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

Abstract

Background In Ethiopia, household Out-Of-Pocket healthcare expenditure accounts for one-third of total healthcare expenditure, is one of the highest in the world, and still creates barriers and difficulties for households to healthcare access and may delay or forgo needed healthcare use. Despite the presence of a few highly dispersed and inconsistent studies, no comprehensive study was conducted. Therefore, in this systematic review and meta-analysis, we aimed at estimating the pooled estimates of the burden of household Out-Of-Pocket healthcare expenditures among Ethiopian households and identifying its determinants. Methods We systematically searched articles from PubMed / Medline and Google scholar databases and direct Google search engine without restriction on publication period. Cross-sectional and cohort articles and grey literature published in English were included. Data were extracted using Microsoft Excel. Two reviewers screened the titles, reviewed the articles for inclusion, extracted the data, and conducted a quality assessment. The third reviewer commented on the review. Articles with no abstracts or full texts, editorials, and qualitative in design were excluded. To assess quality, Joanna Briggs Critical Appraisal Tools was used. A Forest plot was used to present summary information on each article and pooled common effects. Potential heterogeneity was checked using Cochrane’s Q test and I-squared statistic. We checked publication bias using a Funnel plot. Moreover, subgroup and sensitivity analyses were performed. Meta-analysis was used for the pooled estimates using RevMan statistical software Version 5.4.1. Results In this review, a total of 27 primary articles were included (with a total sample size of 331,537 participants). Because of the presence of heterogeneity, we employed a random-effects model; therefore, the pooled burden household Out-Of-Pocket / catastrophic healthcare expenditure in Ethiopia was strongly positively associated with household economic status. The odds of facing Out-Of-Pocket / catastrophic healthcare expenditures among the poorest quintile was about three times that of the richest (AOR = 3.09, 95% CI: 1.63, 5.86) p-value < 0.001. In addition, on pooled analysis, the mean direct Out-Of-Pocket healthcare expenditures were $32 per month (95%CI: $11, $52) (SD = $45), and the mean indirect Out-of-Pocket healthcare expenditures were $15 per month (95%CI: $3, $28) (SD = $17). The mean catastrophic healthcare expenditure at 10% of threshold was also disproportionately higher: 40% (95%CI: 28, 52%) (SD = 20%). Moreover, the common coping mechanisms were a sale of household assets, support from family, or loan: 40% (95%CI: 28, 52%) (SD = 20%). Conclusion Our study revealed the evidence of inequity in financial hardship that the burden of household Out-Of-Pocket / catastrophic healthcare expenditures gap persists among Ethiopian households that is unfair and unjust. To reduce the detected disparities in seeking healthcare among Ethiopian households, national healthcare priorities should target poor households. This calls for the Ministry of Health to improve the challenges and their impact on equity and design better prepayment policies and strengthen financial protection strategies to protect more vulnerable Ethiopian households. Protocol registration The details of this protocol have been registered on the PROSPERO database with reference number ID: CRD42021255977.

Assessing the inequality in out-of-pocket health expenditure among the chronically and non-chronically ill in Saudi Arabia: a Blinder-Oaxaca decomposition analysis

“…Moreover, the curves for the chronically and non-chronically ill both showed a pro-poor distribution, meaning that inequalities are concentrated amongst the less well-off. This confirms that the poor spend a higher share of their income on health compared to the well-off, a finding that is dominant in literature [ 35 , 36 ]. The inequality analysis showed that poor people that also have chronic illness experience even a much higher relative OOP compared to the poor who are not chronically ill.…”

Impact of community-based health insurance on health services utilisation among vulnerable households in Amhara region, Ethiopia

“…With no appropriate financial mechanisms, healthcare seeking in poorly functioning health systems is associated with a risk of catastrophic expenditures [ 50 ]. Borde et al [ 51 ] find that in Ethiopia the average direct out-of-pocket healthcare expenditures were USD 32 per month, the average indirect out-of-pocket healthcare expenditures were USD 15 per month and the average catastrophic healthcare expenditure at 10% of threshold was 40%. Accordingly, consistent with past related studies [ 52 – 55 ], our first hypothesised pathway is that CBHI may have reduced the high out-of-pocket health spending, thereby encouraging utilisation of healthcare services among the PSNP-participating households.…”

The financial burden of out of pocket payments on medicines among households in Ethiopia: analysis of trends and contributing factors

“…A high rate of OOP health expenditure and CHE headcount was also reported in Kenya, Cameroon, and Nigeria after ten years of implementation of health insurance [ 7 , 8 , 27 ]. Likewise, in Ethiopia, according to a review by Borde et al (2022), the pooled CHE due to OOP expenses during healthcare services was 40.1% at the 10% threshold of non-food expenditure [ 18 ].…”

“…Despite the presence of a relatively better level of information in the rest of the world, there is limited evidence on the catastrophic and impoverishing effects of OOP medicine payments in Ethiopia. Previous studies in Ethiopia focused on the total catastrophic and impoverishing implications of OOP health expenditures in general [ 6 , 10 , 18 ]. As such, this study aimed to assess the catastrophic and impoverishing effects of OOP payments on medicines and its trend over time and the contributing factors in the Ethiopian context.…”