School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA.
Present address:Universal Health Coverage/Health Systems Department, World Health Organization, Regional Office for the Eastern Mediterranean, Monazamet El Seha El Alamia Str, Extension of Abdel Razak El Sanhouri Street, Nasr City, P.O. Box 7608, Cairo, 11371, Egypt.
BMC Health Serv Res. 2021 Feb 25;21(1):178. doi: 10.1186/s12913-021-06170-4.
As low- and middle-income countries progress toward Universal Health Coverage, there is an increasing focus on measuring out-of-pocket (OOP) expenditure and health services utilization within countries. While there have been several reforms to improve health services coverage and financial protection in Pakistan, there is limited empirical research comparing OOP expenditure and health services utilization between public and private facilities and exploring their determinants, a knowledge gap addressed in this study.
We used data from 2013 to 14 OOP Health Expenditure Survey, a population-based household survey carried out for Pakistan's National Health Accounts. The analysis included 7969 encounters from 4293 households. We conducted bivariate analyses to describe patterns of care utilization, estimated annualized expenditures by type and sector of care, and assessed expenditure composition. We used multivariable logistic regression modeling to identify factors associated with sector of care and generalized linear model (GLM) with log link and gamma distribution to identify determinants of OOP expenditures stratified by type of care (inpatient and outpatient).
Most encounters (82.5%) were in the private sector and were for outpatient visits (85%). Several public-private differences were observed in annualized expenditures and expenditure components. Logistic regression results indicate males, wealthier individuals, Punjab and Sindh residents, and those in smaller households were more likely to access private outpatient care. In the inpatient model, rural residents were more likely to use a private provider, while Khyber Pakhtunkhwa residents were less likely to use private care. GLM results indicate private sector inpatient expenditures were approximately PKR 6660 (USD 61.8) higher than public sector expenditures, but no public-private differences were observed for outpatient expenditures. Several demographic factors were significantly associated with outpatient and inpatient expenditures. Of note, expenditures increased with increasing wealth, decreased with increasing household size, and differed by province and region.
This is the first study comprehensively investigating how healthcare utilization and OOP expenditures vary by sector, type of care, and socio-economic characteristics in Pakistan. The findings are expected to be particularly useful for the next phase of social health protection programs and supply side reforms, as they highlight sub-populations with higher OOP and private sector utilization.
随着中低收入国家向全民健康覆盖迈进，越来越关注国家内部的自付支出和卫生服务利用情况。尽管巴基斯坦已经进行了多次改革以改善卫生服务的覆盖范围和财务保障，但关于公共和私人设施之间的自付支出和卫生服务利用情况的比较以及探索其决定因素的实证研究有限，本研究旨在填补这一知识空白。
我们使用了 2013-14 年自付卫生支出调查的数据，这是一项针对巴基斯坦国家卫生账户进行的基于人群的家庭调查。分析包括了来自 4293 户家庭的 7969 次就诊。我们进行了描述性分析，以描述利用情况的模式，估算了按护理类型和部门计算的年化支出，并评估了支出构成。我们使用多变量逻辑回归模型来确定与护理部门相关的因素，并使用对数链接和伽马分布的广义线性模型（GLM）来确定按护理类型（住院和门诊）分层的自付支出的决定因素。
大多数就诊（82.5%）发生在私营部门，且为门诊就诊（85%）。在年化支出和支出构成方面观察到了一些公私部门的差异。逻辑回归结果表明，男性、富裕程度较高的个体、旁遮普省和信德省的居民以及家庭规模较小的个体更有可能获得私营部门的门诊护理。在住院模型中，农村居民更有可能使用私营医疗机构，而开伯尔-普赫图赫瓦省的居民则不太可能使用私营医疗机构。GLM 结果表明，私营部门住院支出比公共部门支出高出约 6660 巴基斯坦卢比（61.8 美元），但门诊支出方面没有公私部门差异。几个人口统计学因素与门诊和住院支出显著相关。值得注意的是，支出随着财富的增加而增加，随着家庭规模的增加而减少，且因省份和地区而异。
这是第一项全面调查巴基斯坦医疗保健利用情况和自付支出如何按部门、护理类型和社会经济特征变化的研究。这些发现对于下一阶段的社会健康保护计划和供应方改革尤其有用，因为它们突出了自付支出和私营部门利用率较高的亚人群。
