of Science, and SciELO. Studies were included if they reported original data on epilepsy surgery in Latin American populations. Data on demographics, epilepsy type, and surgical outcomes were extracted and analyzed descriptively. Barriers such as geographic centralization, economic constraints, lack of specialized centers, and limited diagnostic infrastructure were also identified and examined.Of 103 initial records, 10 studies met all inclusion criteria. Most were retrospective observational studies from Colombia, Brazil, Mexico, and Chile. The mean age at surgery was 30.3 years, with an average diagnostic-to-surgery delay of 17.1 years. Mesial temporal lobe epilepsy was the most common subtype. Seizure freedom (Engel Class I) was achieved in 43.7% to 85% of cases. However, only 3.8% of eligible patients underwent surgery in some cohorts. Barriers included geographic centralization, economic constraints, lack of specialized centers, limited diagnostic infrastructure, cultural stigma, and under-referral from physicians. Quality-of-life improvements and psychosocial reintegration were observed postoperatively, yet disparities in access persisted.Despite favorable surgical outcomes, epilepsy surgery in Latin America remains significantly delayed and centralized. Health system limitations and socioeconomic inequities continue to restrict timely and equitable access. Regional policies must prioritize early referral pathways, surgical infrastructure, and financial protection to reduce the epilepsy treatment gap.

ObjectiveTo examine how subjective financial well-being (SFWB) relates to subjective well-being (SWB) among older adults in the U.S. Beyond material resources, SFWB reflects perceptions of present and future security, stability, and freedom of choice. This study tested whether hopelessness mediates the SFWB–SWB relationship and whether perceived social support, both positive (PSS) and negative (NSS), moderates this pathway.MethodsData came from 4,570 respondents (Mean age = 69; 56% female) in the Health and Retirement Study, a nationally representative panel survey of U.S. adults over age 50, sponsored by the National Institute on Aging. SFWB was measured using the Consumer Financial Protection Bureau’s (CFPB) 10-item scale, a multidimensional instrument that captures not only current financial security but also expectations for future financial stability and control. SWB was measured using Diener’s Satisfaction With Life Scale. Hopelessness was assessed with a 4-item index, and perceived social support was measured across four relational domains (spouse, children, family, friends), using 28 items divided into PSS and NSS. Analyses were conducted using PROCESS (v5.0) in SPSS, controlling for sociodemographic factors.ResultsSFWB was positively associated with SWB and negatively associated with hopelessness. Hopelessness significantly mediated the SFWB–SWB link, accounting for 24.4% of the total effect. NSS significantly moderated the SFWB–hopelessness pathway, amplifying the indirect effect of low SFWB on SWB. PSS had a weaker but still significant moderating effect. When both forms of support were modeled simultaneously, only NSS remained a significant moderator.ConclusionSFWB significantly contributes to older adults’ life satisfaction, partly by reducing hopelessness. This multidimensional measure is important in aging research because it reflects not just income or assets but also perceived financial security, stability, and the freedom to make choices in the present and future. Negative social support intensifies the psychological toll of financial insecurity, while positive support provides limited buffering. Interventions should address both financial perceptions and social relationships to strengthen resilience and well-being in later life.

The article provides a comprehensive analysis of the sustainability of the pension system of the Republic of Azerbaijan in the context of contemporary demographic and economic challenges. Using statistical comparative analysis and forecasting methods, the study examines key indicators such as the ratio of pension expenditures to GDP, the ratio of active to passive insured persons, the old-age dependency ratio, the pension replacement rate, the ratio of the minimum pension to the subsistence minimum for pensioners, as well as projections of mandatory state social insurance revenues and expenditures of the State Social Protection Fund through 2030.The findings indicate that although the share of pension expenditures in GDP increased during 2006–2024, a 65% rise in the number of insured persons and an improvement in the active-to-passive ratio from 2.4 to 4.7 significantly strengthened the financial sustainability of the system. The minimum pension exceeding the subsistence minimum by 137.9% ensures the social adequacy of pension benefits. Forecast results suggest continued growth in social insurance revenues; however, by 2030 these revenues are expected to fall short of fully covering fund expenditures. The article emphasizes the importance of investing pension fund assets and expanding digitalization as key policy directions for enhancing the long-term sustainability of the pension system.

Financial protection in health care across the West African Economic and Monetary Union: a multidimensional analysis.

Faith-based organisations and religious affiliation and their interactions with financial risk protection in health in Sub-Saharan Africa: A systematic review.

ObjectiveTo examine the association between Health Information System (HIS) performance and maternal health service (MHS) utilization in the Oromia and Gambella regions, Ethiopia.MethodsA comparative cross-sectional study was conducted (15–25 October 2023) among 840 mothers in catchment areas of health facilities categorized as model (high HIS performance) or candidate (lower HIS performance). HIS performance was evaluated based on infrastructure (30%), data quality (30%), and data use (40%). MHS utilization was measured using a modified composite coverage index (CCI) integrating 10 essential interventions. Multivariable logistic regression (Stata/MP 17.0) identified predictors, reporting adjusted odds ratios (AORs) and 95% confidence intervals (CIs).ResultsMHS utilization was 60.3%, with higher crude odds in model facility areas (COR = 2.03, 95% CI [1.4–3.0]). After adjustment, this association attenuated (AOR = 1.4, 95% CI [0.92–2.15]). Key barriers included poverty (poorest quintile AOR = 0.45, 95% CI [0.30–0.68]) and limited transport access (AOR = 0.21, 95% CI [0.15–0.29]), which were associated with significantly lower MHS utilization. Sensitivity analyses confirmed robustness, and transport access modified the effect of facility type.ConclusionHIS performance alone did not independently predict MHS utilization after accounting for structural inequities. Transportation and economic barriers disproportionately hinder access, even in high-performing systems. Integrating HIS strengthening with poverty-sensitive interventions (e.g., transport support, financial protection) is critical to achieving equitable maternal health outcomes

Paddy is a staple crop and a vital component of Indonesia's agriculture, significantly contributing to food security and rural livelihood. Nevertheless, paddy cultivation is highly vulnerable to risks such as pests, diseases, extreme weather, and natural disasters, which can lead to significant productivity losses. Thus, schemes like Area Yield Index (AYI) insurance have a critical role in mitigating these risks because. It provides financial protection to farmers by compensating them for losses due to area-wide productivity shortfalls. Hence, accurate predictions of paddy productivity are essential for setting fair and precise AYI premiums. Therefore, this study proposes an innovative framework by developing a four-parameter beta distribution Generalized Linear Mixed Model (GLMM) based on a Bayesian approach for predicting paddy productivity. The approach is motivated by the model’s ability to apply a four-parameter beta distribution that effectively models the bounded nature of paddy productivity and ensures that predictions remain within realistic range value. The inclusion of random effects also accounts for variability of paddy productivity across areas, which is commonly found in Indonesia and other countries. Meanwhile, the Bayesian framework further enhances robustness by integrating prior knowledge and providing probabilistic predictions. Based on the proposed approach, we then design an enhanced AYI policy based on district and sub district conditions. The framework is first developed through simulation studies designed to replicate real paddy productivity conditions. Comparative testing of the Stan and BRMS packages in R reveals that the proposed four-parameter beta GLMM implemented in Stan is more flexible and accurate. The methodology is then applied to an empirical case study predicting paddy productivity in Central Kalimantan (2020), using farmer survey data and lagged values of Sentinel-2A satellite indices (bands 4, 8, and NDVI) as covariates. Results show that agronomic practices such as pest management and current and historical satellite data enhance prediction accuracy, demonstrating the model's potential to predict productivity with high precision, proving that the proposed method is well-suited for calculating premiums and risks under AYI crop insurance policies. The estimated pure AYI premium ranges from IDR 300.000 to 410.000. Unlike conventional premium calculations based on average historical yields, the proposed GLMM approach provides a nuanced, data-driven alternative that accounts for various productivity factors, ensuring greater adaptability, accuracy, and responsiveness to changes in agricultural conditions, including those driven by climate change.

Lebanon's ongoing economic collapse has severely disrupted the health care system, particularly access to essential cancer therapies. Small cell lung cancer (SCLC) is an aggressive malignancy with limited treatment options and poor prognosis. Immune checkpoint inhibitors (ICIs) have provided modest survival benefits in extensive-stage SCLC (ES-SCLC), but access in resource-limited settings is highly vulnerable to financial instability. In October 2022, Lebanon officially withdrew public subsidies for ICIs, threatening equitable cancer care. This study evaluates the impact of the Ministry of Public Health subsidy withdrawal on access to ICIs and associated outcomes in patients with ES-SCLC. A mixed-methods study was conducted at Hôtel-Dieu de France (HDF) University Hospital in Beirut. The qualitative component involved a semi-structured interview with the HDF pharmacy to characterize operational challenges. The quantitative component was a retrospective cohort study of patients diagnosed with ES-SCLC from 2019 to 2024. Data included demographics, treatment access, and survival. Analyses included bivariate statistics, Kaplan-Meier survival analysis, and Cox proportional hazards regression. The interview identified financial hardship and drug shortages as major barriers. Among 71 patients, 75% did not receive guideline-concordant optimal treatment. Access to ICIs was significantly associated with method of payment (χ2 = 13.8, P = .037) and public insurance coverage (χ2 = 8.6, P = .035). Survival was higher among patients receiving optimal treatment (P = .021), male patients (P = .004), and those treated before subsidy withdrawal (P = .037). In multivariable Cox regression, male gender, optimal treatment, and public insurance were independently associated with improved survival. The withdrawal of public subsidies amid Lebanon's economic crisis critically disrupted access to ICIs and contributed to poorer outcomes. Robust financial protection mechanisms are urgently needed to sustain equitable cancer care.

Moving beyond catastrophic health expenditure for financial protection in west Africa.

Background: Achieving universal health coverage is the biggest challenge in post-conflict situations. Community-based health insurance is an alternative mechanism to improve healthcare utilization and coverage through a prepayment mechanism and pooling health risks in the informal sector. However, there is limited data on the feasibility of community-based health insurance in countries emerging from conflict or war. Objective: This systematic review aims to summarize the evidence on the feasibility of implementing community-based health insurance in post-conflict situations. Methods: The search process included peer-reviewed and gray literature published between 1990 and 2023 in the electronic databases of Global Health, Pub Med, CINAHL, Science Direct, and Gray Publications. The search was conducted manually on December 10, 2023. We conducted a systematic review of articles published since 1990 using a search strategy. The Mixed Methods Assessment Tool (MMAT) was used for quality assessment to evaluate the methodological quality of various studies. Results: In this review, a total of 30 articles were included and synthesized. Out of the eligible articles, cross-sectional studies, issue reports, and strategic documents were reviewed. In general, 66.7% of the studies were qualitative, and 33.3% were quantitative. We summarize and describe the feasibility of introducing community health insurance, its impact on universal health coverage, and the limitations of financial risk allocation and protection in the postwar period. Community-based health insurance (CBHI) schemes face several significant obstacles, such as poor financial risk protection, a limited risk pool, adverse selection, a lack of professional and standardized management, and a lack of availability and quality of services. Although they are less successful in reaching marginalized populations, community-based health insurance programs with access to external or additional funding sources are more successful in extending access to healthcare services and offering financial security. Regardless of scheme type, community-based health insurance schemes that involve the community in the design and implementation process are more effective at guaranteeing access to healthcare and financial protection. Furthermore, households with community-based health insurance have lower out-of-pocket medical costs, high odds of overall healthcare utilization, outpatient service use, health facility deliveries, and a lower frequency of catastrophic medical costs at various thresholds. Conclusions: Community-based health insurance (CBHI) schemes have emerged as an alternative health financing mechanism in low- and middle-income countries. These schemes aim to improve access to healthcare and provide financial protection. However, their effectiveness is limited by several challenges. Studies have found that community-based health insurance schemes often exclude the ultra-poor and suffer from adverse selection. While there is evidence that community-based health insurance increases healthcare utilization, particularly for outpatient services, and reduces out-of-pocket spending, the overall impact remains small. Key challenges include limited risk pools, poor financial risk protection, and a lack of quality services. Factors influencing enrollment and sustainability include awareness, trust, perceived service quality, and community involvement. Despite some positive outcomes, community-based health insurance schemes are considered complementary to more effective health financing systems rather than a standalone solution.

Globally, approximately 15% to 20% of newborns are born with low birth weight (LBW), with over 90% of these cases occurring in low- and middle-income countries (LMICs). Although previous research on LBW has largely focused on clinical and nutritional factors, economic barriers associated with LBW remain under-researched. This study aimed to assess the association between out-of-pocket (OOP) payment for antenatal care and LBW in Eastern Ethiopia. A prospective cohort study followed pregnant women for ten months to examine the incidence of LBW. The cost of ANC and other follow up variables were collected during pregnancy. Direct medical and non-medical costs were summed to calculate total OOP expenditures. Face to face interviews were used to collect baseline and follow-up data. Poisson regression with robust variance was used to assess the independent predictors of LBW. Adjusted risk ratios (aRR) with 95% confidence intervals (CI) were computed. The direct and indirect association between OOP and LBW were estimated using Generalized Structural Equation Modeling (GSEM). A total of 385 women was followed for 10 months. The study found that 10.9% of women gave birth to LBW neonates. After controlling for confounding factors, OOP expenditure (aRR = 3.21, 95% CI: 1.19, 8.64), prenatal depression (aRR = 2.91, 95% CI: 1.65, 5.13), and lack of birth preparedness and complication readiness (BPCR) (aRR = 4.12, 95% CI: 1.52, 11.20), poor wealth status (aRR = 3.30, 95% CI: 1.16, 9.38), incomplete ANC visits (aRR = 2.37, 95% CI: 1.01, 5.53), unplanned pregnancy (aRR = 1.92, 95% CI: 1.14, 3.22) and long travelling time (1.99, 95% CI: 1.15, 3.44) were significantly associated with LBW. In GSEM, prenatal depression (β = 1.30 (95% CI: 0.21, 2.80) and lack of preparation for birth (β = 1.55 (95% CI: 0.29, 2.80) mediated the association between LBW and OOP expenditures, while ANC visits mediated the association between long travelling time and LBW (β = 1.04, 95% CI: 0.04, 1.05). There was a significant positive association between OOP payment and LBW which was partly mediated by prenatal depression and lack of BPCR. To reduce the incidence of LBW, an integrated approach should be adopted that combines financial risk protection, psychosocial support and geographical accessibility of services.