Out-of-Pocket Surgical Costs and Catastrophic Health Expenditure in Ethiopia: Results From a Nationwide Multicenter Cross-Sectional Study

Abstract

Introduction: Globally, over 4.8 billion people lack access to safe, timely, and affordable surgical care, with the burden falling heaviest on low- and middle-income countries. In Ethiopia, where surgical services are urban-centered and out-of-pocket (OOP) health spending is among the highest globally, financial barriers often deter care-seeking. This study provides the first nationally representative assessment of catastrophic health expenditure (CHE) among surgical patients in Ethiopia to quantify financial risk and inform future equitable health financing reforms. Method: This national cross-sectional survey was conducted as part of the Ethio-SOS study, which includes 32 hospitals across Ethiopia. A total of 412 surgical patients were enrolled. Data were collected on direct and indirect costs, sociodemographic characteristics, and surgical indication. CHE was defined as OOP medical expenditure exceeding 10% of annual household expenditure. Results: Of 412 participants (53.6% female, 46.4% male), 103 (25.0%) experienced catastrophic health expenditure (CHE). Key cost drivers included medications (37%), laboratory tests (14%), and surgical fees (14%). Non-medical expenses, such as food, transportation, and caregiver support, accounted for 20% of total spending. Risk factors for CHE included smaller household size (OR = 0.52, p = 0.046), unmarried status (OR = 0.38, p = 0.002), greater distance from the hospital, and trauma-related surgery (OR = 1.95, p = 0.042). Coping mechanisms included borrowing money (16.6%) and selling assets (13.9%). Conclusions: One in four surgical patients in Ethiopia experiences CHE, with increased vulnerability among unmarried individuals, smaller households, and those undergoing trauma-related procedures. Medication and non-medical costs, such as transportation, remain significant financial burdens. These findings highlight urgent gaps in financial protection and underscore the need for targeted policy reforms, such as improved access to medicine, transportation support, and expanded safety nets, to reduce out-of-pocket surgical costs and promote equitable access to care.