Leaving no one behind in health: Financial hardship to access health care in Ethiopia

PLOS ONE RESEARCH ARTICLE Leaving no one behind in health: Financial hardship to access health care in Ethiopia Yawkal Tsega ID1*, Gebeyehu Tsega ID2, Getasew Taddesse2, Gebremariam Getaneh2 1 School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia, 2 Department of Health Systems Management and Health Economics, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia * a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 Abstract Background OPEN ACCESS Citation: Tsega Y, Tsega G, Taddesse G, Getaneh G (2023) Leaving no one behind in health: Financial hardship to access health care in Ethiopia. PLoS ONE 18(3): e0282561. https://doi.org/10.1371/ journal.pone.0282561 Editor: Khurshid Alam, Murdoch University, AUSTRALIA Received: August 14, 2022 Accepted: February 20, 2023 Published: March 13, 2023 Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. The editorial history of this article is available here: https://doi.org/10.1371/journal.pone.0282561 Copyright: © 2023 Tsega et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data were included in the paper and Supporting Information files. Funding: The author(s) received no specific funding for this work. We (all authors) have Financial hardship (of health care) is a global and a national priority area. All people should be protected from financial hardship to ensure inclusive better health outcome. However, financial hardship of healthcare has not been well studied in Ethiopia in general and in Debre Tabor town in particular. Therefore, this study aimed to assess the incidence of financial hardship of healthcare and associated factors among households in Debre Tabor town. Methods Community based cross sectional study was conducted, from May 24/2022 to June 17/ 2022, on 423 (selected through simple random sampling) households. Financial hardship was measured through catastrophic (using 10% threshold level) and impoverishing (using $1.90 poverty line) health expenditures. Patient perspective bottom up and prevalence based costing approach were used. Indirect cost was estimated through human capital approach. Bi-variable and multiple logistic regressions were used. Results The response rate was 95%. The mean household annual healthcare expenditure was Ethiopian birr 12050.64 ($227.37). About 37.1% (95%CI: 32, 42%) of the households spend catastrophic health expenditure with a 10% threshold level and 10.4% of households were impoverished with $1.90 per day poverty line. Being old, with age above 60, (AOR: 4.21, CI: 1.23, 14.45), being non-insured (AOR: 2.19, CI: 1.04, 4.62), chronically ill (AOR: 7.20, CI: 3.64, 14.26), seeking traditional healthcare (AOR: 2.63, CI: 1.37. 5.05) and being socially unsupported (AOR: 2.77, CI: 1.25, 6.17) were statistically significant factors for catastrophic health expenditure. Conclusion The study showed that significant number of households was not yet protected from financial hardship of healthcare. The financial hardship of health care is stronger among the less privileged populations: non-insured, the chronically diseased, the elder and socially PLOS ONE | https://doi.org/10.1371/journal.pone.0282561 March 13, 2023 1 / 17 PLOS ONE reviewed the manuscript and agreed to submit to your journal, PLOS ONE. Financial hardship to access health care unsupported. Therefore, financial risk protection strategies should be strengthened by the concerned bodies. Competing interests: The authors have declared that no competing interests exist. Introduction Universal health coverage (UHC), one (the overarching) target of Sustainable Development Goals (SDGs), ensures that all people receive quality essential health services they need without exposing them to financial hardship. Financial risk protection is at the core of universal health coverage and it is one priority area in Ethiopian health sector as indicated in Health Sector Transformational Plan two (HSTP II). It is achieved when there are no financial barriers (mainly due to direct out of pocket health expenditure) to access essential health services [1– 3]. Out of pocket (OOP) health spending is defined as any spending incurred by a household when any member uses a healthcare, including promotive, preventive, curative, rehabilitative and palliative care. To access (high quality) health care, the household incurs direct medical and non-medical costs, indirect cost and intangible cost. These costs impose financial hardship to the households, and worst in low income countries like Ethiopia [1,2]. Financial hardship (FH) is measured through Catastrophic Health Expenditure (CHE) and Impoverishing Health Expenditure (IHE). These metrics are standards that used to monitor and track Sustainable Development Goal indicator 3.8.2 (SDG indicator 3.8.2) across United Nations (UN) member states. CHE is considered when healthcare spending exceeds a certain threshold (varied from 10% to 40%) of household expenditure or income. From these thresholds, 10%(the lower threshold level) and 25%(the higher threshold level) are used in a joint report of World Bank(WB) and World Health Organization(WHO), a report in every 2 years, for monitoring and tracking SDG indicator 3.8.2. Whereas, IHE is considered when households’ health expenditure is making the households below a given poverty line (in our cases a World Bank $1.9 a day extreme poverty line) or further impoverish to extreme poverty [1,2,4]. Globally, the incidence of financial hardship of healthcare has been increased since 2000. For example, the incidence of CHE increased by 3.6% annually, from 571 million in 2000 to 927 million in 2015 with 10% threshold level. Similarly, the incidence of catastrophic health expenditure has increased from 12.7% in 2015 to 13.2% in 2017 at 10% threshold level. CHE, as measured by SDG indicator 3.8.2, will continue to rise to the year 2030 if the share of outof-pocket health spending continues at its current rate [1,2]. Furthermore, OOP healthcare costs lead more people falling into poverty. About 89.7 million individuals (1.2% of global population) were forced into extreme poverty (below $1.90 a day poverty line) and 98.8 million (1.4% of global population) were pushed below $3.20 a day poverty line and 183.2 million were pushed into poverty defined in relative terms (below 60% of median daily per capita consumption or income in their country). At all of these poverty levels, lower and middle-income countries (LMICs) had the highest number and proportion of the (...truncated)