CKD in rural communities in Uddanam. RESULTS We enrolled a total of 221 patients (mean age: 57.4 years, 51.6% females) with a mean estimated glomerular filtration rate of 21 ml/min per 1.73 m2 (95% CI: 20–22 ml/min per 1.73 m2 ) and duration of illness of 4.1 3.2 years (Supplementary Table S1). A total of 77 (34.8%) had hypertension, 11 (5%) had diabetes, and 8 (3.6%) had both. Socioeconomic status was evaluated by modified Kuppuswamy scale,6 which classifies families into 5 groups based on education, occupation, and aggregate income of the family (details in Supplementary Methods). Most (75.6%) belonged to the upper lower socioeconomic status category (Table 1). The median annual household income was US$ 2468.7 (95% CI: 2248.5–2688.9). Most of the patients (57%) sought treatment from private hospital/clinics, with 23% going to government hospitals whereas 44 (19.9%) had used a mix of both government and private facilities. Health Care Costs Median total annual cost of illness was estimated at US$ 308 (interquartile range: 184–482). Direct costs made up for 79.9% of the total treatment costs. The costs for medicines constituted the highest portion of the direct cost, followed by laboratory charges and transport (Table 2). Patients made 6 (95% CI: 4–10) clinic visits in a year and were receiving 5 2 medicines. Approximately 57% reported obtaining medicines from private pharmacies. The cost of care was higher in those who attended private facilities, largely owing to the high costs of medicines (Supplementary Figure S1). Kidney International Reports (2022) 7, 319–321 319 RESEARCH LETTER CHE and Distress Financing Costs for CKD care services were catastrophic for 149 patients (67.4%) at the 10% annual household income threshold.7 Supplementary Table S2 reveals the frequency of CHE at other income thresholds. Those visiting private facilities experienced CHE more frequently. A total of 86 patients (39%) engaged in distress financing (Table 2). Patients seeking care in private facilities were more likely to resort to distress financing. DISCUSSION This is the first study to evaluate the economic impact of treatment of predialysis CKD. Almost 7 of every 10 households that have a member with CKD experienced high expenditure attributable to medical care, and 40% of this population living at the margins of subsistence resorted to distress financing. Our data are of policy relevance because almost 1 of every 5 adult residents in the region has CKD.5 The current focus of government spending on the care of patients with kidney disease is almost entirely on dialysis. The cost of outpatient care for earlier stages of CKD is not covered by government programs. Given that the far greater number of patients with earlier stages of CKD will not need dialysis, the neglect of the economic burden of these patients who are left to seek care from private facilities on their own represents a major failure of the principles of the universal health coverage that will continue to push households into impoverishment. The most effective way to forestall this economic hardship is to institute programs for early detection of CKD and implementation of measures that can prevent progression and development of complications. Uddanam is in the state of Andhra Pradesh, one of the better performing states in terms of health care indicators—placed at number 4 of the 35 Indian states. Nevertheless, a lot needs to be done to improve noncommunicable disease care. Our previous study had found a 42% and 13% population prevalence of hypertension and diabetes, respectively, in the region in addition to the 21% CKD prevalence.5 Most of these conditions were previously undiagnosed. These findings support the case to expand the scope of the national noncommunicable disease program to bring into its ambit early detection and evidence-based management of CKD, at least in the high CKD prevalence areas. Given the high cost of care in the private sector, health care delivery needs to be strengthened in public health systems. Medications are responsible for more than 60.7% of total health care costs; hence, universal free access to essential medicines to patients Table 2. Components of health care expenditure in 1 year according to the type of facility visited (public or private) Parameter Type of facility Public Private Both Total As a % of total cost Number of cases 51 126 44 221 Direct cost Doctor’s fees 0. Distress financing for the care of chronic kidney disease Parameter Number of cases Number resorting to distress financinga Total 221 86 (39) Sex Male 107 44 (41.1) Female 114 42 (36.8) Type of facility Government 51 6 (11.8) Private 126 58 (46) Both 44 22 (50) Socioeconomic status Upper 0 0 Upper middle 22 6 (27.3) Lower middle 29 6 (20.7) Upper lower 167 73 (43.7) Lower 3 1 (33.3) a Defined as borrowing from family/friends, selling possessions, or taking out loans to fund health care. Figures in parentheses are percentages. RESEARCH LETTER 320 Kidney International Reports (2022) 7, 319–321 with kidney diseases is critical. The state government has introduced a program that provides financial aid to patients on dialysis to offset out-of-pocket costs. If publicly funded health programs do not reach those in need, similar cash transfers may be needed to support households that have people with earlier stages of CKD. Investment will be