Beyond Catastrophic Health Expenditure: An Evidence-Informed Integrative Framework of Health-Related Financial Vulnerability Based on Bibliometric Mapping and Systematic Evidence Synthesis

Conventional indicators such as out-of-pocket expenditure (OOP), catastrophic health expenditure (CHE), and impoverishing health expenditure (IHE) capture important dimensions of financial hardship but do not fully represent the structural conditions, healthcare-related exposures, access constraints, and institutional mechanisms through which health-related financial vulnerability develops and persists. This study developed an evidence-informed integrative framework by combining bibliometric science mapping with systematic integrative evidence synthesis. Scopus and Web of Science searches identified 3702 records, of which 2300 remained after deduplication and 367 met the eligibility criteria. Bibliometric analysis characterized scientific production and conceptual structure, while evidence synthesis examined structural inequalities, healthcare-related financial exposure, institutional protection mechanisms, and financial and access outcomes. Keyword co-occurrence mapping revealed three broad, interconnected thematic groupings related to health financing and policy, economic burden, and healthcare delivery. The synthesis showed that financial vulnerability reflects interactions among socioeconomic disadvantage, healthcare-related costs and access constraints, and heterogeneous institutional protection. The resulting framework extends expenditure-based approaches by conceptualizing financial vulnerability as a multidimensional process shaped by structural disadvantage, healthcare-related exposure, and the effectiveness of institutional protection.