The Economic Burden of Healthcare Utilization: Findings from a Health and Well-Being Survey in Informal Settlements of Freetown, Sierra Leone
Open accessPublished version of a preprint
Abstract
The fragile health system in Sierra Leone undermines healthcare, leading to substantial patient costs. We aimed to estimate the economic burden and inequalities in healthcare in urban informal settlements in Freetown, Sierra Leone. A cross-sectional survey was conducted in three informal settlements in Freetown in April and May 2023 to collect data on healthcare usage within and outside the boundaries of the informal settlements. Catastrophic expenditures were estimated using the payer's household budget. Logistic regression explored socioeconomic characteristics associated with catastrophic expenditures. Inequalities in healthcare expenditures were assessed through concentration curves and indices. A total of 2575 participants reported healthcare utilization. Dwarzark (US$6.9) and Moyiba (US$7.1) had higher costs than Cockle Bay (US$5.5) when utilizing healthcare within the communities. Households incurred higher costs when seeking healthcare outside their informal settlements than within (US$14 vs US$ 7). Over half of the households across the settlements incurred catastrophic expenditures when seeking care outside the communities (57%), with the poorest wealth quintile (poorest, 89%; wealthier, 12%) incurring in higher incidence. Attending informal healthcare had a protective effect against catastrophic expenditure for healthcare within the communities. Age + 35, residence in Dwarzark and Moyiba, and length of residence + 4 years were associated with catastrophic expenditures. Healthcare expenditure was progressive in Dwarzark and equally distributed across wealth quintiles in the other communities. Our findings indicate the need to provide accessible, affordable, and good-quality healthcare within communities to alleviate the catastrophic costs of healthcare utilization. The regulation of informal health providers and their integration into the formal health system should be considered.
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Financial barriers to access healthcare among reproductive-age women in Sierra Leone contribute to high maternal morbidity and mortality rates.
“Studies by Dickson et al. [36], Sserwanja et al. [37], and Fullah et al. [38] consistently identify financial barriers to access healthcare among reproductive-age women in Sierra Leone, thereby contributing to high maternal morbidity and mortality rates.”
From Financial barriers to healthcare access among reproductive-age women in Sierra Leone: evidence from demographic health surveys of 2008, 2013, and 2019 (2026) · cites this paper as [38]
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References 28 · Cited by 2
- Authors
- Fullah, S., Vangahun, D., Gandi, I., Tengbe, S. M., Koroma, B., Sesay, S., Kibuchi, E., Lakshman, R. W. D., Sesay, I. J., Conteh, A., Saidu, S., Elsey, H., Quayyum, Z., Mansaray, B., Whittaker, L., Georgi, N. W., Nganda, M., Tolhurst, R., & de Siqueira Filha, N. T.
- Affiliations
- Sierra Leone Urban Research Centre (SL)
- University of Sierra Leone (SL)
- MRC/CSO Social and Public Health Sciences Unit (GB)
- Institute of Development Studies (GB)
- Liverpool School of Tropical Medicine (GB)
- University of York (GB)
- BRAC (BD)
- ORCID
- Venue
- Journal of Urban Health
- Published
- 2025-03-10
- Volume
- 102
- Issue
- 3
- Pages
- 692-712
- ISSN
- 0028-7091 (ISSN-L)
- 1099-3460
- 1468-2869
- OpenAlex
- W4408268065
- Cited by
- 2
- References
- 28
- Citations by year
- 2026: 2
- FWCI
- 1.81
- Type
- journal article
- Language
- en
- Open access
- green
- doi.org
- Licence
- Locations
- Journal of Urban Health (publishedVersion)
- Research Square (acceptedVersion, cc-by)
- PubMed (publishedVersion)
- PubMed Central (publishedVersion)
- ENLIGHTEN (Jurnal Bimbingan dan Konseling Islam) (acceptedVersion, cc-by-sa)
- White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (acceptedVersion)
- LSTM Online Archive (Liverpool School of Tropical Medicine) (acceptedVersion)
- Funders
- UK Research and Innovation (ES/S00811X/1)
- Topics
- Social Sciences › Economics, Econometrics and Finance › Finance › Healthcare Systems and Reforms
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Economic and Financial Impacts of Cancer
- Social Sciences › Health › Public Health and Social Inequalities
- Keywords
- catastrophic health expenditure, health care utilization, informal settlements, Freetown, health disparities, informal health providers, community-based care, socioeconomic determinants of health, concentration curves, urban health
- MeSH terms
- Adolescent, Adult, Aged, Child, Cross-Sectional Studies, Health Expenditures, Female, Humans, Male, Middle Aged, Patient Acceptance of Health Care, Sierra Leone, Socioeconomic Factors, Urban Population, Cost of Illness, Young Adult
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