Assessing medical impoverishment and associated factors in health care in Ethiopia

Abstract

Background: About 5% of the global population, predominantly in low-and middle-income countries, is forced into poverty because of out-of-pocket (OOP) health spending. In most countries in sub-Saharan Africa, the share of OOP health spending in current health expenditure exceeds 35%, increasing the likelihood of impoverishment. In Ethiopia, OOP payments remained high at 37% of current health expenditure in 2016. This study assesses the impoverishment resulting from OOP health spending in Ethiopia and the associated factors. Methods: This paper uses data from the Ethiopian Household Consumption Expenditure Survey (HCES) 2010/11. The HCES covered 10,368 rural and 17,664 urban households. OOP health spending includes spending on various outpatient and inpatient services. Impoverishing impact of OOP health spending was estimated by comparing poverty estimates before and after OOP health spending. A probit model was used to assess factors that are associated with impoverishment. Results: Using the Ethiopian national poverty line of Birr 3781 per person per year (equivalent to US$2.10 per day), OOP health spending pushed about 1.19% of the population (i.e. over 957,169 individuals) into poverty. At the regional level, impoverishment ranged between 2.35% in Harari and 0.35% in Addis Ababa. Living in rural areas (highland, moderate, or lowland) increased the likelihood of impoverishment compared to residing in an urban area. Households headed by males and adults with formal education are less likely to be impoverished by OOP health spending, compared to their counterparts. Conclusion: In Ethiopia, OOP health spending impoverishes a significant number of the population. Although the country had piloted and initiated many reforms, e.g. the fee waiver system and community-based health insurance, a significant proportion of the population still lacks financial protection. The estimates of impoverishment from out-ofpocket payments reported in this paper do not consider individuals that are already poor before paying out-of-pocket for health services. It is important to note that this population may either face deepening poverty or forgo healthcare services if a need arises. More is therefore required to provide financial protection to achieve universal health coverage in Ethiopia, where the informal sector is relatively large.

The burden of household out-of-pocket healthcare expenditures in Ethiopia: a systematic review and meta-analysis

“…Twenty-one articles were done by cross-sectional study design [ 33 , 35 – 54 ], two articles by longitudinal cohort study design [ 14 , 34 ], one article by a combination of retrospective and retrospective cohort study design [ 55 ], one report of national data [ 56 ], and two articles that used secondary data from a survey [ 13 , 57 ] (Table 1 ). Moreover, these studies were conducted from 2005 and 2021.…”

“…et.al. (2020) [ 57 ] National Data from the Ethiopian Household Consumption Expenditure Survey (HCES) 2010/11 10,368 rural and 17,664 urban households 7 Low risk Debelo S. et.al. (2020) [ 51 ] Benishangul-Gumuz Cross-sectional 488 households 7 Low risk Mizan K. et al (2020) [ 13 ] National Data from the 2015/16 Ethiopian household consumption and expenditure and welfare monitoring surveys 30, 229 households 6 Low risk Addisu B. et al (2020) [ 50 ] Oromiya Cross-sectional 354 patients 7 Low risk Assebe LF.…”

“…The pooled analysis of 21 studies identified that the mean direct Out-of-Pocket healthcare expenditures during utilization of healthcare services was $32 per month in Ethiopia (95%CI: $11.5, $52.5) (SD = $45.1) [ 14 , 33 , 34 , 36 , 37 , 39 – 41 , 43 , 45 – 53 , 55 – 57 ].…”

Contributions and challenges of healthcare financing towards universal health coverage in Ethiopia: a narrative evidence synthesis

“…At the same time, SNNP allowed health facilities to introduce user fee revisions [ 11 , 26 , 27 ] •Discrepancy in adherence to regional legislation was another challenge. For example, the regional law gave the mandate of user fee revision to the regional council in the Amhara region, but some health facilities revised user fees on their own [ 27 ] Health insurance •Health insurance helps the population with special assistance mechanisms for those who cannot afford to pay [ 11 ] •Helps risk pooling and social solidarity for the non-predicted illness [ 40 , 41 ] •Contribute to financial risk protection to the users [ 11 , 36 ] •Contribute to protecting rural dwellers from facing financial hardship to achieve UHC [ 42 ] •Contributed to increasing financial risk protection and ensuring UHC for all [ 43 , 44 ] •Reduce out-of-pocket expenditure (OOP), which increases protection from catastrophic health expenditure [ 33 – 35 ] •Establish financial protection equitably and sustainably for all citizens [ 29 ] •Enhance healthcare access and reduce the burden of OOP expenditure as a means of achieving UHC [ 14 , 45 ] •Low quality health service; long bureaucracy in reimbursement for institutions and high burden of payroll contributions for SHI [ 13 ] •Under coverage of the poor [ 11 ] •Unable to pay the premium; inadequate benefit packages; and preference for OOP payment [ 46 ] •Voluntary participation in the CBHI scheme results in adverse selection. For instance, households with chronic diseases within their family members purposely enrolled on the CBHI scheme associated with their disease status [ 47 ] •Premium load for CBHI is only decided based on family size without considering their income level [ 48 ] •High premium contribution, unclear benefit packages, high cost of living and burden of other deductions from salary for SHI [ 49 , 50 ] •High SHI contribution might lead us to further crisis and illness associated with being unable to wear clean clothes and eat right [ 49 ] •Low contract renewal rate related to the inability to afford the pre...…”

“…For instance, households with chronic diseases within their family members purposely enrolled on the CBHI scheme associated with their disease status [ 47 ] •Premium load for CBHI is only decided based on family size without considering their income level [ 48 ] •High premium contribution, unclear benefit packages, high cost of living and burden of other deductions from salary for SHI [ 49 , 50 ] •High SHI contribution might lead us to further crisis and illness associated with being unable to wear clean clothes and eat right [ 49 ] •Low contract renewal rate related to the inability to afford the premiums and expected returns from the insurance [ 51 , 52 ] •Free health care services for healthcare providers from their employer health care institution [ 53 ] Strategic purchasing of services Revenue retention and utilisation •Increase resource availability for service provision [ 11 ] •Use of retained revenue for procurement of drugs and medical supplies, and oversight implementation [ 27 ] •Improve infrastructures, utilities, procure medical equipment, supplies, medical supplies, drugs, information systems, management procedures, and training to enhance services quality [ 26 , 29 , 54 ] •Avail of essential medicines; reduce stock-outs of essential drugs; improve the diagnostic capacity of health facilities; maintain continual quality of care; improve water supply, electricity to health facilities; and health infrastructures [ 27 , 54 ] •Lack of understanding of the working procedures and fear of accountability led health facilities to be reluctant to use the retained revenues. This led to health facilities being reluctant to use the retained revenues and demonstrated the loss of efficiency in health service delivery [ 11 ] Systematising fee-waivers •Provide free of charge to the poorest segments of the population to access the full range of health services [ 29 ] •Access free health care for poor households [ 27 ] •Contribute to increasing financial protection and ensuring UHC for all in Ethiopia [ 43 ] •Reduce inequities in access to health care services [ 29 ] •Increase healthcare service utilisation for the poor [ 55 …”