ORIGINAL RESEARCH article
Front. Reprod. Health
Sec. Access and Barriers to Reproductive Health Services
This article is part of the Research TopicExploring Healthcare Access in Low- and Middle Income Countries: Achievements, Synergies, Opportunities and ChallengesView all 6 articles
Financial Barriers and Inequalities in Healthcare Access Across East Africa: Evidence from Demographic and Health Surveys
Provisionally accepted
Hodo Abdikarim*
Omer Adam Farih
Saeed Hassan Mohamed
Asma Mahamoud AbdillahiAbdirizak Hassan AbokorMustafe Abdillahi Ali
Abdisalam Hassan Muse- Amoud University, Borama, Somalia
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Background: Financial barriers are a critical impediment to achieving Universal Health Coverage (UHC), particularly in sub-Saharan Africa. In East Africa, high out-of-pocket health expenditures persist, potentially exacerbating inequities in healthcare access, especially for vulnerable groups like women of reproductive age. This study aimed to assess the prevalence and socioeconomic inequalities of financial barriers to healthcare access among women in eight East African countries. Methods: We conducted a cross-sectional analysis of nationally representative Demographic and Health Surveys (DHS) from Burundi, Ethiopia, Kenya, Rwanda, Somalia, Somaliland, Tanzania, and Uganda (2016-2022), comprising a weighted sample of 108,175 women. The outcome variable was a self-reported big problem with "money needed for treatment." We performed descriptive statistics, calculated concentration indices to measure economic inequality, and used a multivariable multilevel binary logistic regression to identify associated factors. Results: Nearly half (49.7%) of the women reported financial barriers, with significant cross-country variation, ranging from 64.8% in Somalia to 36.2% in Tanzania. Financial hardship was disproportionately concentrated among poorer economic groups, as evidenced by negative concentration indices across all countries (e.g., Rwanda: -0.0825; Ethiopia: -0.0737). Multilevel analysis revealed that lower wealth quintile (AOR=0.21 for richest vs. poorest), no formal education (AOR=0.41 for higher vs. no education), and lack of a bank account (AOR=0.69) were strongly associated with higher odds of financial barriers. A key finding was the reversal of the rural-urban disparity upon adjusting for socioeconomic confounders, suggesting that poverty, not rurality itself, is the primary factor associated with financial access problems Conclusion: Financial barriers are the most prevalent and inequitable obstacle to healthcare access for women in East Africa, disproportionately affecting the poor, less educated, and financially excluded. Accelerating progress toward UHC requires health financing reforms that reduce out-of-pocket payments, alongside multi-sectoral policies that address underlying socioeconomic disadvantages through pro-poor interventions and financial inclusion. This focus is justified given their heightened need for maternal, sexual, and reproductive healthcare, and their heightened vulnerability to financial exclusion and catastrophic health expenditures. Keywords: Financial Barriers; Healthcare Access; Universal Health Coverage; East Africa; Socioeconomic Inequality; Demographic and Health Surveys (DHS).
Keywords: Demographic and Health Surveys (DHS), East Africa, Financial barriers, Healthcare access, socioeconomic inequality, Universal Health Coverage
Received: 22 Oct 2025; Accepted: 17 Dec 2025.
Copyright: © 2025 Abdikarim, Farih, Mohamed, Abdillahi, Abokor, Ali and Muse. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Hodo Abdikarim
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