Magnitude and Associated Factors of Out-of-Pocket Healthcare Expenditure among Outpatients Visiting Public Hospitals in Jigjiga Town, Somali Region, Eastern Ethiopia

This study reveals that out-of-pocket healthcare expenditure is highly prevalent among outpatients in Jigjiga, Ethiopia, with nearly 90% of patients incurring costs, and identifies female sex, unmarried status, higher education, and longer travel distances as significant predictors of these expenses.

The Gist

Imagine you have to pay for a taxi, a meal, and a doctor's visit all at once, right before you can get the medicine you need. That is the reality of Out-of-Pocket Healthcare Expenditure (OOPHE). It's when you pull money directly from your own pocket to get medical help, rather than having it covered by insurance or the government.

This paper is like a detective story set in Jigjiga, a town in the Somali region of Eastern Ethiopia. The researchers wanted to solve a mystery: How much are people paying out of their own pockets, and who is paying the most?

Here is the breakdown of their findings, explained with some everyday analogies.

1. The Big Picture: The "Pay-As-You-Go" Trap

The study looked at 400 people visiting public hospitals. The shocking news? Nearly 9 out of 10 people (89.5%) had to pay cash just to get treated.

• The Analogy: Imagine a toll booth on a highway to the hospital. Almost everyone has to stop and pay a toll to get through. Only a tiny few (about 7%) had a "season pass" (health insurance) that let them drive through for free.
• The Cost: On average, a person spent about $3.12 (roughly 485 Ethiopian Birr) per visit. While that sounds small to some, for many families in this region, that is a significant chunk of their daily food budget. It's like spending your entire grocery money for the day just to fix a flat tire on your car.

2. Who is Paying the Most? (The "Risk Factors")

The researchers didn't just count the money; they looked for patterns. They found that certain groups of people were much more likely to be hit with these bills. Think of it like a game where some players start with a disadvantage.

• The "Female" Factor:

  • Finding: Women were 3.4 times more likely to pay out of pocket than men.
  • The Analogy: Women are often the "managers" of family health. They take care of children, manage pregnancies, and visit doctors more often. It's like being the designated driver for the whole family's health; you end up paying the tolls more often because you are on the road more.

• The "Single" Factor:

  • Finding: Unmarried people were 5 times more likely to pay than married people.
  • The Analogy: In Ethiopia, health insurance (CBHI) is often sold to whole families. If you are married, you might be covered under your spouse's plan or a family package. If you are single, you are like a solo traveler trying to buy a ticket alone, often without the safety net of a group rate.

• The "Educated" Paradox:

  • Finding: Surprisingly, people with a college education were 7 times more likely to pay than those who couldn't read or write.
  • The Analogy: This seems backwards, right? Usually, education helps you save money. But here's why: The insurance scheme (CBHI) is mostly for farmers and rural workers. Educated people often work in offices or government jobs. They should have a different kind of insurance (Social Health Insurance), but that system isn't working well yet. So, the educated are like people who have a "Gold Card" that is currently broken, forcing them to pay cash while the "Bronze Card" holders (rural farmers) are actually covered.

• The "Long Distance" Factor:

  • Finding: People who traveled 5 km or more to get to the hospital were 7 times more likely to pay.
  • The Analogy: This is the "Travel Tax." If you live next door, you just walk in. If you live far away, you have to pay for a taxi (transportation) and maybe buy food for the trip. The further you have to go, the more your wallet hurts before you even see the doctor.

3. The Solution: Building a "Safety Net"

The authors conclude that this "pay-as-you-go" system is dangerous. It stops people from seeking help and can push families into poverty.

• The Recommendation: They suggest fixing the "season passes."
  1. Expand the Community Insurance: Make sure the rural "family passes" cover more people and are easier to get.
  2. Fix the "Gold Card": Create a better insurance system for government workers and office employees so the educated don't get stuck paying cash.

The Takeaway

This paper tells us that in Jigjiga, going to the doctor is still a financial gamble for most people. While the cost per visit isn't huge in dollars, the frequency and the lack of insurance make it a heavy burden.

The main lesson: To fix this, the government needs to stop relying on people paying at the counter and start building a system where the cost is shared in advance, so no one has to choose between buying medicine and buying food.

Technical Summary

1. Problem Statement

Out-of-Pocket Healthcare Expenditure (OOPHE) remains a critical barrier to Universal Health Coverage (UHC), particularly in low- and middle-income countries. High OOPHE forces households to discontinue treatment, avoid seeking care, or fall into poverty. While Ethiopia aims to shift toward prepayment systems like Community-Based Health Insurance (CBHI), OOPHE still accounts for approximately 31% of total health expenditure, exceeding the global recommendation of 20%.

Specifically, the Somali Region in Ethiopia, characterized by a predominantly pastoralist population and developmental inequities, lacks empirical data regarding the financial burden of healthcare. Residents in Jigjiga Town have reported rapid growth in healthcare costs, yet no prior studies had quantified the magnitude of OOPHE or identified its specific predictors in this setting. This study addresses this gap to inform health planners and policymakers.

2. Methodology

• Study Design: A hospital-based cross-sectional study.
• Study Setting: Three public hospitals in Jigjiga Town, Somali Region: Sheik Hassan Yabare Comprehensive Specialized Hospital, Karamara General Hospital, and Jigjiga Primary Hospital.
• Study Period: November 15–30, 2023.
• Population: Outpatients visiting the selected public hospitals.
  • Inclusion: Patients receiving outpatient services during the data collection period.
  • Exclusion: Patients with severe illnesses preventing communication and non-residents of the region.
• Sample Size & Sampling:
  • Target sample: 406 participants (calculated using EPI Info v7, 95% CI, 80% power, 10% non-response rate).
  • Technique: Systematic random sampling with proportional allocation across the three hospitals.
  • Actual Respondents: 400 (Response rate: 98.5%).
• Data Collection:
  • Interview-administered questionnaires translated into Somali and back-translated to English.
  • Data collectors were trained public health professionals.
  • Variables included socio-demographics, economic status, insurance coverage, distance to facility, and specific cost components (consultation, medication, investigation, transport, food).
• Data Analysis:
  • Software: SPSS version 25.0.
  • Descriptive statistics for demographics and cost means.
  • Binary and Multivariable Logistic Regression: Used to identify factors associated with OOPHE. Variables with $p < 0.25$ in bivariate analysis were entered into the multivariable model. Significance was set at $p < 0.05$.

3. Key Contributions

• Baseline Data: Provides the first empirical evidence on OOPHE magnitude and determinants specifically for the Somali Region of Ethiopia.
• Granular Cost Breakdown: Distinguishes between direct medical costs (consultation, meds, labs) and direct non-medical costs (transport, food), offering a holistic view of the financial burden.
• Identification of Vulnerable Groups: Highlights specific demographic and geographic predictors (e.g., unmarried status, higher education, long travel distances) that increase the likelihood of incurring OOPHE, challenging the assumption that only the poor are affected.
• Policy Relevance: Offers evidence-based recommendations for strengthening health financing mechanisms, specifically targeting the gaps in CBHI enrollment and the lack of Social Health Insurance (SHI) for formal sector employees.

4. Key Results

• Magnitude of OOPHE:

  • 89.5% of outpatients incurred out-of-pocket payments at the point of service.
  • Only 7.2% were covered by health insurance.
  • Mean OOPHE: 485.6 ETB (approx. $3.12 USD) ± 349 ETB per outpatient.
  • Mean Non-Medical Cost: 140.8 ETB per participant.
  • Cost Breakdown: Medication (253.3 ETB) and Investigation (218.2 ETB) were the highest cost drivers.

• Factors Associated with OOPHE (Multivariable Analysis):
  Four variables were significantly associated with higher odds of incurring OOPHE:

  1. Sex: Females were 3.38 times more likely to pay OOPHE than males (AOR = 3.38; 95% CI: 1.54–7.42).
  2. Marital Status: Unmarried individuals were 5.32 times more likely to pay OOPHE than married individuals (AOR = 5.32; 95% CI: 1.77–16.03).
  3. Educational Attainment: Individuals with college education or higher were 7.07 times more likely to pay OOPHE compared to illiterate participants (AOR = 7.07; 95% CI: 1.55–32.28).
  4. Distance to Facility: Patients traveling ≥5 km were 7.07 times more likely to incur OOPHE than those traveling <5 km (AOR = 7.07; 95% CI: 1.46–34.29).

5. Significance and Conclusion

The study concludes that the burden of OOPHE in Jigjiga is high, with nearly 90% of patients paying directly for services. The findings reveal a paradox where higher education and female gender correlate with higher OOPHE, likely due to better health-seeking behaviors and the exclusion of formal sector workers (who are often educated) from the household-based CBHI scheme.

Policy Implications:

• Strengthen CBHI: Expand enrollment and improve financial protection, particularly for vulnerable groups.
• Implement Social Health Insurance (SHI): Develop prepayment mechanisms specifically for formal sector employees (e.g., government workers) who are currently exposed to high OOPHE due to a lack of SHI coverage.
• Geographic Equity: Address the financial burden on those traveling long distances, potentially through decentralized services or transport subsidies.

This research underscores the urgent need for Ethiopia to transition away from reliance on out-of-pocket payments to achieve financial risk protection and equitable access to healthcare in the Somali Region.