The fragile health system in Sierra Leone undermines healthcare, leading to substantial patient costs. We aimed to estimate the economic burden and inequalities in healthcare in urban informal settlements in Freetown, Sierra Leone. A cross-sectional survey was conducted in three informal settlements in Freetown in April and May 2023 to collect data on healthcare usage within and outside the boundaries of the informal settlements. Catastrophic expenditures were estimated using the payer's household budget. Logistic regression explored socioeconomic characteristics associated with catastrophic expenditures. Inequalities in healthcare expenditures were assessed through concentration curves and indices. A total of 2575 participants reported healthcare utilization. Dwarzark (US$6.9) and Moyiba (US$7.1) had higher costs than Cockle Bay (US$5.5) when utilizing healthcare within the communities. Households incurred higher costs when seeking healthcare outside their informal settlements than within (US$14 vs US$ 7). Over half of the households across the settlements incurred catastrophic expenditures when seeking care outside the communities (57%), with the poorest wealth quintile (poorest, 89%; wealthier, 12%) incurring in higher incidence. Attending informal healthcare had a protective effect against catastrophic expenditure for healthcare within the communities. Age + 35, residence in Dwarzark and Moyiba, and length of residence + 4 years were associated with catastrophic expenditures. Healthcare expenditure was progressive in Dwarzark and equally distributed across wealth quintiles in the other communities. Our findings indicate the need to provide accessible, affordable, and good-quality healthcare within communities to alleviate the catastrophic costs of healthcare utilization. The regulation of informal health providers and their integration into the formal health system should be considered.
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