BackgroundOut-of-pocket payments in health care have been shown to impose significant burden on households in Sub-Saharan Africa, leading to constrained access to health care and impoverishment. In an effort to reduce the financial burden imposed on households by user fees, some countries in Sub-Saharan Africa have abolished user fees in the health sector. Zambia is one of few countries in Sub-Saharan Africa to abolish user fees in primary health care facilities with a view to alleviating financial burden of out-of-pocket payments among the poor. The main aim of this paper was to examine the extent and patterns of financial protection from fees following the decision to abolish user fees in public primary health facilities.MethodsOur analysis is based on a nationally representative health expenditure and utilization survey conducted in 2014. We calculated the incidence and intensity of catastrophic health expenditure based on households’ out-of-pocket payments during a visit as a percentage of total household consumption expenditure. We further show the intensity of the problem of catastrophic health expenditure (CHE) experienced by households.ResultsOur analysis show that following the removal of user fees, a majority of patients who visited public health facilities benefitted from free care at the point of use. Further, seeking care at public primary health facilities is associated with a reduced likelihood of incurring CHE after controlling for economic wellbeing and other covariates. However, 10% of households are shown to suffer financial catastrophe as a result of out-of-pocket payments. Further, there is considerable inequality in the incidence of CHE whereby the poorest expenditure quintile experienced a much higher incidence.ConclusionDespite the removal of user fees at primary health care level, CHE is high among the poorest sections of the population. This study also shows that cost of transportation is mainly responsible for limiting the protective effectiveness of user fee removal on CHE among particularly poorest households.

Background: Access to appropriate and affordable healthcare is needed to achieve better health outcomes in Africa. However, access to healthcare remains low, especially among the poor. In Zambia, poor access exists despite the policy by the government to remove user fees in all primary healthcare facilities in the public sector. The paper has two main objectives: (i) to examine the factors associated with healthcare choices among sick people, and (ii) to assess the determinants of the magnitude of out-of-pocket (OOP) payments related to a visit to a health provider. Methods: This paper employs a multilevel multinomial logistic regression to model the determinants of an individual’s choice of healthcare options following an illness. Further, the study analyses the drivers of the magnitude of OOP expenditure related to a visit to a health provider using a two-part generalised linear model. The analysis is based on a nationally representative healthcare utilisation and expenditure survey that was conducted in 2014. Results: Household per capita consumption expenditure is significantly associated with increased odds of seeking formal care (odds ratio [OR] = 1.12, P = .000). Living in a household in which the head has a higher level of education is associated with increased odds of seeking formal healthcare (OR = 1.54, P = .000) and (OR = 1.55, P = .01), for secondary and tertiary education, respectively. Rural residence is associated with reduced odds of seeking formal care (OR = 0.706, P = .002). The magnitude of OOP expenditure during a visit is significantly dependent on household economic well-being, distance from a health facility, among other factors. A 10% increase in per capita consumption expenditure was associated with a 0.2% increase in OOP health expenditure while every kilometre travelled was associated with a K0.51 increase in OOP health expenditure. Conclusion: Despite the removal of user fees on public primary healthcare in Zambia, access to healthcare is highly dependent on an individual’s socio-economic status, illness type and region of residence. These findings also suggest that the benefits of free public healthcare may not reach the poorest proportionately, which raise implications for increasing access in Zambia and other countries in sub-Saharan Africa.

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Despite the removal of user fees on public primary healthcare in Zambia, prior studies suggest that out-of-pocket payments are still significant. However, we have little understanding of the extent to which out-of-pocket payments lead patients to hardship methods of financing out-of-pocket costs. This study analyses the prevalence and determinants of hardship financing arising from out-of-pocket payments in healthcare, using data from a nationally-representative household health expenditure survey conducted in 2014. We employ a sequential logistic regression model to examine the factors associated with the risk of hardship financing conditional on reporting an illness and an out-of-pocket expenditure. The results show that up to 11% of households who reported an illness had borrowed money, or sold items or asked a friend for help, or displaced other household consumption in order to pay for health care. The risk of hardship financing was higher among the poorest households, female headed-households and households who reside further from health facilities. Improvements in physical access and quality of public health services have the potential to reduce the incidence of hardship financing especially among the poorest.

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