Inequities in Household Out-Of-Pocket Spending Among Urban Slum Dwellers in Southeast Nigeria

High out-of-pocket expenditure (OOPE) is an inequitable health financing mechanism that involves health consumers directly paying money that may or may not be reimbursed later while accessing healthcare services. For poorer households, high OOPE may mean forgoing other important needs, thus incurring catastrophic health expenditures and further impoverishment. This points to the problem of inequity in accessing healthcare services.

To prevent this problem of inequity in healthcare access, one important goal of health systems is to promote fairness of financial contributions. This means that each household should contribute to the country’s health system according to their ability to pay (ATP), exempting impoverished households from making any payments and shielding from financial risks due to high health expenditures.

Approximately 5 million Nigerians, only 3% of the population, have health insurance coverage through the National Health Insurance Scheme (NHIS), leaving about 97% of the population uninsured, relying on out-of-pocket payments to access health services. The high level of OOPE has worsened the Nigerian health system, and inequities in accessing healthcare services particularly affects the urban poor. The lack of reliable, affordable public services and the reliance on the private sector also contribute to exorbitant healthcare costs, resulting in catastrophic healthcare expenditures for the most vulnerable populations living in urban slums

This paper aims to assess the level of health inequity in OOPE for different socio-economic groups among households in urban slums in Enugu and Anambra states in Nigeria. Findings highlight that healthcare costs vary widely, particularly for residents of Anambra State and those employed in the informal sector, who face higher expenses. Although OOPE for healthcare in urban slums in Enugu and Anambra states is progressive, this is mainly driven by the lack of access to quality and formal healthcare by the poorest rather than fair payment for health services. Our findings underscore the disparities in access to quality healthcare in urban slums in both states and call for more attention to the plight of the urban poor in the states.

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Ozor O, Nwokolo C, Teixeira de Siqueira Filha N, Odii A, Hicks JP, Li S, Ezenwaka U, Dawkins B and Onwujekwe O (2025) . Int. J. Public Health 70:1607969. doi: 10.3389/ijph.2025.1607969