Steinhardt Laura C, Waters Hugh, Rao Krishna Dipankar, Naeem Ahmad Jan, Hansen Peter, Peters David H
Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Suite E8132, Baltimore, MD 21205, USA.
Health Policy Plan. 2009 Jan;24(1):1-17. doi: 10.1093/heapol/czn043. Epub 2008 Dec 5.
This paper analyses the effect of wealth status on care-seeking patterns and health expenditures in Afghanistan, based on a national household survey conducted within public health facility catchment areas. We found high rates of reported care-seeking, with more than 90% of those ill seeking care. Sick individuals from all wealth quintiles had high rates of care-seeking, although those in the wealthiest quintile were more likely to seek care than those from the poorest (odds ratio 2.2; 95% CI 1.6, 3.0). The nearest clinic providing the government's Basic Package of Health Services (BPHS) was the most commonly sought first provider (53% overall), especially for relatively poor households (62% in poorest vs. 42% in least poor quintile, P < 0.0001). Sick individuals from wealthier quintiles used hospitals and for-profit private providers more than those in poorer quintiles. Multivariate analysis showed that wealth quintile was the strongest predictor of seeking care, and of going first to private providers. More than 90% of those seeking care paid money out-of-pocket. Mean (median) expenditures among those paying for care in the previous month were 873 Afghanis (200 Afghanis), equivalent to US$17.5 (US$4). Expenditures were lowest at BPHS clinics and highest at private providers. Financing care through borrowing money or selling assets/land ('any distress' financing) was reported in nearly 30% of cases and was almost twice as high among households in the poorest versus the least poor quintile (P < 0.0001). Financing care through selling assets/land ('severe distress' financing) was less common (10% overall) and did not differ by wealth status. These findings indicate that BPHS facilities are being used by the poor who live close to them, but further research is needed to assess utilization among populations in more remote areas. The high out-of-pocket health expenditures, particularly for private sector services, highlight the need to develop financial protection mechanisms in Afghanistan.
本文基于在公共卫生机构服务范围内开展的一项全国家庭调查，分析了财富状况对阿富汗就医模式和医疗支出的影响。我们发现，报告的就医率很高，超过90%的患病者寻求医疗服务。所有财富五分位数组的患病个体就医率都很高，不过最富有的五分位数组的人比最贫穷的人更有可能寻求医疗服务（优势比为2.2；95%置信区间为1.6至3.0）。提供政府基本卫生服务包（BPHS）的最近诊所是最常被作为首选的医疗机构（总体占53%），尤其是相对贫困的家庭（最贫困五分位数组为62%，最不贫困五分位数组为42%，P<0.0001）。较富裕五分位数组的患病个体比贫困五分位数组的人更多地使用医院和营利性私立医疗机构。多变量分析表明，财富五分位数是寻求医疗服务以及首先前往私立医疗机构就医的最强预测因素。超过90%的就医者自掏腰包付费。上个月付费就医者的平均（中位数）支出为873阿富汗尼（200阿富汗尼），相当于17.5美元（4美元）。BPHS诊所的支出最低，私立医疗机构的支出最高。近30%的病例报告通过借钱或出售资产/土地来支付医疗费用（“任何困难”融资），最贫困五分位数组家庭的这一比例几乎是最不贫困五分位数组家庭的两倍（P<0.0001）。通过出售资产/土地来支付医疗费用（“严重困难”融资）不太常见（总体为10%），且在不同财富状况的家庭中没有差异。这些发现表明，生活在附近的穷人正在使用BPHS设施，但需要进一步研究以评估更偏远地区人群的利用情况。高额的自付医疗费用，尤其是私立部门服务的费用，凸显了在阿富汗建立财务保护机制的必要性。
