Health Services Utilization and Out-of-Pocket Health Expenditure in Sudan: A Study of a Tertiary Public Hospital 2017-2020.

Abstract Background: Financial protection should be guaranteed to ensure universal health coverage. Out-of-pocket (OOP) expenditure may hinder financial protection for low-income populations; however, the use of OOP expenditure in healthcare remains controversial. Objectives: This study aimed to examine OOP expenditure and health service utilization in the setting of a Sudanese tertiary hospital as a sample. Materials and Methods: This study was a retrospective chart review conducted at one of the largest tertiary public hospitals in Khartoum, Sudan, from 2017 to 2020. Monthly hospital records of service utilization and OOP expenditures were obtained from the statistical and financial units of the hospital. Monthly inflation rates were obtained from the Sudanese ministry of finance. The data was analyzed using SPSS V28. Results: The average number of services provided per month for all services was significantly decreasing throughout the study period (2017–2020); however, operations showed no significant change (from 0.94± 0.58.16 to 1.19± 0.59 thousand service/ month, p-value 0.22). The monthly average OOP expenditure on all services was rising, except expenditure on outpatient services which declined from 6.36± 7.71 to 1.91± 4.86 thousand SDGs/month (p-value <0.001) and refereed clinic services which declined from 521.11± 90.78 to 53.20± 41.16 thousand SDGs/ month (p-value <0.001) between 2017 and 2020. Univariate analysis showed that inflation (p-value 0.001) was negatively associated with health services utilization, which remained significant (<0.001) after adjustment with OOP expenditure and showed no association with health services utilization in univariate analysis (p-value 0.24). Conclusion: Health service utilization has been declining in recent years, accompanied by increasing OOP expenditure. Inflation-driven high pricing is an explanation for this pattern; however, many factors should be studied. Policymakers and governors should consider applying strategic interventions such as increasing governmental share and expanding insurance.