Out-of-pocket health expenditure (OOPHE) is defined as household spending incurred when using a service to obtain any type of health care (Promotive, preventive, curative, rehabilitative, palliative, or long-term).

Out-of-pocket health expenditures include payment of cash or goods for direct health care services, such as medicines, consultation fees, and laboratory diagnostic tests. Out-of-pocket spending on health care can constitute a substantial portion of household expenditure.

According to the World Health Organization, catastrophic out-of-pocket health expenditure occurs when direct OOP payments exceed 40% of household income minus subsistence needs or OOP payments exceed 10% of total household income.

According to a research study conducted in low- and middle-income countries, household health expenditure is estimated to account for 45% of total global health expenditure and 23% of health expenditure in the developing world.

An estimated 1.3 billion people worldwide lack access to effective and affordable health care.

Out-of-pocket payments for health services are related to a number of institutional and provider-level factors, including inefficiencies in the delivery of health care that range from over-prescription of antibiotics and injections, use of expensive medicines in place of cheaper alternatives, medical errors, and incorrect diagnosis or treatment (World Health Organization 2010).

Individual and household characteristics also influence out-of-pocket health expenditure. The most commonly cited covariates include age, gender, education, household socioeconomic status, household location, type of illness or condition and its severity, type of health care provider (public versus private), and health insurance coverage.

Household socioeconomic status is the household characteristic most commonly associated with variation in out-of-pocket health expenditure. However, the relationship between income or household socioeconomic status and out-of-pocket expenditure can be mixed.

Rwanda adopted a community-driven approach to public primary health care, wherein about 40% of facilities, predominantly health centers, are owned by faith-based organizations (FBOs) and non-governmental organizations (NGOs).

These entities, considered part of the public health system, adhere to government standards. Public health spending tripled between 2002 and 2007, with an emphasis on three key financing strategies: community-based insurance, performance-based financing, and fiscal decentralization.

The government-subsidized "Mutuelle de Santé" insurance, initiated in 2004, offers low premiums, including no cost for the poorest 25% of the population, covering a broad range of preventive, curative, and delivery care services.

In 2012, 96% of the population was covered by health insurance, significantly reducing household out-of-pocket health expenditures and signalling a commitment to enhancing the role of private-sector health facilities, particularly in urban areas.

However, a research study observed an increase in out-of-pocket medical expenditures from 24.46% in 2000 to 26% in 2015. Despite the policies that guide financial protection through community-based health insurance schemes (CBHIs) and other insurance providers.

Despite the progress that has been made globally in reducing OOP payments for households, African countries continue to lag behind in achieving effective financing strategies that protect their populations.

This is because the increase in social protection schemes as a means of mitigating the effect of out-of-pocket payments has not been fully grasped.

For example, some health insurance schemes in Africa are mandatory by law however, may operate on a voluntary basis. Purchasing health insurance or remaining a beneficiary is often perceived as risky behaviour due to the nature of insurance itself.

In the event of the non-occurrence of illness or a medical emergency, individuals may view the premiums paid as a loss since they have not directly benefited from the insurance coverage.

Unlike other goods or services, the value of health insurance is realized primarily during times of need, making it a unique and potentially challenging investment for those fortunate enough to remain in good health.

This perception of loss can deter individuals from seeing the long-term financial and health security benefits that health insurance provides, emphasizing the need for effective communication on the broader advantages of maintaining coverage even in times of apparent well-being.

While some African countries may exhibit high levels of health insurance coverage, it remains imperative to consistently minimize and monitor out-of-pocket expenditures within their health systems.

The efficacy of health insurance extends beyond mere coverage statistics; it necessitates a vigilant approach to ensure financial accessibility and equity in healthcare services.

Despite having insurance, excessive out-of-pocket costs can still burden individuals, hindering their access to necessary medical care.

Health systems should adopt proactive monitoring mechanisms to assess and address any surges in out-of-pocket expenses, safeguarding the broader goal of achieving comprehensive and affordable healthcare.