Financial risk of seeking maternal and neonatal healthcare in southern Ethiopia: a cohort study of rural households

Abstract

Introduction: Ethiopian households' out-of-pocket healthcare payments constitute one-third of the national healthcare budget and are higher than the global and low-income countries average, and even the global target. Such out-of-pocket payments pose severe financial risks, can be catastrophic, impoverishing, and one of the causal barriers for low utilisation of healthcare services in Ethiopia. This study aimed to assess the financial risk of seeking maternal and neonatal healthcare in southern Ethiopia.

Methods: A population-based cohort study was conducted among 794 pregnant women, 784 postpartum women, and their 772 neonates from 794 households in rural kebeles of the Wonago district, southern Ethiopia. The financial risk was estimated using the incidence of catastrophic healthcare expenditure, impoverishment, and depth of poverty. Annual catastrophic healthcare expenditure was determined if out-of-pocket payments exceeding 10% of total household or 40% of non-food expenditure. Impoverishment was analysed based on total household expenditure and the international poverty line of ≈ $1.9 per capita per day.

Results: Approximately 93% (735) of pregnant women, 31% (244) of postpartum women, and 48% (369) of their neonates experienced illness. However, only 56 households utilised healthcare services. The median total household expenditure was $527 per year (IQR = 390: 370,760). The median out-of-pocket healthcare payment was $46 per year (IQR = 46: 46, 92) with two episodes per household, and shared 19% of the household's budget. The poorer households paid more than did the richer for healthcare, during pregnancy-related and neonatal illness. However, the richer paid more than did the poorer during postpartum illness. Forty-six percent of households faced catastrophic healthcare expenditure at the threshold of 10% of total household expenditure, or 74% at a 40% non-food expenditure, and associated with neonatal illness (aRR: 2.56, 95%CI: 1.02, 6.44). Moreover, 92% of households were pushed further into extreme poverty and the poverty gap among households was 45 Ethiopian Birr per day. The average household size among study households was 4.7 persons per household.

Conclusions: This study demonstrated that health inequity in the household's budget share of total OOP healthcare payments in southern Ethiopia was high. Besides, utilisation of maternal and neonatal healthcare services is very low and seeking such healthcare poses a substantial financial risk during illness among rural households. Therefore, the issue of health inequity should be considered when setting priorities to address the lack of fairness in maternal and neonatal health.

Keywords: Cohort study; Financial risk; Maternal and neonatal healthcare; Rural households; Southern Ethiopia.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1

Flowchart of recruitment of pregnant women, postpartum women, and their neonates in rural southern Ethiopia, May 2017 to July 2018

Fig. 2

Healthcare payment shares by quintiles in rural southern Ethiopia, 2017/18

Fig. 3

Pen’s Parade of total household expenditure gross of and net of out-of-pocket healthcare payments during pregnancy-related, postpartum, and neonatal illness in rural southern Ethiopia, 2017/18

Fig. 4

A. concentration curve for out-of-pocket healthcare payments in ETB; 4.B. concentration curve for utilisation of healthcare services during pregnancy-related illness; 4.C. concentration curve for utilisation of healthcare services during the postpartum illness; and 4.D. concentration curve for utilisation of healthcare services during the neonatal illness in rural southern Ethiopia, 2017/18