Financial protection should be guaranteed to ensure universal health coverage. Out-of-pocket expenditure may hinder financial protection for low-income populations; however, the use of direct user payments in healthcare remains controversial. This study investigated this controversial relationship between OOP expenditure and health service utilization in the setting of a Sudanese tertiary hospital as a sample.
The mean service utilization in the studied hospital has been continuously decreasing in recent years. All services, including outpatient services, referred clinics, hospital admission and inpatient services, laboratory services, and diagnostic services, were found to decline significantly during the study period, but not operational services. The current study also highlighted that, patterns of OOP expenditure and health service utilization varied according to the type of service provided. This is similar to what was reported by K. Sing et al. (2016), who showed that the impact on OOP healthcare expenditure of healthcare utilization varies according to the purposes of such utilization [15].
Regarding the variation of OOP expenditure and health services utilization, three different patterns were identified: firstly, outpatient services were the lowest-cost services; despite this, the provision of outpatient services continued to decline throughout the study period; however, OOP expenditure also declined concomitantly, suggesting that utilization of outpatient services may have other significant independent predictors and that the estimated expenditure is only a product of the numbers and the prices of services.
The second pattern identified concerned surgical operations; despite the fact that the average monthly expenditure on surgical operations significantly increased during the study period, no significant difference in the frequency of surgical operations was reported. This indicates that despite the increasing cost of surgical operations, people had to have them, pushing them into impoverishment. Catastrophic health expenditure and impoverishment due to surgical operations are emphasized worldwide and in Sub Sahara Africa particularly [16, 17].
The commonest pattern was identified in the hospital admission and inpatient services, laboratory services, and diagnostic services. Increased OOP expenses and declining use of the mentioned services describe this pattern. An increase in service prices would be the most appropriate explanation for this pattern. To explain this common pattern, an analysis was conducted, revealing that inflation was a significant negative predictor of health service utilization. The adjustment to the analysis that included OOP as another independent variable had no impact on this relationship. A recent report on the impact of inflation on health care showed that inflation either drove health service utilization down or was expected to do so in the coming years, even in high-income countries [18].
The findings of this study have important implications for policymakers and healthcare providers in Sudan. Policymakers should consider implementing strategies to address these barriers, such as expanding insurance coverage, increasing the governmental share in health service costs, and improving the affordability of healthcare services. Healthcare providers should also be aware of the financial burden faced by patients and explore ways to reduce costs and improve access to care. By addressing the financial barriers to healthcare, policymakers and healthcare providers can work towards achieving universal health coverage and ensuring financial protection for the population.
Many studies support these strategic interventions; Saksena et al. (2012) suggested that a larger share of government expenditure in total health expenditure would be expected to be associated with higher use of public facilities [19]. Moreover, a brilliant recent analysis by Sirag et al. (2021) indicated that in middle- and low-income countries, above 29% OOP health spending led to increased poverty; nevertheless, OOP health expenditure below this threshold had a positive or insignificant effect on poverty reduction [20].
Policies should be legislated to guarantee forwarding governmental share to the people in need. For example, the government can either pay for the service in public facilities directly to ensure wide distribution of certain services or purchase private providers through social health insurance reimbursements that cover the private sector. Anyhow, increasing the governmental share was shown to reduce catastrophic health expenditures in many instances. According to the findings of Pirooz et al. (2016), Iran's health reform plan, which was implemented in 2014 with the intention of reducing OOP payments for inpatient care and eliminating informal payments, had a significant impact on reducing catastrophic health expenses at the household level by a factor of two [21]. Dainton et al. (2018) demonstrate that the free maternal health policy that was established in 2008 as part of the National Health Insurance Scheme in Ghana has made it possible to reduce the OOP expenses that are incurred by female patients [22].
For instance, while the study identifies trends in OOP expenditure and health service utilization, it does not delve deeply into the underlying reasons for these trends. Further exploration of factors such as healthcare financing mechanisms, health system infrastructure, and socioeconomic determinants could enhance the interpretation of the findings. Identifying the reasons behind the decrease in healthcare utilization is crucial for policymakers and healthcare providers to create specific strategies to enhance access to healthcare services and meet the population's requirements. Additionally, the reliance on administrative data and retrospective chart reviews may introduce limitations in terms of data accuracy and completeness, which should be acknowledged and mitigated to the extent possible.
In a nutshell, the present study is an insight into the OOP and health service utilization issues in Sudan, a low-income country. The study showed that this relationship is manifold and cannot be studied efficiently without breaking down its components. Three patterns for this relationship were identified in this study according to the type of service provided: either both health service utilization and OOP expenditure are declining and affected by other predictors, such as in the case of out-patient services, increasing OOP expenditure without affecting health service utilization, pushing users to impoverishment, such as in the case of surgical operations, or more commonly, declining health service utilization accompanied by increasing OOP expenditure driven by inflation.