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. 2025 Mar 27:70:1607969.
doi: 10.3389/ijph.2025.1607969. eCollection 2025.

Inequities in Household Out-Of-Pocket Spending Among Urban Slum Dwellers in Southeast Nigeria

Okechukwu Ozor  1 , Chukwudi Nwokolo  1   2 , Noemia Teixeira de Siqueira Filha  3 , Aloysius Odii  1   4 , Joseph Paul Hicks  5 , Shushan Li  3 , Uchenna Ezenwaka  1 , Bryony Dawkins  6 , Obinna Onwujekwe  1
Affiliations

Inequities in Household Out-Of-Pocket Spending Among Urban Slum Dwellers in Southeast Nigeria

Okechukwu Ozor et al. Int J Public Health. .

Abstract

Objectives: This study examines the economic burden and inequities in out-of-pocket expenditures (OOPEs) to access healthcare in urban slums in Nigeria.

Methods: The cross-sectional study was undertaken in eight urban slums in Enugu and Anambra, Nigeria. Participants (n = 1,025) responded to questions on health expenditures and access to healthcare. Gamma regression was used to estimate the mean differences in OOPE. Financing incidence analysis was used to estimate inequities in OOPE.

Results: Enugu residents and individuals with formal occupations incurred lower costs than the residents in Anambra and those employed in informal occupations. Households in the middle wealth quintile incurred higher costs than those in the poorest quintile. Gini, concentration, and Kakwani indices indicated a progressive financing system, with the richest contributing proportionately more than their share of ability to pay (ATP). Poorest households used informal healthcare more.

Conclusion: Although payment for healthcare in urban slums is progressive, the poorest households may be at risk of poor health outcomes due to reliance on informal healthcare providers. Our findings highlight the role ATP may play in healthcare denial among the urban poor.

Keywords: Kakwani index; ability to pay; inequity; out-of-pocket expenditure; urban slum.

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Conflict of interest statement

The authors declare that they do not have any conflicts of interest.

Figures

FIGURE 1
FIGURE 1
Concentration and Lorenz curves of ability to pay (Enugu and Anambra, Nigeria. 2022). The red line indicates the Concentration curve, the blue line indicates the Lorenz curve of ATP and the black line indicates the line of equality. (A) Anambra. (B) Enugu. (C) Pooled sample.
FIGURE 2
FIGURE 2
Type of health provider accessed according to the wealth quintile (Enugu and Anambra, Nigeria. 2022). (A) Anambra. (B) Enugu. (C) Pooled sample.
See this image and copyright information in PMC

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