Examining out of pocket payments for maternal health in rural Ethiopia: Paradox of free health care un-affordability

  • A Tibebe
  • G Amarech
  • T Melesse
  • DH Mariam


Background: One of the components of reproductive health is maternal care. Maternal health care is supposed to be provided free of charge for public health concerns thus women have the right to get services related to maternal care free of charge at government health care facilities. But there is low utilization of the services. Only 12% of women receive ANC and only 6% get assistance of skilled health worker during delivery in Ethiopia. There are different factors for the low utilization of services. Un-affordability of services is cited as the first main reason contributing to the low utilization.
Objectives: To examine the magnitude of out of pocket expenditure for maternal health series in rural Ethiopia.
Methods: This study was conducted within ten randomly selected kebeles of the Butajira DSS from October 2007 to May 2008 using a cross-sectional survey design and a source population of households that expend out-of-pocket on RH services during the period of 12 months prior to the study.
Results: In the study, nearly three fifth of the studied families paid out of pocket expenditures exceeding 20% of their monthly household expenditure for maternal health care seeking. Excluding expenditures for food, about 61% of them paid more than 40% of their non-food expenditure on maternal health care. Households in the lower wealth quintiles are paying greater proportion of their income (49%) than those in the highest wealth quintile who paid 19% of their income. In addition to the direct expenditures made at point of service, the indirect expenditures of reaching to the services are also found to be substantial. These indirect expenditures share 32% of ANC, 31% of obstetric care, and 44% of abortion services. Thus even if direct expenditures at point of service in public providers are assumed to be negligible, women are obliged to go to expensive private providers to reduce the indirect costs of care seeking such as waiting time. Regarding coping mechanism to respond to expenditure, households usually borrow from relatives and friends and 4.4% of the households resorted to distress sale of their assets.
Conclusions: This study identified the presence of price elasticity among the poor that suggests out-of-pocket expenditure has a regressive distributional impact and poor and very poor people were expending more. On top of this, all expenses were covered from regular income which leads to catastrophic household economic crises.
Recommendations: Health care providers should be evenly distributed, easily accessible and work on awareness creation on the advantages of early care seeking and preventive care. On the other hand, health care financing should also be based on the principle of cost sharing and move into prepayment schemes or insurance.

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eISSN: 1021-6790