Determinants of healthcare seeking and out-of-pocket expenditures in a “free” healthcare system: evidence from rural Malawi

Abstract

Background: Monitoring financial protection is a key component in achieving Universal Health Coverage, even for health systems that grant their citizens access to care free-of-charge. Our study investigated out-of-pocket expenditure (OOPE) on curative healthcare services and their determinants in rural Malawi, a country that has consistently aimed at providing free healthcare services. Methods: Our study used data from two consecutive rounds of a household survey conducted in 2012 and 2013 among 1639 households in three districts in rural Malawi. Given our explicit focus on OOPE for curative healthcare services, we relied on a Heckman selection model to account for the fact that relevant OOPE could only be observed for those who had sought care in the first place. Results: Our sample included a total of 2740 illness episodes. Among the 1884 (68.75%) that had made use of curative healthcare services, 494 (26.22%) had incurred a positive healthcare expenditure, whose mean amounted to 678.45 MWK (equivalent to 2.72 USD). Our analysis revealed a significant positive association between the magnitude of OOPE and age 15-39 years (p = 0.022), household head (p = 0.037), suffering from a chronic illness (p = 0.019), illness duration (p = 0.014), hospitalization (p = 0.002), number of accompanying persons (p = 0.019), wealth quartiles (p 2 = 0.018; p 3 = 0.001; p 4 = 0.002), and urban residency (p = 0.001). Conclusion: Our findings indicate that a formal policy commitment to providing free healthcare services is not sufficient to guarantee widespread financial protection and that additional measures are needed to protect particularly vulnerable population groups.

How Equitable Is Health Spending On Curative Services And Institutional Delivery In Malawi? Evidence From A Quasi-Longitudinal Benefit Incidence Analysis

“…The persistent OOPE can probably explain this remaining inequality even in the presence of a formal free healthcare policy [27,29]. The fact that inequality was observed mostly at non-public facilities is aligned with prior literature suggesting that OOPE in Malawi is driven mainly by people re-directing demand towards private services when human resources and medical supplies are absent at public facilities [22,24].…”

“…In the current study, the share of OOPE incurred by the top quintile group for using curative services compared to the share of the bottom quintile group is approximately 67% higher than the share of OOPE incurred by making use of institutional delivery. People still incur some OOPE for curative health services in Malawi due to the persistently high prevalence of HIV and its concurrent infections, the emergence of high-cost treatment for non-communicable diseases, and the introduction of fees in private wards [26] in response to chronic underfunding of the EHP [22,23,27,52]. Therefore, our ndings call for removing instead of introducing nancial barriers at the point of care, especially for the poorer segments of the population [53].…”

“…Across SSA, higher-level health facilities are concentrated in urban areas, often only accessible to the least poor, given the higher direct and indirect costs of seeking care at this level [57], including considerable transport costs [58][59][60]. For instance, a study by Nakovics and colleagues [27] indicated that transport costs in Malawi represent as much as 43% of the total cost of care. Our ndings indicate the need for action on the supply-side by increasing the density of secondary level facilities and on the demandside by introducing reimbursements for transport costs to overcome existing inequalities due to geographical disparities [58].…”

“…In particular, the underfunding of the EHP services under SLA contracts pushed some CHAM facilities to reintroduce user fees for curative services [26]. Previous studies revealed that the more a uent disproportionately use both curative services [27] and maternal services [28] and hence incur higher OOPE than the poorer segments of the population [27]. A recent study by Mchenga and colleagues indicated that OOPE caused 9.37% of households to face catastrophic health expenditure, leading to an increase of the poverty gap of almost 2.54% [29].…”

Drivers of respiratory healthcare demand in Acre state, Brazilian Amazon: a cross-sectional study

“…In uenza vaccination campaigns which achieve over 80% coverage in Acre state (SI-PNI, 2021) could also better inform about symptoms and contagiousness (as recommended for TB bySeid and Metaferia, 2018) and the need to seek care even whether vaccinated or experiencing tolerable pain. A speci c study on alternatives to increase healthcare usage during the wet season is needed, what requires assessing the possibility of temporarily expanding health workers' teams in rural areas when rain is intense enough to prevent rural-urban displacements.To nish, the results here achieved are generalizable only to other developing countries that also have a public health system targeting universal coverage and offering free healthcare (as Malawi;Nakovics et al, 2020).…”