Moges Tadesse Borde^1,2,3*, Eskindir Loha^1,4, Kjell Arne Johansson⁵, and Bernt Lindtjørn^1,2

¹School of Public and Environmental Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia; ²Centre for International Health, University of Bergen, Bergen, Norway; ³School of Public Health, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia; ⁴Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK5; ⁵Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway

Abstract

Introduction: Ethiopian households’ out-of-pocket healthcare payment (OOP) share 33% to 48% of the national health budget. Such OOP creates severe financial risks in households. Therefore, we aimed to assess the financial risk of seeking maternal and neonatal healthcare during illness in southern Ethiopia.

Methods: A cohort study of 794 rural households was conducted involving 794 pregnant women, 784 women after childbirth, and 772 neonates in three randomly selected kebeles of Wonago district in southern Ethiopia. The financial risk was estimated using: incidence of catastrophic healthcare expenditure (CHE), mean positive catastrophic overshoot, the incidence of impoverishment, and increment of the depth of poverty due to OOP. CHE was estimated by counting the number of households with OOP exceeding 10% or 40% of household total (non-food) expenditure. Impoverishment was analysed of based on gross and net of OOP and the international poverty line ≈ US$1.9 per capita per day.  A logistic regression model was used for analysis.

Results: The total annual per household average OOP for seeking healthcare during illness was 128 US$.  However, the average OOP during pregnancy-related illnesses was 96 US$, 23 US$ during the postpartum, and 9 US$ during the neonatal period. About 46% of rural and poor households faced CHE using a 10% threshold of household total expenditure,. At a 40% threshold of household non-food expenditure, 74% of households also incurred CHE. Using the net of OOP and the international poverty line, 99.6% of households were living below the poverty line. The average deficit or depth of poverty to reach the poverty line was 45.4 Ethiopian Birr. Moreover, 92% of households were more pushed far below the poverty line. Using the poverty headcount, the increase in poverty or the percentage of point change was 0.3 (0.3%) and it was 0.9 (2%) using the poverty gap. Those households with neonatal illnesses were three times more likely to experience CHE than those without neonatal illnesses (aRR: 2.56, 95%CI: 1.02, 6.44).

Conclusions: Both catastrophe and impoverishment were high during illnesses among the poorest rural households in Ethiopia. Therefore, Poverty alleviation interventions like risk pooling policy by the Ministry of Health are recommended at least in the study area to reduce reliance on OOP and finding alternative sources of financing to exempt user fees, and charges.

Keywords: financial; risk; maternal; neonatal; healthcare; southern; Ethiopia; cohort; study; rural; households.