Skip to main content

Out-of-pocket health-care spending and its determinants among households in Nigeria: a national study



This study estimated out-of-pocket health-care spending and its determinants among households in Nigeria.


Using secondary data from the 2009/2010 Harmonized Nigeria Living Standard Survey, we estimated the determinants of out-of-pocket health-care spending in Nigeria. The Heckman two-step selection model was used to analyse household and individual decisions to seek care and how much to spend on health care. Data were analysed using STATA version 12 software.


Results from the Heckman selection model indicated that having household heads with primary education, having household heads with secondary education, having more than five members in the household, households residing in the South East region, having head of the household being employed, households visiting public health facilities, and having household members with chronic illnesses were factors that increased the likelihood of incurring out-of-pocket health-care spending.


Our findings suggest that individual and household characteristics increase the risk of incurring out-of-pocket health-care spending. Policy makers and political actors need to stop the high reliance on out-of-pocket health-care spending as a means of financing the Nigerian health system by increasing public health expenditure. The design and implementation of a tax-based non-contributory health financing system for the poor, vulnerable, and informal sector workers would be more helpful for implication at a national level.

This is a preview of subscription content, access via your institution.


  1. Aday LA, Andersen RM (1974) A framework for the study of access to medical care. Health Serv Res 9:208–220

    CAS  PubMed  PubMed Central  Google Scholar 

  2. Akazili J, Garshong B, Aikins M, Gyapong J, McIntyre D (2012) Progressivity of health care financing and incidence of service benefits in Ghana. Health Policy Plan 27:i13–i22.

    Article  PubMed  Google Scholar 

  3. Bertakis KD, Azari R, Helms LJ, Callahan EJ, Robbins JA (2000) Gender differences in the utilization of health care services. J Fam Pract 49:147–152

    CAS  PubMed  Google Scholar 

  4. Brinda EM, Andres RA, Enemark U (2014) Correlates of out-of-pocket and catastrophic health expenditures in Tanzania: results from a national household survey. BMC Int Health Hum Rights 14(5):1–8

    Google Scholar 

  5. Brinda EM, Kowal P, Attermann J, Enemark U (2015) Health service use, out-of-pocket payment and catastrophic health expenditure among older people in India: the WHO Study on global AGEing and adult health (SAGE). J Epidemiol Community Health 69(5):489–494.

    Article  PubMed  Google Scholar 

  6. Chaze JP (2005) Assessing household health expenditure with Box–Cox censoring models. Health Econ 14:893–907

    Article  Google Scholar 

  7. Chu T, Liu T, Chen C, Tsai Y, Chiu W (2005) Household out-of-pocket medical expenditures and National Health Insurance in Taiwan: income and regional inequality. BMC Health Serv Res 5:60.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Cotlear D, Nagpal S, Smith O, Tandon A, Cortez R (2015) Going universal: how 24 countries are implementing universal health coverage reforms from the bottom up. World Bank, Washington, DC

    Book  Google Scholar 

  9. Federal Ministry of Health (2010) National Strategic Health Development Plan (NSHDP) 2010–2015. Federal Ministry of Health, Abuja

    Google Scholar 

  10. Gottret P, Schieber GJ (2006) Health financing revisited: a practitioner's guide. The World Bank, Washington, DC

    Book  Google Scholar 

  11. Grossman M (1972) On the concept of health capital and the demand for health. J Polit Econ 8(2):223–255

    Article  Google Scholar 

  12. Gupta I, Chowdhury S, Prinja S, Trivedi M (2016) Out-of-pocket spending on out-patient care in India: assessment and options based on results from a district level survey. PLoS One 11(11):e0166775.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  13. Habibov N (2009) What determines healthcare utilization and related out-of-pocket expenditures in Tajikistan? Lessons from a national survey. Int J Public Health 54:260–266

    Article  Google Scholar 

  14. Heckman JJ (1979) Sample selection bias as a specification error. Econometrica 47(1):153–161.

    Article  Google Scholar 

  15. Hjortsberg C (2003) Why do the sick not utilize health care? The case of Zambia. Health Econ 12:755–770

    Article  Google Scholar 

  16. Hong G, Kim SY (2000) Out-of-pocket health care expenditure patterns and financial burden across the life cycle stages. J Consum Aff 34(2):291–313

    Article  Google Scholar 

  17. Hotchkiss DR, Rous JJ, Karmacharya K, Sangraula P (1998) Household health expenditures in Nepal: implications for health care financing reform. Health Policy Plan 13(4):371–383

    CAS  Article  Google Scholar 

  18. Hwang W, Weller W, Ireys H, Anderson G (2001) Out-of-pocket medical spending for care of chronic conditions. Health Aff 20(6):267–278

    CAS  Article  Google Scholar 

  19. International Labour Office (2018) Women and men in the informal economy: a statistical picture (third edition). International Labour Office, Geneva. Accessed 5 February 2019

  20. Kress DH, Su Y, Wang H (2016) Assessment of primary health care system performance in Nigeria: using the Primary Health Care Performance Indicator conceptual framework. Health Systems & Reform 2(4):302–318

    Article  Google Scholar 

  21. Kutzin J (2008) Health financing policy: a guide for decision-makers (Health Financing Policy Paper 2008/1). World Health Organization, Regional Office for Europe, Division of Country Health Systems, Copenhagen. Accessed 5 February 2019

  22. Lu C, Chin B, Li G, Murray CJL (2009) Limitations of methods for measuring out of pocket and catastrophic private health expenditures. Bull World Health Organ 87:238–244

    Article  Google Scholar 

  23. Malik AM, Syed SI (2012) Socio-economic determinants of household out-of-pocket payments on health care in Pakistan. Int J Equity Health 11(51):1–7

    Google Scholar 

  24. Masiye F, Kaonga O (2016) Determinants of healthcare utilisation and out-of-pocket payments in the context of free public primary healthcare in Zambia. Int J Health Policy Manag 5(12):693–703.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Mastilica M, Bozikov J (1999) Out-of-pocket payments for health care in Croatia: implications for equity. Croatian Medical Journal 40(2):152–159

    CAS  PubMed  Google Scholar 

  26. Matsaganis M, Mitrakos T, Tsakloglou P (2008) Modelling household expenditure on health care in Greece. Working Paper 68. Bank of Greece, Athens. Accessed 5 February 2019

  27. McIntyre D, Gilson L, Mutyambizi V (2005) Promoting equitable health care financing in the African context: Current challenges and future prospects. EQUINET discussion paper number 27. Accessed 5 February 2019

  28. McIntyre D (2007) Learning from experience: health care financing in low- and middle-income countries. Global Forum for Health Research, Geneva

    Google Scholar 

  29. Mills A, Ataguba JE, Akazili J, Borghi J, Garshong B, Makawia S, Mtei G, Harris B, Macha J, Meheus F, McIntyre D (2012) Equity in financing and use of health care in Ghana, South Africa, and Tanzania: implications for paths to universal coverage. Lancet 380:126–133

    Article  Google Scholar 

  30. Murphy JF, Hepworth JT (1996) Age and gender differences in health services utilization. Res Nurs Health 19:323–329

    CAS  Article  Google Scholar 

  31. Musgrove P (1983) Family health care spending in Latin America. J Health Econ 2:245–257

    CAS  Article  Google Scholar 

  32. Okunade AA, Suraratdecha C, Benson DA (2010) Determinants of Thailand household health care expenditure: the relevance of permanent resources and other correlates. Health Econ 19:365–376

    Article  Google Scholar 

  33. Oluwatimilehin I (2014) Determinants of household health care expenditure in an African country. Accessed 5 February 5 2019

  34. Onwujekwe OE (2005) Inequities in healthcare seeking in the treatment of communicable endemic diseases in Southeast Nigeria. Soc Sci Med 61(2):455–463

    Article  Google Scholar 

  35. Onwujekwe OE, Uzochukwu BSC, Obikeze EN, Okoronkwo I, Ochonma OG, Onoka CA, Madubuko G, Okoli C (2010) Investigating determinants of out of pocket spending and strategies for coping with payments for health care in Southeast Nigeria. BMC Health Serv Res 10(67):1–10.

    Article  Google Scholar 

  36. Onwujekwe OE, Hanson K, Uzochukwu BS (2012) Are the poor differentially benefiting from provision of priority public health services? A benefit incidence analysis in Nigeria. Int J Equity Health 11(1):70

    Article  Google Scholar 

  37. Oyinpreye ATG, Moses KT (2014) Determinants of out-of-pocket health care expenditure in south-south geo-political zone of Nigeria. IJEFM 3(6):296–300

    Google Scholar 

  38. Parker SW, Wong R (1997) Household income and health expenditures in Mexico. Health Policy 40(3):237–255

    CAS  Article  Google Scholar 

  39. Preker AS, Carrin G (2004) Health financing for poor people: resource mobilization and risk sharing. World Bank, Washington, DC. Accessed 5 February 2019

  40. Rous JJ, Hotchkiss DR (2003) Estimation of the determinants of household health care expenditures in Nepal with controls for endogenous illness and provider choice. Health Econ 12:431–451

    Article  Google Scholar 

  41. Roy K, Howard DH (2007) Equity in out-of-pocket payments for hospital care: evidence from India. Health Policy 80:297–307

    Article  Google Scholar 

  42. Rubin RM, Koelln K (1993) Determinants of household out-of-pocket health expenditures. Soc Sci Q 74(4):721–735

    Google Scholar 

  43. Ruger JP, Kim HJ (2007) Out-of-pocket healthcare spending by the poor and chronically ill in the Republic of Korea. Am J Public Health 97(5):804–811.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Scott-Emuakpor A (2010) The evolution of health care systems in Nigeria: which way forward in the twenty first century. Niger Med J 51:53–65

    Google Scholar 

  45. Sinha RK, Chatterjee K, Nair N, Tripathy PK (2016) Determinants of out-of-pocket and catastrophic health expenditure: a cross-sectional study. Br J Med Med Res 11(8):1–11

    Article  Google Scholar 

  46. Su TT, Pokhrel S, Gbangou A, Flessa S (2006) Determinants of household health expenditure on western institutional health care. Eur J Health Econ 7:199–207

    Article  Google Scholar 

  47. van Doorslaer E, O’Donnell O, Rannain-Eliya RP, Somanathan A, Adhikari SR, Garg CC, Harbianto D, Herrin AN, Huq MN, Ibragimova S, Karan A, Lee TJ, Leung GM, Lu JF, Ng CW, Pande BR, Racelis R, Tao S, Tin K, Tisayaticom K, Trisnantoro L, Vasavid C, Zhao Y (2007) Catastrophic payments for health care in Asia. Health Econ 16:1159–1184

    Article  Google Scholar 

  48. Vyas S, Kumaranayake L (2006) Constructing socio-economic status indices: how to use principal components analysis. Health Policy Plan 21(6):459–468.

    Article  PubMed  Google Scholar 

  49. Wagstaff A (2008) Measuring financial protection in health, Policy research working paper 4554. The World Bank, Washington, DC

    Book  Google Scholar 

  50. World Bank (2015) World development indicators 2015. The World Bank, Washington, DC. Accessed 5 February 2019

  51. World Bank (2018) Nigeria: country at a glance. The World Bank, Washington, DC. Accessed 5 February 2019

  52. World Health Organization (2000) World health report 2000. World Health Organization, Geneva. Accessed 5 February 2019

  53. World Health Organization (2005) Sustainable health financing, universal coverage and social health insurance. World Health Organization, Geneva. Accessed 5 February 2019

  54. World Health Organization (2010) World health report 2010: health systems financing: the path to universal coverage. World Health Organization, Geneva. Accessed 5 February 2019

  55. World Health Organization (2014) World health statistics 2014. World Health Organization, Geneva. Accessed 5 February 2019

  56. World Health Organization (2015) World health statistics 2015. World Health Organization, Geneva. Accessed 5 February 2019

  57. World Health Organization (2016a) World health statistics 2016: monitoring health for the SDGs. World Health Organization, Geneva. Accessed 5 February 2019

  58. World Health Organization (2016b) Public financing for health in Africa: from Abuja to the SDGs. World Health Organization, Geneva. Accessed 5 February 2019

  59. World Health Organization (2018a) World health statistics 2018: monitoring health for the SDGs. World Health Organization, Geneva. Accessed 5 February 2019

  60. World Health Organization (2018b) National health account: Nigeria. World Health Organization, Geneva. Accessed 5 February 2019

  61. Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJL (2003) Household catastrophic health expenditure: a multicountry analysis. Lancet 362:111–117

    Article  Google Scholar 

  62. Yates R (2009) Universal health care and the removal of user fees. Lancet 373(9680):2078–2081

    Article  Google Scholar 

  63. You X, Kobayashi Y (2011) Determinants of out-of-pocket health expenditure in China: analysis using China Health & Nutrition Survey data. Appl Health Econ Health Policy 9(1):39–49.

    Article  PubMed  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Bolaji Samson Aregbeshola.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

Secondary data were used for this study. In obtaining the micro data, a request was made on the National Bureau of Statistics website and approval was granted to download the data; hence, there were no ethical issues of concern. These data are public and freely available to anyone from National Bureau of Statistics on request. The website for NBS is

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material


(DTA 52027 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Aregbeshola, B.S., Khan, S.M. Out-of-pocket health-care spending and its determinants among households in Nigeria: a national study. J Public Health (Berl.) 29, 931–942 (2021).

Download citation


  • Out-of-pocket expenditures
  • Health policy
  • Heckman selection model
  • Households
  • Nigeria