Assessing the burden of medical impoverishment by cause: a systematic breakdown by disease in Ethiopia

Abstract

Background: Out-of-pocket (OOP) medical expenses often lead to catastrophic expenditure and impoverishment in low- and middle-income countries. Yet, there has been no systematic examination of which specific diseases and conditions (e.g., tuberculosis, cardiovascular disease) drive medical impoverishment, defined as OOP direct medical costs pushing households into poverty.

Methods: We used a cost and epidemiological model to propose an assessment of the burden of medical impoverishment in Ethiopia, i.e., the number of households crossing a poverty line due to excessive OOP direct medical expenses. We utilized disease-specific mortality estimates from the Global Burden of Disease study, epidemiological and cost inputs from surveys, and secondary data from the literature to produce a count of poverty cases due to OOP direct medical costs per specific condition.

Results: In Ethiopia, in 2013, and among 20 leading causes of mortality, we estimated the burden of impoverishment due to OOP direct medical costs to be of about 350,000 poverty cases. The top three causes of medical impoverishment were diarrhea, lower respiratory infections, and road injury, accounting for 75 % of all poverty cases.

Conclusions: We present a preliminary attempt for the estimation of the burden of medical impoverishment by cause for high mortality conditions. In Ethiopia, medical impoverishment was notably associated with illness occurrence and health services utilization. Although currently used estimates are sensitive to health services utilization, a systematic breakdown of impoverishment due to OOP direct medical costs by cause can provide important information for the promotion of financial risk protection and equity, and subsequent design of health policies toward universal health coverage, reduction of direct OOP payments, and poverty alleviation.

Keywords: Catastrophic health expenditure; Direct medical payments; Ethiopia; Financial risk protection; Medical impoverishment; Out-of-pocket costs; Poverty.

Fig. 1

a Numbers of poverty cases due to out-of-pocket (OOP) direct medical costs and deaths incurred by each of 20 leading causes of mortality in Ethiopia. Lri = lower respiratory infections, Dia = diarrhea, St = stroke, TB = tuberculosis, Ihd = ischemic heart disease, Pr = preterm birth complications, Mal = malaria, Rti = road traffic injuries, Neo = neonatal encephalopathy, Men = meningitis, Wc = whooping cough, Msl = measles, Cir = cirrhosis, DM = diabetes mellitus, Copd = chronic obstructive pulmonary disease, Cc = cervical cancer, Bc = breast cancer, Ep = epilepsy, Ast = asthma. b Numbers of poverty cases due to OOP direct medical costs and deaths incurred by each of 20 leading causes of mortality in Ethiopia, when the two leading causes of mortality, lower respiratory infections and diarrhea, were omitted. Non-communicable diseases and injuries are indicated in blue; communicable diseases, maternal, and neonatal causes are indicated in red

Fig. 2

a Number of poverty cases due to direct out-of-pocket (OOP) medical costs and number of deaths incurred by each of 20 leading causes of mortality in Ethiopia, when health services utilization was hypothetically set at 75 % across all conditions. Non-communicable diseases and injuries are indicated in blue; communicable diseases, maternal, and neonatal causes are indicated in red. b Number of poverty cases due to direct OOP medical costs by each of 20 leading causes of mortality in Ethiopia, in the base case (orange) and when adding health services utilization set at 75 % across all conditions (yellow). Lri = lower respiratory infections, Dia = diarrhea, St = stroke, TB = tuberculosis, Ihd = ischemic heart disease, Pr = preterm birth complications, Mal = malaria, Rti = road traffic injuries, Neo = neonatal encephalopathy, Men = meningitis, Wc = whooping cough, Msl = measles, Cir = cirrhosis, DM = diabetes mellitus, Copd = chronic obstructive pulmonary disease, Cc = cervical cancer, Bc = breast cancer, Ep = epilepsy, Ast = asthma

Fig. 3

a Number of poverty cases due to direct out-of-pocket (OOP) medical costs by each of 20 leading causes of mortality in Ethiopia, in the base case (orange) and when key inputs (e.g., disease-specific cases, utilization, OOP direct medical costs) were varied across the income distribution (yellow). b Number of poverty cases due to direct OOP medical costs by each of 20 leading causes of mortality in Ethiopia, when key inputs (e.g., disease-specific cases, utilization, OOP direct medical costs) were varied across the income distribution, including the repartition among income quintiles. Lri = lower respiratory infections, Dia = diarrhea, St = stroke, TB = tuberculosis, Ihd = ischemic heart disease, Pr = preterm birth complications, Mal = malaria, Rti = road traffic injuries, Neo = neonatal encephalopathy, Men = meningitis, Wc = whooping cough, Msl = measles, Cir = cirrhosis, DM = diabetes mellitus, Copd = chronic obstructive pulmonary disease, Cc = cervical cancer, Bc = breast cancer, Ep = epilepsy, Ast = asthma