Out-of-pocket (OOP) payments for health care are common in many middle and low-income countries. Nepal is not an exception: 75 to 81 percent of health care expenses come from OOP payments. In the Nepalese context of an increased number of people with chronic diseases, many experience severe financial crises due to the huge OOP expenditures for an often long-term and expensive treatment and medication. Behind the numbers, what is lacking is knowledge about the Nepalese people´s own experience with disease, OOP, and poverty. Similarly, what is lacking is a life-course perspective allowing the study of intra and inter-generational vicious circles. This paper therefore aims to explore (1) how Nepalese people struggle, experience and adapt to chronic disease and poverty and (2) how, within and over generations, chronic diseases and poverty constitute a vicious circle.

Method: In-depth semi-structured interviews were conducted with 21 chronically ill Nepalese people with one or more chronic diseases and/or their caretakers. We applied purposive sampling to select participants. We aimed for sufficient variety of participants regarding geography, wealth, gender, and caste/ethnicity. Allowing the comparison of experiences with disease and OOP, we interviewed rich people and poor people. Data were transcribed and analysed thematically.

Results/Conclusion: The adaptation strategies towards the huge OOP costs made patients and their households financially incapable. The impoverishment had major social impacts and often persisted across generations. The situation forced people to choose between avoiding medical treatment or further impoverishing their families. In many situations, the adaptation strategies obstructed every attempt to escape from the vicious circle of the poverty trap. In conclusion, we may say that poverty and health adversities accumulate within and across generations, thereby contributing to heightened healthcare costs, worse health outcomes, and compromised social lives.

Keywords: Chronic disease, poverty trap, out-of-pocket payments, qualitative study, life course perspective, Nepal.