Determinants of Healthcare Utilisation and Out-of-Pocket Payments in the Context of Free Public Primary Healthcare in Zambia

Abstract

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.

Determinants of individual healthcare expenditure: A cross‐sectional analysis in rural Burkina Faso

“…It is also not surprising and well aligned with existing literature that better‐educated individuals incurred higher OOPE. In addition to SES, education acts as an important enabling factor facilitating informed decision‐making when it comes to healthcare seeking . Grossman postulates that education also increases the efficiency of the investment made, hence suggesting that the money spent by educated people is probably better directed toward selection of the most appropriate treatment.…”

How effective and fair is user fee removal? Evidence from Zambia using a pooled synthetic control

“…A study looking at the financial protection conferred by the free care policy found that 29.9% and 45% of patients in public rural and urban health centres respectively incurred some expenditures (Masiye et al, ). In a follow‐up study using the same data, Masiye and Kaonga () conclude that in 2014, “despite the removal of user fees in public primary healthcare in Zambia, access to healthcare is highly dependent on an individual's socio‐economic status, illness type and region of residence.” Together with our findings, this suggests that user fee removal may not necessarily be the silver bullet to move towards greater access for the poorer population and quicker move towards universal coverage. Evidence from several settings also point to the potential disruptive effects of free care policies on health systems (e.g., drug shortages, staff dissatisfaction, and insufficient funding) and therefore the need to prepare, plan, and introduce complementary measures to ensure a more positive outcome (Ridde, Robert, & Meessen, )…”

Comparison of Healthcare Utilization and Out-of-pocket Expenditure for Severe Disease by Health Security System: based on End-stage Renal Disease in South Korea

“…Third, the higher OOP expenditure burden in NHI than MA was identified over a 6-years trend from 2008 to 2013. OOP expenditure has been reported to have disadvantages that impede healthcare utilization when inevitably seek health care [35][36][37][38][39][40]. Therefore, NHI subjects with a severe disease such as ESRD have a greater financial burden than MA.…”