Article Text

Download PDFPDF

Out-of-pocket expenditures for prevention and treatment of cardiovascular disease in general and specialised cardiac hospitals in Addis Ababa, Ethiopia: a cross-sectional cohort study
  1. Mieraf Taddesse Tolla1,
  2. Ole Frithjof Norheim1,
  3. Stéphane Verguet2,
  4. Abebe Bekele3,
  5. Kassahun Amenu3,
  6. Senbeta Guteta Abdisa4,
  7. Kjell Arne Johansson1
  1. 1Department of Global Public Health and Primary Health Care, University of Bergen, Bergen, Norway
  2. 2Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
  3. 3Department of Health Systems Research, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
  4. 4Department of Internal Medicine, Addis Ababa University School of Medicine, Addis Ababa, Ethiopia
  1. Correspondence to Dr Mieraf Taddesse Tolla; maphy99{at}


Background Cardiovascular disease poses a great financial risk on households in countries without universal health coverage like Ethiopia. This paper aims to estimate the magnitude and intensity of catastrophic health expenditure and factors associated with catastrophic health expenditure for prevention and treatment of cardiovascular disease in general and specialised cardiac hospitals in Addis Ababa.

Methods and findings We conducted a cross-sectional cohort study among individuals who sought cardiovascular disease care in selected hospitals in Addis Ababa during February to March 2015 (n=589, response rate 94%). Out-of-pocket payments on direct medical costs and direct non-medical costs were accounted for. Descriptive statistics was used to estimate the magnitude and intensity of catastrophic health expenditure within households, while logistic regression models were used to assess the factors associated with it.

About 27% (26 .7;95% CI 23.1 to 30.6) of the households experienced catastrophic health expenditure, defined as annual out-of-pocket payments above 10% of a household’s annual income. Family support was the the most common coping mechanism. Low income, residence outside Addis Ababa and hospitalisation increased the likelihood of experiencing catastrophic health expenditure. The bottom income quintile was about 60 times more likely to suffer catastrophic health expenditure compared with the top quintile (adjusted OR=58.6 (16.5–208.0), p value=0.00). Of those that experienced catastrophic health expenditure, the poorest and richest quintiles spent on average 34% and 15% of households’ annual income, respectively. Drug costs constitute about 50% of the outpatient care cost.

Conclusions Seeking prevention and treatment services for cardiovascular disease in Addis Ababa poses substantial financial burden on households, affecting the poorest and those who reside outside Addis Ababa more. Economic and geographical inequalities should also be considered when setting priorities for expanding coverage of these services. Expanded coverage has to go hand-in-hand with implementation of sound prepayment and risk pooling arrangements to ensure financial risk protection to the most needy.

  • Cardiovascular disease
  • prevention strategies
  • treatment

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

Statistics from


  • Acknowledgements Our appreciation goes to patients and their families, enumerators, hospital staff and the Ethiopian public health institute for helping us with the data collection.

  • Contributors MTT, KAJ, SV and OFN led the conceptualisation of the research and methodology for the paper. AB, KA, SGA, KAJ, OFN and SV did critical review of the research proposal and provided feedback. MTT led the data collection process with the help of AB, KA and SGA. MTT led the project administration, write up of the research proposal, data collection, analysis and first draft of the manuscript as well as overall coordination of the manuscript preparation and incorporating feedback from coauthors. KAJ, OFN, SV and KA reviewed the manuscript and provided critical feedback.

  • Funding This work was funded by NORAD and the Norwegian Research Council, through the Priority Setting in Global Health – 2020 grant (project no. 218694/H10) to the University of Bergen. Partial funding was received from the Bill & Melinda Gates Foundation through the Disease Control Priorities Network grant and the Disease Control Priorities – Ethiopia project. The funders had no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript.

  • Competing interests None decared.

  • Ethics approval The Scientific Ethical Review Committee of the Ethiopian Public Health Institute (005-02-2015/EPHI 6.13/65).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data are available from the corresponding author.

  • Correction notice This paper has been amended since it was published Online First. Owing to a scripting error, some of the publisher names in the references were replaced with 'BMJ Publishing Group'. This only affected the full text version, not the PDF. We have since corrected these errors and the correct publishers have been inserted into the references.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.