Healthcare Utilization in the Context of the Implementation of Universal Health Coverage and COVID 19: Evidence from the Household Living Standards Survey, Côte d’Ivoire

Attia-Konan Akissi Regine; Koffi Kouame; Kouame Jerome; Sangare Abou Dramane; Tiade Marie-Laure; Oga Agbaya Serge Stephane; Kouadio Luc

doi:doi:10.11648/j.hep.20261103.12

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Healthcare Utilization in the Context of the Implementation of Universal Health Coverage and COVID 19: Evidence from the Household Living Standards Survey, Côte d’Ivoire

Attia-Konan Akissi Regine^*

, Koffi Kouame

, Kouame Jerome

, Sangare Abou Dramane

, Tiade Marie-Laure, Oga Agbaya Serge Stephane

, Kouadio Luc

Published in International Journal of Health Economics and Policy (Volume 11, Issue 3)

Received: 18 August 2026 Accepted: 2 September 2026 Published: 24 September 2026

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Abstract

Universal Health Coverage was established to reduce financial barriers to healthcare. Nevertheless, inequalities in access—including cases of forgoing care—persist. This study analyzes the determinants of healthcare utilization in Côte d'Ivoire using data from the 2021 Harmonized Survey on Household Living Conditions. This study aims to analyse healthcare utilization in Côte d'Ivoire in the dual context of Universal health coverage scheme (CMU in Côte d’Ivoire) and the COVID-19 pandemic. The individual was taken as the unit of analysis. The analytical sample comprised 64,491 individuals drawn from 12,965 households. Analyses of healthcare utilization were restricted to the 17,220 individuals who reported a health problem in the preceding 30 days. Both the type of care sought and instances of forgone care were recorded. Logistic regression was used to assess associations between sociodemographic, socioeconomic and health-related characteristics and healthcare utilization. Among respondents, 11,017 (64.0%) had sought medical care, whereas 6,203 (36.0%) had renounced despite reporting a health problem. Self-medication was the principal reason for forgoing care. Healthcare utilization was positively associated with younger age (AOR = 2.50; 95% CI [2.03-3.08]), the presence of a chronic condition (AOR = 2.14; 95% CI [1.88-2.45]) and health insurance enrolment, particularly under the UHC scheme (AOR = 2.93; 95% CI [1.86-4.61]). Conversely, primary school education (AOR = 0.83; 95% CI [0.76-0.90]) and living in a household size with one person (AOR = 0.78; 95% CI [0.63-0.96]) were associated with lower odds of seeking care. Neither self-reported COVID-19 infection nor area of residence (rural versus urban) was significantly associated with healthcare utilization. Inequalities in access to care persist despite the introduction of CMU. Strengthening universal access will require both a broader benefit package for people living with chronic conditions and sustained action on health literacy.

Published in	International Journal of Health Economics and Policy (Volume 11, Issue 3)
DOI	10.11648/j.hep.20261103.12
Page(s)	148-158
Creative Commons	This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.
Copyright	Copyright © The Author(s), 2026. Published by Science Publishing Group

Keywords

Access to Healthcare, Healthcare Utilization, Universal Health Coverage, COVID-19 Self Reported Infection, Ivory Coast

1. Introduction

Access to healthcare remains a central policy objective for governments across the globe, as it is recognized as a fundamental right

[1]

. Nonetheless, it constitutes a complex and multidimensional construct, governed by a variety of determinants that jointly shape both patterns of health service utilization and the degree of satisfaction expressed by users

[2]

. According to Aday and Andersen’s conceptual model, access to healthcare depends not only on health needs but also on predisposing factors (sex, age, marital status), enabling factors (income, insurance, location), and contextual factors (organization of services)

[3]

. In this search of care, as with other goods, consumer are led to weigh trade-offs between several alternatives in terms of healthcare services or categories of practitioners

[4]

. Under budget constraints, individuals then opt for informal sources or forgo care altogether

[5-7]

In sub-Saharan Africa, inequalities in healthcare utilization remain particularly pronounced and are exacerbated by socioeconomic, demographic, and geographic factor

[8]

. When using health services, populations may face catastrophic health expenditures or forgo care

[9-11]

. Such care-seeking renunciation is frequent in countries where out-of-pocket payments represent a substantial share of health financing

[5-7, 12]

. However, such forgone care can contribute to increased mortality and morbidity rates. To address these challenges, WHO recommends that countries implement financial risk protection system related to health services utilization

[1]

In 2014, Côte d'Ivoire established Universal Health Coverage (CMU in Côte d’Ivoire) to improve financial accessibility and reduce household vulnerability to health expenditures

[13]

. Its rollout was gradual, starting with a student-focused pilot, before expanding to the general population in 2019, with collection of contribution on July 1, 2019, followed by full access to healthcare services on October 1, 2019. Despite this reform, challenges persist, most notably a low insurance coverage rate, estimated at 3.5% in 2021

[14]

This is the observation made in most health systems across West Africa - a situation aggravated by poverty, disparities in healthcare infrastructure, and high level of out-of-pocket payments

[8, 15]

. Furthermore, the COVID-19 pandemic exacerbated these disparities by disrupting healthcare delivery, deepening economic insecurity, and limiting access to essential services

[5, 16, 17]

. It thus highlighted the fragility of health systems and the need to rethink resilience and equity strategies

[18]

. Understanding care-seeking behaviors is essential for reformulating health policies and strategies. Within the dual context of Universal Health Coverage and the COVID-19 pandemic, this study aims to analyze the care-seeking behaviors of the population living in Côte d'Ivoire.

2. Materials and Methods

2.1. Data Source and Sampling

This study is a secondary data analysis of the Harmonized Survey on Household Living Conditions (EHCVM), conducted in Côte d'Ivoire in 2021 by the National Statistic Agency (ANStat). Carried out according to a standardized protocol across the West African Economic and Monetary Union (WAEMU), this survey provides a consolidated analytical dataset derived from individual and health data from the 2021 EHCVM. It includes sociodemographic variables, self-reported health information, variables related to health insurance and healthcare utilization, as well as complementary contextual variables regarding the area of residence.

The dataset comprises 12,965 households and 64,491 individuals sampled nationwide using a two-stage stratified random sampling method across 33 existing regions. Further details of the sampling procedure and participants’ information are available elsewhere

[19]

. A total of 17,220 individuals who reported a health issue in the four weeks prior to the survey were included in the analysis.

2.2. Study Variables

2.2.1. Dependent Variable

The dependent variable is healthcare utilization, coded into two categories: care-seeking (consultation at a health facility, pharmacy, or traditional healer within the previous 30 days) and forgone care (no consultation despite a reported health problem).

2.2.2. Independent Variables

The explanatory variables include:

Sociodemographic characteristics: age, sex, marital status, educational attainment;

Socioeconomic characteristics: consumption expenditure quintiles (used as a proxy for living standards), health insurance status (CMU, other insurance, no insurance), area of residence (urban, rural), household size;

Health-related characteristics: type of self-reported morbidity, presence of a chronic illness, exposure to a COVID-19-related shock, exemption from care costs for specific population groups (special state-funded coverage).

2.3. Analytical Methods

Statistical analyses were performed using Stata software, version 17. Descriptive analysis was conducted to calculate frequencies and proportions in order to describe the population characteristics and healthcare utilization patterns.

Associations between healthcare utilization and individual characteristics were examined using Pearson's Chi-square test when the conditions of their application were satisfied. Binary logistic regression was then performed to identify the factors associated with healthcare utilization, while simultaneously accounting for all variables included in the model. The threshold for statistical significance was set at 5%.

2.4. Ethical Considerations

The study was carried out using anonymized secondary data which guarantees the confidentiality and anonymity of the individuals surveyed. The use of Household Survey data was conducted within a formal legal framework, following a letter addressed to the National Institute of Statistics, which granted its authorization.

3. Results

3.1. Sociodemographic Characteristics of the Sample

The sociodemographic characteristics of the individuals are summarized in Table 1. The sample was slightly dominated by women (50.9%), with a sex ratio of 0.96. The population was young: 43.7% of individuals were under 15 years of age, and the mean age was 23.86 years (±19.28). The median age was 18 years, with a range from 0 to 122 years. The distribution by age group (8 categories) showed a predominance of the 5-14 year age group (31.0%), followed by the 15-24 year group (16.1%) and the 0-4 year group (12.8%). Individuals aged 65 years and older accounted for only 3.8% of the sample.

Regarding marital status (n=45,567 eligible individuals), 80.5% were single, 17.0% were married or in a consensual union, and 2.5% were divorced or widowed.

With respect to educational attainment among individuals over 3 years of age (n=43,936), nearly half (48.1%) had no formal schooling, 32.8% had reached primary level, 14.5% secondary level, and 4.6% tertiary level. Among those with no formal schooling, literacy data were available for only 373 of 21,146 individuals (98.2% missing data).

This population was predominantly rural (61%).

The mean household size was 4.97 (±2.83), with a median of 5 persons. The most frequent category was >7 persons (32.2%), followed by 4-5 persons (28.4%) and 6-7 persons (25.9%).

Table 1. Sociodemographic and economic characteristics of individuals in the EHCVM (n=64,491).

Variables	Category	Number	Percentage (%)
Sex	Male	31,661	49.1
	Female	32,830	50.9
	Sex ratio (M/F)	1.0
Age (year)	0 - 4	8241	12.8
	5 - 14	19,968	31.0
	15 - 24	10,385	16.1
	25 - 34	7774	12.1
	35 - 44	7503	11.6
	45 - 54	4985	7.7
	55 - 64	3168	4.9
	65 and over	2467	3.8
	Average age (standard deviation)	23.86 (±19.28)
	Median (Min - Max)	18 (0 - 122)
Marital status (n=45 567)	Married/ Consensual union	7758	17.0
	Widowed/ Divorced	1140	2.5
	Single	36,669	80.5
Schooling level (n=43 936)	None	21,146	48.1
	Primary	14,408	32.8
	Secondary	6376	14.5
	Superior level	2006	4.6
No formal schooling (n=373)	Yes	1	0.3
No formal schooling (n=373)	No	372	99.7
Spending quintile	Q1	12,902	20
	Q2	12,905	20
	Q3	12,893	20
	Q4	12,897	20
	Q5	12,894	20
Aera of residence	Rural	39,318	61.0
Aera of residence	Urban	25,173	39.0
Household size	1	1294	2.0
	2 - 3	7416	11.5
	4 - 5	18,311	28.4
	6 - 7	16,728	25.9
	7 and over	20,742	32.2
	Average (standard deviation)	4.97 (±2.83)
	Median (Min - Max)	5 (1 - 28)

3.2. Health-related Characteristics

Morbidity reported over the past 30 days concerned 17,220 individuals, representing 26.7% of the sample. Among these, 10.9% (n=1,875) had a chronic illness (Table 2).

Distance to the primary healthcare facility (PHCF) was measured only among those who sought consultation (n=11,017). Among them, 76.8% resided less than 5 km away, 11.3% between 5 and 10 km, and 11.9% more than 10 km away.

Health insurance affiliation remained very low: 96.5% of the population had no coverage. The Universal Health Coverage scheme (CMU) covered 1.1%, the “Mutuelle Generale des Fonctionnaires de Cote d'Ivoire (MUGEFCI)” 1.2%, and private insurance 1.2% of the population. Only 1.5% of individuals benefited from special assistance (state support).

Table 2. Health-related characteristics of the EHCVM 2021 sample (n=64,491).

Variables	Category	Number	Percentage (%)
Morbidity reported	Yes	17,220	26.7
Morbidity reported	No	47,271	73.3
Chronic disease (n=17,220)	Yes	1875	10.9
Chronic disease (n=17,220)	No	15,345	89.1
Distance to the primary healthcare facility (km) (n=11,017)	Less than 5	8462	76.8
	[5 - 10]	1247	11.3
	10 and over	1308	11.9
Health insurance affiliation	CMU	687	1.1
	MUGEFCI	797	1.2
	Private insurance	764	1.2
	None	62,243	96.5
Individuals benefited from special assistance	Yes	993	1.5
Individuals benefited from special assistance	No	63,498	98.5
COVID-19 self-reported	Only COVID-19	2412	3.7
	COVID and other illness	644	1.0
	Other illness	687	1.1
	No	60,748	94.2

3.3. Frequency of Healthcare Utilization

Among the 17,220 individuals who reported a health problem, 64.0% (n=11,017) had sought healthcare, while 36.0% (n=6,203) had forgone care. (Table 3).

Among those who consulted, the vast majority (97.3%) had opted for formal health care, compared with 2.7% for traditional medicine (healers/traditional practitioners).

Healthcare utilization was predominantly within the public sector (74%), with rural health centers/dispensaries as the most frequent first point of consultation (34.1%), followed by general hospitals (20.0%) and urban health centers (16.0%). Private hospitals/clinics ranked fourth (12.5%). Pharmacies accounted for 6.3% of first consultations. Secondary- and tertiary-level facilities ranked lowest; university teaching hospitals (CHU in french) and regional hospitals (CHR in french) accounted for only 0.9% and 2.2%, respectively.

Regarding hospitalization over the past 12 months, only 3.9% (n=663) of individuals had been hospitalized.

Table 3. Types of healthcare utilization among individuals with reported morbidity (n=17,220).

Types of healthcare utilization	Number	Percentage (%)
Renouncement to care	6203	36.0
Healthcare utilization	11,017	64.0
Type of health care
Formal health care	10,723	97.3
Traditional medicine	294	2.7
Place of first consultation
University teaching hospital	94	0.9
Regional hospital	243	2.2
General hospital	2199	20.0
Urban health center	1761	16.0
Rural health center/ dispensary	3762	34.1
Other center	92	0.8
Private hospitals/clinics	1381	12.5
Medical/dental practice	21	0.2
Nursing/care practice	76	0.7
Pharmacy	692	6.3
Company clinic / NGO	271	2.5
Traditional medicine	294	2.7
Home visit	131	1.2
Hospitalization (12 last month)
Yes	663	3.9
No	16,557	96.1

3.4. Reasons for Non-utilization of Care

Self-medication was the main reason for forgoing care, reported by 55.63% of individuals, followed by lack of money (24.39%) and the perception that consultation was "not necessary" (13.77%).

Download: Download full-size image

Figure 1. Reasons for non-utilization of care in cases of self-reported morbidity.

3.5. Determinants of Health Care Utilization

Bivariate analysis identified several factors significantly associated with health care utilization (Table 4). The associated sociodemographic and economic characteristics were age, marital status, educational attainment, expenditure quintiles, and household size. The presence of financial risk protection mechanisms against illness (health insurance and state assistance) was significantly associated with health care utilization, as was the presence of a chronic disease.

In contrast, sex, place of residence, and COVID-19 self-reported were not significantly associated with health care utilization. Regardless of distance to a primary health care facility, no forgone care was observed.

Table 4. Bivariate analysis of the factors associated with health care utilization (n=17,220).

Variables	Category	Number	Utilization (%)	Renouncement (%)	p
Sexe	Male	8184	63.8	36.2	0.618
Sexe	Female	9036	64.2	35.8	0.618
Age (year)	0-4	2955	77.0	23.0	<0.001
	5-14	4070	62.0	38.0
	15-24	1833	54.8	45.2
	25-34	1968	61.4	38.6
	35-44	2237	63.0	37.0
	45-54	1696	61.6	38.4
	55-64	1266	64.1	35.9
	65 and over	1195	61.7	38.3
Marital status	Single	14,711	63.4	36.6	<0.001
	Married or Consensual union	2165	66.9	33.1
	Widowed/ Divorced	344	68.3	31.7
Schooling level (n=11 996)	None	7280	65.2	34.8	<0.001
	Primary	3480	58.2	41.8
	Secondary	800	63.6	36.4
	Superior level	436	62.4	37.6
Spending quintile	Q1	2514	51.3	48.7	<0.001
	Q2	3272	59.1	40.9
	Q3	3272	61.1	38.9
	Q4	3961	64.1	35.9
	Q5	4201	66.5	33.5
Household size	1	524	55.2	44.8	<0.001
	2-3	2545	62.6	37.4
	4-5	5340	64.8	35.2
	6-7	4231	66.1	33.9
	7 and over	4580	62.9	37.1
Chronic disease	Yes	1875	76.7	23.3	<0.001
Chronic disease	No	15,345	62.4	37.6	<0.001
Distance ESPC* (n=11 017)	Less than 5	8462	100	0.0	NA
	[5 - 10]	1247	100	0.0
	10 and over	1308	100	0.0
Health insurance affiliation	CMU	268	72,8	27,2	<0.001
	MUGEFCI	237	82,3	17,7
	Private insurance	256	80,5	19,5
	None	16 459	63,3	36,7
Individuals benefited from special assistance	Yes	354	81,9	18,1	<0.001
Individuals benefited from special assistance	No	16 866	63,6	36,4	<0.001
Area of residence	Rural	10 532	63,9	36,1	0.692
Area of residence	Urban	6 688	64.2	35.8	0.692
COVID 19 self reported	Only COVID-19	2412	63.2	36.8	0.301
	COVID and other illness	644	62.6	37.4
	Other illness	687	49.3	50.7
	No	13,183	63.4	36.6

Factors significantly associated with increased health care utilization were:

Age 0-4 years (AOR=2.50; 95% CI [2.03-3.08]; p<0.001): children under 5 years old were 2.5 times more likely to seek care than those over 65, reflecting the priority given to child health.

Chronic disease (AOR=2.14; 95% CI [1.88-2.45]; p<0.001): individuals with a chronic disease were 2.1 times more likely to consult, reflecting a need for regular care.

CMU health insurance (OR=2.93; 95% CI [1.86-4.61]; p<0.001): affiliation with CMU increased the odds of utilization 2.9-fold.

Private insurance (OR=1.92; 95% CI [1.43-2.58]; p<0.001) and MUGEFCI (OR=1.56; 95% CI [1.16-2.08]; p=0.003): all forms of insurance favored utilization.

Special assistance/subsidized coverage (OR=1.82; 95% CI [1.34-2.49]; p<0.001): receiving a subsidy increased the odds of utilization by 82%.

Being married (OR=1.23; 95% CI [1.08-1.39]; p=0.001): spousal support favored health care utilization.

The factors significantly associated with reduced of utilization were:

Primary education level (OR=0.83; 95% CI [0.76-0.90]; p<0.001): individuals with primary education had 17% lower odds of utilization than those with no schooling.

Household size = 1 (OR=0.78; 95% CI [0.63-0.96]; p=0.016): individuals living alone had 22% lower odds of health care utilization.

Age groups 5-64 years, divorced/widowed status, secondary and higher education levels, and household sizes 2-7 were not significant in multivariate analysis.

Table 5. Multivariate analysis of the factors associated with utilization of healthcare (n=11,996).

Variables	Category	Adjusted OR	95% CI	p
Age (Ref: 65 and over)	0-4	2.497	[2.027 - 3.076]	<0.001
	5-14	1.088	[0.919 - 1.287]	0.328
	15-24	0.892	[0.749 - 1.062]	0.199
	25-34	1.155	[0.973 - 1.370]	0.099
	35-44	1.141	[0.967 - 1.346]	0.118
	45-54	1.100	[0.927 - 1.305]	0.275
	55-64	1.144	[0.956 - 1.369]	0.141
Marital status (Ref: Single)	Married or Consensual union	1.227	[1.084 - 1.387]	0.001
Marital status (Ref: Single)	Widowed/ Divorced	1.120	[0.849 - 1.477]	0.422
Schooling level (Ref: none)	Primary	0.826	[0.757 - 0.902]	<0.001
	Secondary	0.991	[0.846 - 1.161]	0.910
	Superior level	0.953	[0.766 - 1.187]	0.670
Household size (Ref: 7 and over)	1	0.777	[0.632 - 0.955]	0.016
	2-3	1.040	[0.921 - 1.174]	0.529
	4-5	1.016	[0.917 - 1.125]	0.760
	6-7	1.043	[0.936 - 1.162]	0.446
Chronic disease (Ref: No)	Yes	2.142	[1.876 - 2.445]	<0.001
Health insurance affiliation (Ref: none)	CMU	2.926	[1.858 - 4.609]	<0.001
	MUGEFCI	1.557	[1.164 - 2.082]	0.003
	Private insurance	1.923	[1.431 - 2.583]	<0.001
Individuals benefited from special assistance (Ref: No)	Yes	1.824	[1.338 - 2.486]	<0.001

4. Discussion

4.1. Health Care Utilization and Forgone Care

Utilization of public facilities remains dominant, in contrast to Audibert's study in Senegal, which recorded a rate of 58.44%

[20]

. This could reflect better accessibility in the public sector. Indeed, in the context of the CMU rollout, health coverage has improved, with the number of ESPCs (primary health care facilities) increasing by nearly 30% between 2018 and 2020

[21, 22]

, and our study showed that nearly two people in ten lived within 5 km of an ESPC. However, although the use of modern health care predominates, the high rate of forgone care (36%) raises questions about the real effectiveness of the CMU and its uptake by the population. Furthermore, the low level of education among the population constitutes a barrier to health care utilization. Indeed, educational attainment is a determinant of individuals' health care-seeking behavior

[20]

. The main reasons for non-utilization were self-medication (55.6%), lack of financial means (24.4%), and the perception that care was not necessary (13.8%). This finding is a reminder that universal coverage cannot be limited to formal enrollment but must guarantee care that is effectively provided and perceived as useful by the population

[23]

The prominence of self-medication suggests distrust of, or a perceived mismatch with, the formal health care supply. In sub-Saharan Africa, the pursuit of alternative, less costly, and more accessible solutions is common in the face of financial and organizational barriers

[8, 15]

Individuals with a chronic disease made greater use of health care, although instances of forgone care were nonetheless recorded. This suggests a need to extend CMU coverage for the relevant care services. Indeed, a study in Côte d'Ivoire showed that, in the absence of protection mechanisms, forgone care among diabetic patients was often substantial

[24]

4.2. Role of the CMU and Insurance Coverage

The results confirm the protective role of health insurance: insured individuals, particularly those covered by the CMU, make greater use of modern health care and forgo care less often than the uninsured. Nevertheless, the low effective coverage rate of the CMU limits its impact. In 2021, less than 10% of the Ivorian population was effectively covered

[25]

, which 11ance of care continues to be significant. The high reliance on self-medication reflects both financial constraints and a perceived inadequacy of the formal healthcare supply. These findings advocate scaling up the implementation of Universal Health Coverage (CMU) while addressing public perceptions of care to enhance health literacy and trust in the health system. Ultimately, an inclusive and sustainable strategy is essential to driving progress toward equity and universal health coverage. The development of equitable health policy requires a better understanding of healthcare-seeking behaviors and of the influence of health system reforms on the effective utilization of services for better suited to the realities of population.

Abbreviations

AOR	Adjusted Odd Ratio
CMU	Couverture Maladie Universelle

Acknowledgments

The authors thank the National Statistics Agency (ANStat) for allowing the release of data from the Harmonised Survey on Household Living Conditions Survey 2021.

Author Contributions

Attia-Konan Akissi Regine: Conceptualization, Data curation, Formal Analysis, Methodology, Software, Writing – original draft

Koffi Kouame: Conceptualization, Data curation, Formal Analysis, Investigation, Methodology, Writing – review & editing

Kouame Jerome: Formal Analysis, Methodology, Writing – review & editing

Sangare Abou Dramane: Investigation, Supervision, Validation, Visualization

Tiade Marie-Laure: Software, Supervision, Validation, Visualization

Oga Agbaya Serge Stephane: Software, Supervision, Validation, Visualization

Kouadio Luc: Supervision, Validation, Visualization

Data Availability Statement

The data supporting the results of this study are available from the corresponding author upon reasonable request.

Conflicts of Interest

The authors declare no conflicts of interest.

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Regine, A. A., Kouame, K., Jerome, K., Dramane, S. A., Marie-Laure, T., et al. (2026). Healthcare Utilization in the Context of the Implementation of Universal Health Coverage and COVID 19: Evidence from the Household Living Standards Survey, Côte d’Ivoire. International Journal of Health Economics and Policy, 11(3), 148-158. https://doi.org/10.11648/j.hep.20261103.12

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Regine, A. A.; Kouame, K.; Jerome, K.; Dramane, S. A.; Marie-Laure, T., et al. Healthcare Utilization in the Context of the Implementation of Universal Health Coverage and COVID 19: Evidence from the Household Living Standards Survey, Côte d’Ivoire. Int. J. Health Econ. Policy 2026, 11(3), 148-158. doi: 10.11648/j.hep.20261103.12

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AMA Style

Regine AA, Kouame K, Jerome K, Dramane SA, Marie-Laure T, et al. Healthcare Utilization in the Context of the Implementation of Universal Health Coverage and COVID 19: Evidence from the Household Living Standards Survey, Côte d’Ivoire. Int J Health Econ Policy. 2026;11(3):148-158. doi: 10.11648/j.hep.20261103.12

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@article{10.11648/j.hep.20261103.12,
  author = {Attia-Konan Akissi Regine and Koffi Kouame and Kouame Jerome and Sangare Abou Dramane and Tiade Marie-Laure and Oga Agbaya Serge Stephane and Kouadio Luc},
  title = {Healthcare Utilization in the Context of the Implementation of Universal Health Coverage and COVID 19: Evidence from the Household Living Standards Survey, Côte d’Ivoire},
  journal = {International Journal of Health Economics and Policy},
  volume = {11},
  number = {3},
  pages = {148-158},
  doi = {10.11648/j.hep.20261103.12},
  url = {https://doi.org/10.11648/j.hep.20261103.12},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.hep.20261103.12},
  abstract = {Universal Health Coverage was established to reduce financial barriers to healthcare. Nevertheless, inequalities in access—including cases of forgoing care—persist. This study analyzes the determinants of healthcare utilization in Côte d'Ivoire using data from the 2021 Harmonized Survey on Household Living Conditions. This study aims to analyse healthcare utilization in Côte d'Ivoire in the dual context of Universal health coverage scheme (CMU in Côte d’Ivoire) and the COVID-19 pandemic. The individual was taken as the unit of analysis. The analytical sample comprised 64,491 individuals drawn from 12,965 households. Analyses of healthcare utilization were restricted to the 17,220 individuals who reported a health problem in the preceding 30 days. Both the type of care sought and instances of forgone care were recorded. Logistic regression was used to assess associations between sociodemographic, socioeconomic and health-related characteristics and healthcare utilization. Among respondents, 11,017 (64.0%) had sought medical care, whereas 6,203 (36.0%) had renounced despite reporting a health problem. Self-medication was the principal reason for forgoing care. Healthcare utilization was positively associated with younger age (AOR = 2.50; 95% CI [2.03-3.08]), the presence of a chronic condition (AOR = 2.14; 95% CI [1.88-2.45]) and health insurance enrolment, particularly under the UHC scheme (AOR = 2.93; 95% CI [1.86-4.61]). Conversely, primary school education (AOR = 0.83; 95% CI [0.76-0.90]) and living in a household size with one person (AOR = 0.78; 95% CI [0.63-0.96]) were associated with lower odds of seeking care. Neither self-reported COVID-19 infection nor area of residence (rural versus urban) was significantly associated with healthcare utilization. Inequalities in access to care persist despite the introduction of CMU. Strengthening universal access will require both a broader benefit package for people living with chronic conditions and sustained action on health literacy.},
 year = {2026}
}

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TY - JOUR
T1 - Healthcare Utilization in the Context of the Implementation of Universal Health Coverage and COVID 19: Evidence from the Household Living Standards Survey, Côte d’Ivoire
AU - Attia-Konan Akissi Regine
AU - Koffi Kouame
AU - Kouame Jerome
AU - Sangare Abou Dramane
AU - Tiade Marie-Laure
AU - Oga Agbaya Serge Stephane
AU - Kouadio Luc
Y1 - 2026/09/24
PY - 2026
N1 - https://doi.org/10.11648/j.hep.20261103.12
DO - 10.11648/j.hep.20261103.12
T2 - International Journal of Health Economics and Policy
JF - International Journal of Health Economics and Policy
JO - International Journal of Health Economics and Policy
SP - 148
EP - 158
PB - Science Publishing Group
SN - 2578-9309
UR - https://doi.org/10.11648/j.hep.20261103.12
AB - Universal Health Coverage was established to reduce financial barriers to healthcare. Nevertheless, inequalities in access—including cases of forgoing care—persist. This study analyzes the determinants of healthcare utilization in Côte d'Ivoire using data from the 2021 Harmonized Survey on Household Living Conditions. This study aims to analyse healthcare utilization in Côte d'Ivoire in the dual context of Universal health coverage scheme (CMU in Côte d’Ivoire) and the COVID-19 pandemic. The individual was taken as the unit of analysis. The analytical sample comprised 64,491 individuals drawn from 12,965 households. Analyses of healthcare utilization were restricted to the 17,220 individuals who reported a health problem in the preceding 30 days. Both the type of care sought and instances of forgone care were recorded. Logistic regression was used to assess associations between sociodemographic, socioeconomic and health-related characteristics and healthcare utilization. Among respondents, 11,017 (64.0%) had sought medical care, whereas 6,203 (36.0%) had renounced despite reporting a health problem. Self-medication was the principal reason for forgoing care. Healthcare utilization was positively associated with younger age (AOR = 2.50; 95% CI [2.03-3.08]), the presence of a chronic condition (AOR = 2.14; 95% CI [1.88-2.45]) and health insurance enrolment, particularly under the UHC scheme (AOR = 2.93; 95% CI [1.86-4.61]). Conversely, primary school education (AOR = 0.83; 95% CI [0.76-0.90]) and living in a household size with one person (AOR = 0.78; 95% CI [0.63-0.96]) were associated with lower odds of seeking care. Neither self-reported COVID-19 infection nor area of residence (rural versus urban) was significantly associated with healthcare utilization. Inequalities in access to care persist despite the introduction of CMU. Strengthening universal access will require both a broader benefit package for people living with chronic conditions and sustained action on health literacy.
VL - 11
IS - 3
ER -

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Author Information

Attia-Konan Akissi Regine

Department of Analytical Sciences and Public Health, University of Felix Houphouet Boigny, Abidjan, Cote d’Ivoire;Research and Study Center on Population and Health Systems, National Institute of Public Health, Abidjan, Cote d’Ivoire

Contact Email

http://orcid.org/0000-0003-1790-2767
Koffi Kouame

Department of Analytical Sciences and Public Health, University of Felix Houphouet Boigny, Abidjan, Cote d’Ivoire

http://orcid.org/0000-0003-2805-3051
Kouame Jerome

Department of Analytical Sciences and Public Health, University of Felix Houphouet Boigny, Abidjan, Cote d’Ivoire;Research and Study Center on Population and Health Systems, National Institute of Public Health, Abidjan, Cote d’Ivoire

http://orcid.org/0000-0002-2146-9110
Sangare Abou Dramane

Department of Public Health, University of Felix Houphouet Boigny, Abidjan, Cote d’Ivoire

http://orcid.org/0000-0001-7210-8086
Tiade Marie-Laure

Department of Analytical Sciences and Public Health, University of Felix Houphouet Boigny, Abidjan, Cote d’Ivoire;Research and Study Center on Population and Health Systems, National Institute of Public Health, Abidjan, Cote d’Ivoire
Oga Agbaya Serge Stephane

Department of Analytical Sciences and Public Health, University of Felix Houphouet Boigny, Abidjan, Cote d’Ivoire

http://orcid.org/0000-0003-4956-474X
Kouadio Luc

Department of Analytical Sciences and Public Health, University of Felix Houphouet Boigny, Abidjan, Cote d’Ivoire

http://orcid.org/0000-0002-2489-3494

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Figure 1

Figure 1. Reasons for non-utilization of care in cases of self-reported morbidity.

Plain Text BibTeX RIS

APA Style

Regine, A. A., Kouame, K., Jerome, K., Dramane, S. A., Marie-Laure, T., et al. (2026). Healthcare Utilization in the Context of the Implementation of Universal Health Coverage and COVID 19: Evidence from the Household Living Standards Survey, Côte d’Ivoire. International Journal of Health Economics and Policy, 11(3), 148-158. https://doi.org/10.11648/j.hep.20261103.12

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ACS Style

Regine, A. A.; Kouame, K.; Jerome, K.; Dramane, S. A.; Marie-Laure, T., et al. Healthcare Utilization in the Context of the Implementation of Universal Health Coverage and COVID 19: Evidence from the Household Living Standards Survey, Côte d’Ivoire. Int. J. Health Econ. Policy 2026, 11(3), 148-158. doi: 10.11648/j.hep.20261103.12

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AMA Style

Regine AA, Kouame K, Jerome K, Dramane SA, Marie-Laure T, et al. Healthcare Utilization in the Context of the Implementation of Universal Health Coverage and COVID 19: Evidence from the Household Living Standards Survey, Côte d’Ivoire. Int J Health Econ Policy. 2026;11(3):148-158. doi: 10.11648/j.hep.20261103.12

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@article{10.11648/j.hep.20261103.12,
  author = {Attia-Konan Akissi Regine and Koffi Kouame and Kouame Jerome and Sangare Abou Dramane and Tiade Marie-Laure and Oga Agbaya Serge Stephane and Kouadio Luc},
  title = {Healthcare Utilization in the Context of the Implementation of Universal Health Coverage and COVID 19: Evidence from the Household Living Standards Survey, Côte d’Ivoire},
  journal = {International Journal of Health Economics and Policy},
  volume = {11},
  number = {3},
  pages = {148-158},
  doi = {10.11648/j.hep.20261103.12},
  url = {https://doi.org/10.11648/j.hep.20261103.12},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.hep.20261103.12},
  abstract = {Universal Health Coverage was established to reduce financial barriers to healthcare. Nevertheless, inequalities in access—including cases of forgoing care—persist. This study analyzes the determinants of healthcare utilization in Côte d'Ivoire using data from the 2021 Harmonized Survey on Household Living Conditions. This study aims to analyse healthcare utilization in Côte d'Ivoire in the dual context of Universal health coverage scheme (CMU in Côte d’Ivoire) and the COVID-19 pandemic. The individual was taken as the unit of analysis. The analytical sample comprised 64,491 individuals drawn from 12,965 households. Analyses of healthcare utilization were restricted to the 17,220 individuals who reported a health problem in the preceding 30 days. Both the type of care sought and instances of forgone care were recorded. Logistic regression was used to assess associations between sociodemographic, socioeconomic and health-related characteristics and healthcare utilization. Among respondents, 11,017 (64.0%) had sought medical care, whereas 6,203 (36.0%) had renounced despite reporting a health problem. Self-medication was the principal reason for forgoing care. Healthcare utilization was positively associated with younger age (AOR = 2.50; 95% CI [2.03-3.08]), the presence of a chronic condition (AOR = 2.14; 95% CI [1.88-2.45]) and health insurance enrolment, particularly under the UHC scheme (AOR = 2.93; 95% CI [1.86-4.61]). Conversely, primary school education (AOR = 0.83; 95% CI [0.76-0.90]) and living in a household size with one person (AOR = 0.78; 95% CI [0.63-0.96]) were associated with lower odds of seeking care. Neither self-reported COVID-19 infection nor area of residence (rural versus urban) was significantly associated with healthcare utilization. Inequalities in access to care persist despite the introduction of CMU. Strengthening universal access will require both a broader benefit package for people living with chronic conditions and sustained action on health literacy.},
 year = {2026}
}

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