Financial barriers and inequalities in healthcare access across East Africa: evidence from demographic and health surveys

TL;DR

This study finds that financial barriers to healthcare are common in East Africa, especially among poor and less educated women, and suggests policy changes to reduce these inequalities.

Contribution

The study reveals that poverty—not rurality—is the main driver of financial barriers to healthcare access for women in East Africa.

Findings

Nearly half of women in East Africa reported financial barriers to healthcare, with Somalia having the highest rate.

Financial barriers were more common among poorer, less educated women and those without bank accounts.

Adjusting for socioeconomic factors reversed the rural-urban disparity in financial barriers.

Abstract

Financial barriers are a critical impediment to achieving Universal Health Coverage (UHC), particularly in sub-Saharan Africa. In East Africa, high out-of-pocket health expenditures persist, potentially exacerbating inequities in healthcare access, especially for vulnerable groups like women of reproductive age. This study aimed to assess the prevalence and socioeconomic inequalities of financial barriers to healthcare access among women in eight East African countries.

We conducted a cross-sectional analysis of nationally representative Demographic and Health Surveys (DHS) from Burundi, Ethiopia, Kenya, Rwanda, Somalia, Somaliland, Tanzania, and Uganda (2016–2022), comprising a weighted sample of 108,175 women. The outcome variable was a self-reported big problem with “money needed for treatment.” We performed descriptive statistics, calculated concentration indices to measure economic inequality, and used a multivariable multilevel binary logistic regression to identify associated factors.

Nearly half (49.7%) of the women reported financial barriers, with significant cross-country variation, ranging from 64.8% in Somalia to 36.2% in Tanzania. Financial hardship was disproportionately concentrated among poorer economic groups, as evidenced by negative concentration indices across all countries (e.g., Rwanda: −0.0825; Ethiopia: −0.0737). Multilevel analysis revealed that lower wealth quintile (AOR=0.21 for richest vs. poorest), no formal education (AOR=0.41 for higher vs. no education), and lack of a bank account (AOR=0.69) were strongly associated with higher odds of financial barriers. A key finding was the reversal of the rural-urban disparity upon adjusting for socioeconomic confounders, suggesting that poverty, not rurality itself, is the primary factor associated with financial access problems.

Financial barriers are the most prevalent and inequitable obstacle to healthcare access for women in East Africa, disproportionately affecting the poor, less educated, and financially excluded. Accelerating progress toward UHC requires health financing reforms that reduce out-of-pocket payments, alongside multi-sectoral policies that address underlying socioeconomic disadvantages through pro-poor interventions and financial inclusion. This focus is justified given their heightened need for maternal, sexual, and reproductive healthcare, and their heightened vulnerability to financial exclusion and catastrophic health expenditures.

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