In many low- and middle-income countries, particularly in sub-Saharan Africa, severe acute malnutrition (SAM) is a major public health issue. In the Democratic Republic of Congo (DRC), nearly 2 million children under five are affected by SAM annually [1]-[3]. The Kasai region, particularly affected, has recently experienced armed conflict, mass population migration, and a persistent food crisis [4].

In the Kalonda West health zone, especially in its rural areas, access to medical care remains difficult. Local populations face a health system weakened by a lack of infrastructure, qualified personnel, and essential medicines. This situation is exacerbated by insecurity and insufficient public funding, making healthcare inaccessible to a large portion of the population [5].

Faced with inadequate public assistance and a shortage of nutritious food, families frequently find themselves bearing the costs of hospital care. The DRC’s National Multisectoral Strategic Nutrition Plan highlights that chronic and acute malnutrition affects a significant proportion of the population, particularly children and women, and that households bear a large share of nutrition-related costs [6]-[8].

Geographical constraints on access and inadequate health infrastructure further increase the economic vulnerability of households. In several eastern provinces, patients must travel long distances to access care, often without any guarantee of finding staff or available medication upon arrival [9].

In this situation, malnutrition not only becomes a public health issue but also generates a considerable financial burden. Healthcare costs are borne primarily by households, contributing to their impoverishment and limiting their ability to meet other essential needs [10].

Furthermore, while numerous studies have examined the prevalence of malnutrition and its medical or dietary origins, few have focused on the factors determining the cost associated with its management. Understanding these factors is crucial for improving equitable access to care, targeting financial assistance to the most vulnerable households, and better planning local health policies.

The study participants were predominantly sick but not malnourished children (66.7%), with a slight female predominance (54.4%). Most fathers and mothers had a secondary education or higher, representing 49.7% and 63.8%, respectively. The median monthly household income was low (US$75). The median age of the children was 24 months, with relatively large households (median = 7 people). The median distance between the home and the healthcare facility was 3 km. The median length of stay was 6 days, while the median age of the child’s caregiver was 33 years (See Table 1).

Table 1. Participant characteristics.

Bivariate analysis showed that the cost of hospital care was significantly higher for malnourished children compared to non-malnourished children (p < 0.001). No significant difference in cost was observed according to the child’s sex (p > 0.05). In contrast, the father’s and mother’s education levels were significantly associated with the cost of care, with a progressive increase in the median cost as the education level increased (p < 0.01 and p < 0.001, respectively). Monthly income was not significantly correlated with the cost (p > 0.05). In correlation analysis, the age of the caregiver, household size, and duration of care were positively and significantly correlated with the cost, while the distance between the home and the healthcare facility was negatively associated with the cost (p < 0.001) (See Table 2).

Table 2. Bivariate analysis of factors associated with the cost of hospital care.

In this study, several sociodemographic and clinical factors were independently associated with the cost of hospital care after multivariate adjustment, highlighting the multifactorial nature of hospital expenditures in paediatric care settings.

The mother’s level of education appeared to be a significant determinant of the cost of hospital care (Table 3). Children whose mothers were educated had approximately 14% higher hospital costs compared to those whose mothers were not educated. This result is consistent with the literature and demonstrates that more educated parents have a greater ability to recognize signs of severity, request more additional tests, and adhere to more intensive care pathways, which may indirectly increase the use of hospital resources. Previous studies have also reported a positive association between parental education level and direct hospital costs, thus demonstrating an interaction between educational capital, healthcare-seeking behaviors, and treatment intensity [11][12].

Table 3. Factors associated with the cost of hospital care by multiple linear regression.

The distance between home and hospital was also positively associated with cost, with a median increase of 1.6% per additional kilometer (Table 3). This finding suggests that geographical distance contributes to increased hospital expenditures, likely through delayed admissions or more severe clinical presentations requiring more intensive care. These observations are consistent with those of Moukoumbi Lipenguet et al. (2023) [13], who reported that distance increases the consumption of hospital resources. However, some urban settings or those with good healthcare coverage show little or no effect of distance on hospital costs, likely due to better access to primary care and organized transportation [14]. These discrepancies highlight that the impact of distance is highly dependent on the local organization of the healthcare system and the density of healthcare services.

Length of hospital stay was one of the most significant determinants of cost, with each additional day associated with a median increase of 6.8% (Table 3) in expenses. This result is expected and well-documented, as length of stay is a direct proxy for the consumption of hospital resources, including nursing care, treatments, additional tests, and accommodation costs. Previous studies have confirmed that length of hospital stay is one of the main drivers of hospital costs, regardless of the initial pathology [15][16].

The child’s nutritional status was also an independent factor in the cost of care. Malnourished children incurred approximately 19% higher costs compared to normally nourished children. This observation is explained by the greater clinical vulnerability of malnourished children, their increased risk of complications, associated infections, and prolonged hospital stays, requiring more intensive care. The literature consistently highlights that pediatric malnutrition is associated with a substantial increase in hospital costs, both in low- and middle-income countries [17][18].

Finally, parental age was positively associated with hospital costs, with each additional year of parental age associated with a median cost increase of 2.8%. This could reflect older parents’ greater ability to understand the healthcare system and request more comprehensive care, or a greater propensity to adhere to additional treatments and tests. [11][12] also observed that caregivers’ sociodemographic characteristics influence hospital consumption and costs. However, some studies have shown that parental age does not always affect costs, especially when decisions are highly standardized by hospital protocols or when the parent has a less decisive role in care [5]. Thus, the influence of parental age can vary depending on the degree of decision-making autonomy and the cultural context.

This research identified the key factors explaining the financial cost of hospital care for children aged 0 to 59 months in the Kalonda West health zone, Kasai province (DRC). The findings were:

The mother’s level of education was significantly associated with the cost of care, with a progressive increase in the median cost of approximately 14% as the level of education increased (β = 0.135; 95% CI 0.066 - 0.205; p < 0.001).Distance from home: Each additional kilometer between home and hospital was associated with an increase in cost of approximately 1.6% (β = 0.016; 95% CI 0.007 - 0.025; p < 0.001).Parental age: Each additional year of parental age was associated with a median cost increase of 2.8% (β = 0.028; 95% CI 0.020 - 0.036; p < 0.001).The econometric model robustly explains the cost variations (adjusted R² = 0.235).

In a context of poverty, insecurity, and underfunding of the health system, these expenditures represent a significant barrier to accessing care, especially for children suffering from severe acute malnutrition.

The sample is limited to hospitalized children, which risks selection bias due to the lack of community data. Furthermore, this study does not distinguish between costs covered by technical and financial partners and those paid by households. Finally, the specific context of the Kalonda West Health District limits the generalizability of these results to other provinces in the country and in Africa.