Beyond access: The role of out-of-pocket costs in shaping healthcare choices for children under five in Uganda

<title>Abstract</title> <p> <bold>Background:</bold> This study examines how out-of-pocket health expenditure influences care-seeking and provider choice for recent illness among children under five in Uganda. <bold>Methods:</bold> We analysed data from 3,615 children under five years of age using the Uganda National Household Survey (UNHS - 2023/24). Expected out-of-pocket expenditure (OOPE) was estimated using local median healthcare costs. We modelled healthcare seeking using survey-weighted probit regression and provider choice (public, private, pharmacy/self-care) using multinomial logit models. Analyses accounted for potential endogeneity and were stratified by rural–urban residence and socioeconomic status <bold>Results:</bold> Among children with recent illness, 84.6% sought care. Most OOPE occurred in private facilities (69%), followed by public facilities (20.7%) and pharmacy/self-care (10.3%). Higher expected OOPE reduced the probability of seeking care by 2 to 4 percentage points, with stronger effects among poorer and rural households. Among those seeking care, higher expected OOPE was associated with increased use of private providers and reduced use of public and informal care. These effects remained robust after adjustment for endogeneity. <bold>Conclusions:</bold> Anticipated healthcare costs influence both whether care is sought and which provider is chosen. Higher expected costs discourage care-seeking among disadvantaged households and shift provider choice toward private facilities. Policies to improve child health must address both financial barriers and the accessibility and quality of public healthcare services. </p>