Tsega Yawkal, Birhan Zelalem, Adamu Kidist
Department of Health System and Management, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia.
Department of Psychiatry, School of Medicine, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia.
Front Public Health. 2025 Mar 26;13:1484671. doi: 10.3389/fpubh.2025.1484671. eCollection 2025.
The 2030 Agenda for Sustainable Development aims to ensure that no one is left behind in health. However, the high magnitude of catastrophic health expenditure (CHE) and impoverishing health expenditure (IHE) remain global challenges. The financial hardship caused by healthcare has not been extensively studied in Ethiopia to date. Therefore, this study aimed to assess socioeconomic inequality in financial hardship and its determinants among households in the South Wollo zone, Ethiopia.
This cross-sectional study surveyed 845 households in the South Wollo zone from 1 May to 31 May 2023. Financial hardship was measured using the IHE and CHE metrics. The households were considered to experience IHE if their health expenditure pushed them below a poverty line of $2.15 (ETB 118.25) and considered to experience CHE if their health expenditure exceeded 10% of their total expenditure. Costs were estimated using prevalence-based and patient-perspective approaches. STATA version 17.0 was used for data management and analysis. We used the cixr and lorenz estimate STATA commands to estimate the concentration index (CIX) and generate the concentration curve (CC), respectively. An adjusted odds ratio (AORs) with a 95% confidence interval and a -value of <0.05 were used to determine statistical significance.
The CIX for wealth status was -0.17 (CI: -0.23, -0.11), with a -value <0.001, indicating significant socioeconomic inequality in financial hardship of healthcare. The incidence of CHE was ~30% (95%CI; 26.91-33.16%) at the 10% threshold, while the incidence of IHE was ~4% at the $2.15 poverty line. Significant determinants of CHE included the poorest wealth status (AOR: 4.80, CI: 2.61-8.86), older age of the household head (AOR: 3.40, CI: 1.52-7.60), lack of insurance (AOR: 2.70, CI: 1.67-4.38), chronic illnesses (AOR: 5.12, CI: 3.24-8.10), being widowed (AOR: 4.30, CI: 1.27-14.57) or divorced (AOR: 6.45, CI: 1.89-21.10) in terms of marital status of the household head, and seeking traditional healthcare (AOR: 2.47, CI: 1.60-3.81).
This study revealed that there was significant inequality in financial hardship of health expenditure across household wealth categories. The incidences of CHE and IHE were higher. The wealth status of the household, insurance status, marital status of the household head, chronic illness, and seeking traditional healthcare were the key determinant factors of CHE. Therefore, policymakers should focus on underprivileged households to ensure effective healthcare financial risk protection (FRP).
《2030年可持续发展议程》旨在确保在健康方面不让任何人掉队。然而，高额灾难性卫生支出（CHE）和致贫性卫生支出（IHE）仍是全球性挑战。迄今为止，埃塞俄比亚尚未对医疗保健造成的经济困难进行广泛研究。因此，本研究旨在评估埃塞俄比亚南沃洛地区家庭在经济困难方面的社会经济不平等及其决定因素。
这项横断面研究于2023年5月1日至5月31日对南沃洛地区的845户家庭进行了调查。使用IHE和CHE指标衡量经济困难程度。如果家庭的卫生支出使其低于2.15美元（118.25埃塞俄比亚比尔）的贫困线，则认为该家庭经历了IHE；如果家庭的卫生支出超过其总支出的10%，则认为该家庭经历了CHE。成本采用基于患病率和患者视角的方法进行估算。使用STATA 17.0版本进行数据管理和分析。我们分别使用cixr和lorenz estimate STATA命令来估计集中指数（CIX）并生成集中曲线（CC）。采用调整后的比值比（AOR）及95%置信区间和P值<0.05来确定统计学意义。
财富状况的CIX为-0.17（置信区间：-0.23，-0.11），P值<0.001，表明医疗保健经济困难方面存在显著的社会经济不平等。在10%的阈值下，CHE的发生率约为30%（95%置信区间；26.91-33.16%），而在2.15美元贫困线时，IHE的发生率约为4%。CHE的显著决定因素包括最贫困的财富状况（AOR：4.80，置信区间：2.61-8.86）、户主年龄较大（AOR：3.40，置信区间：1.52-7.60）、缺乏保险（AOR：2.70，置信区间：1.67-4.38）、慢性病（AOR：5.12，置信区间：3.24-8.10）、户主婚姻状况为丧偶（AOR：4.30，置信区间：1.27-14.57）或离婚（AOR：6.45，置信区间：1.89-21.10），以及寻求传统医疗保健（AOR：2.47，置信区间：1.60-3.81）。
本研究表明，不同家庭财富类别在卫生支出经济困难方面存在显著不平等。CHE和IHE的发生率较高。家庭财富状况、保险状况、户主婚姻状况、慢性病以及寻求传统医疗保健是CHE的关键决定因素。因此，政策制定者应关注贫困家庭，以确保有效的医疗保健财务风险保护（FRP）。
