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This research identifies the factors leading to catastrophic health expenditure among households in Côte d'Ivoire.

March 25, 2026Open Access

Factors Associated with Catastrophic Health Expenditure Among Households in Côte dIvoire

Key Points

This research identifies the factors leading to catastrophic health expenditure among households in Côte d'Ivoire.
Conducted a cross-sectional analytical study using secondary data from the 2021 Harmonized Household Living Conditions Survey.
Utilized a two-stage probability sampling method to select households; validated 12,965 households for analysis.
Defined catastrophic health expenditure based on the ability-to-pay approach (OOPCAP ≥ 40%).
Employed descriptive statistics, a bivariate Chi² test, and binary logistic regression for analysis.
CHE was found in only 0.11% of the total sample and 0.35% among those making direct payments.
Household size significantly reduces the risk of CHE (OR = 0.07 for 6-7 members; OR = 0.03 for >7).
Households headed by married individuals and those in rural areas exhibit higher risks of CHE (OR = 5.27 and OR = 4.72, respectively).
Upper quintiles indicate better financial protection, with odds ratios below 1 for Q2 to Q5.

Abstract

Protection against financial risk is an essential pillar of Universal Health Coverage (UHC), particularly through the reduction of out-of-pocket payments that can lead to catastrophic health expenditure (CHE). This study aims to identify the determinants of CHE among households in Côte dIvoire. We conducted a cross-sectional analytical study using data from the 2021 Harmonized Household Living Conditions Survey (HLCS) (secondary analysis). The survey is based on a two-stage probability sampling method; 1,084 clusters and 13,008 households were initially selected, and 12,965 households were retained after validation. CHE was defined according to the ability to pay approach: a dichotomous variable (CHE=1) when OOPCAP = OOP/CAP ≥ 40%, otherwise CHE=0. Descriptive statistics, a bivariate Chi² test and binary logistic regression were used (Stata 17). Households spend more than half of their consumption expenditure on food (52.2%). The frequency of CHE is low: 0.11% in the total sample (14 households) and 0.35% among those who received direct payments. The concentration curve indicates a relatively homogeneous distribution (Gini = 0.187). The logistic model is significant (Chi² = 38.38; p 0.001; pseudo-R² = 0.094). The risk of CHE decreases significantly with household size (OR = 0.07 for 6–7 members; OR = 0.03 for 7). Conversely, households headed by a married person have an increased risk (OR = 5.27), as do those residing in rural areas (OR = 4.72). With regard to standard of living, the upper quintiles show odds ratios below 1 (Q2 to Q5), suggesting better financial protection, although some associations are of marginal significance. No significant link is observed for the gender of the head of household or for residence in Abidjan. CHE are rare, but their distribution remains socially differentiated: increased risk in rural areas, increased vulnerability when the head of household is married, and a protective effect of household size, linked to intra-family mutualization. A socioeconomic gradient also appears, with wealthier households being less exposed, but the significance is marginal. These results call for strengthening financial protection, especially in rural areas, and interpreting CHE with caution, given their rarity and sensitivity to methodological choices.

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