This is the first study that had comprehensively investigated how healthcare utilization and OOP expenditures differ by sector, type of care, and socio-economic characteristics in Pakistan. Its findings will be useful for the federal and provincial health ministries in planning and monitoring the impact of next phase of their social health protection programs and supply side reforms. This study adds to the limited evidence base of research in LMICs for gauging disparities in healthcare utilization and OOP expenditures across different population groups. We used data from the National Health Accounts OOP expenditure survey, which would enable the utilization of findings for future research both within Pakistan and across LMICs.
An important finding from our study is the high utilization of private sector providers - in our sample, 82.5% of care took place in the private sector. This high utilization of the private sector was also observed in other studies from Pakistan including the Demographic and Health Survey (20, 21, 29, 30). Globally, there is a growing consensus about private sector engagement for achieving UHC due to the high utilization of private sector facilities in LMICs (2, 27). The global evidence on the benefits of engaging the private sector in countries with high private sector utilization, and our province-specific findings on the high utilization of private sector in Punjab and Sindh may provide a rationale for reforms which partner with the private sector in these provinces.
The goal of universal health coverage (UHC) is to ensure that individuals and communities can access health services that they need without risk of financial hardship. A key finding from our study is that that both poorer and larger households are accessing less care than their richer and smaller household counterparts, respectively. Households in the poorest household quintile were found to have reported illnesses the least and spend the least on care compared to higher income groups. On average, the wealthiest quintile paid approximately PKR. 7,700 more for outpatient care, and roughly PKR 32,000 more for inpatient care compared to the poorest quintile across both public and private facilities. Similarly, our findings show that households with 1 to 4 members paid approximately PKR 3,300 more for outpatient compared to households with over 13 members, and PKR16,625 more for inpatient care compared households with 9 to 12 members.
The wide difference between wealth groups and household size in utilization and OOP expenditures on health care may signal that poorer families and larger families could be forgoing care and may have significant unmet need due to financial constraints. This interpretation of our results on the influence of relative wealth validates the bottom-up approach opted by the social health protection programs recently adopted by the government, whereby the poorest segment of the population has been targeted as beneficiaries (10, 11). It also supports the programs’ decision to enroll all members of the household regardless of family size. Overall, this is a very important area for future research as there is very little information available on the population unable to access care, and unaffordable diseases in Pakistan; such information would be greatly useful for social health protection programs to design an appropriate benefit package.
This study has yielded other important findings for social health protection programs. Invariably, the benefit packages of the social health protection programs cover expenditures on inpatient care, including doctors’ consultation, admission, medicines, supplies and medical durables, diagnostic tests, operation theater/intervention room, and transport (for a certain number of visits in a year). Our analysis shows that the same expenditures were the main cost drivers for inpatient care in both public and private facilities, signaling that social health protection programs have appropriately selected the expenditure categories, however, each program has an annual coverage limit, and future research should explore the extent to which programs have been able to provide financial protection for inpatient needs.
Further, based on our findings, we recommend that any expansion in benefit package of social health protection programs should include outpatient care, as 90% of utilization for communicable diseases and chronic conditions was for outpatient care. The current benefit package only includes coverage for inpatient care which may not be enough to provide adequate financial protection. Similar studies from other countries also show that the total OOP for outpatient utilization is substantially higher than inpatient utilization(5, 6, 31). Our findings regarding outpatient utilization and OOP expenditures, especially those related to geographic location, household size, and wealth status, can be used for developing appropriate payment mechanism for strategically purchasing outpatient care.
As has been found in several other LMICs, consultation fee (usually including doctors and paramedics fee, facility visit or admission charges) was not found to be among the main cost drivers for both outpatient and inpatient care in public facilities (4). Further, no significant difference was found in OOP expenditures on inpatient care in public and private facilities. Hence, the reforms, either supply or demand sided, should go beyond abolishment of user fee and should focus on the provision of essential services, including supply of medicines, medical durables, and diagnostics.
More than 5% of healthcare clients visited traditional practitioners/healers both for outpatient and inpatient. This finding reiterates the need for integration of traditional modes of care into mainstream health system through appropriate education, training, and regulation for rational prescription and usage of traditional medicines in the country (32, 33).
Our study also shows three important results that should be explored for further research. The timing of our study coincides with contracting out reforms in the province of Sindh, where currently all public primary care facilities have been contracted out to private providers. Our analysis shows that 82% of respondents in Sindh used private sector facilities, and it may be helpful to evaluate the impact of contracting out on OOP expenditures and public sector utilization through a follow-up survey. Another interesting finding from our analysis is that rural populations were 11.8% more likely to visit private sector providers for inpatient care than urban populations. This finding may be a result of multiple causes, such as limited presence and perception of poor quality of care in public facilities and could be an important area for further research. Lastly, this study analyses the determinants of OOP expenditures and utilization between public and private providers. Further research could include respondents with self-medication and non-users to explore the determinants of self-medication or non-utilization for those who were sick.
Our analysis also has several limitations which should be accounted for while using these results for policy making. For instance, this analysis has only used one wave for the national health accounts, as the other waves have used different recall periods for outpatient care. As explained above in the methodology section, this was causing great variation in the average OOP expenditure across different waves and would make it impossible to interpret the results while controlling for any bias due to reporting periods. Therefore, our findings are a snapshot in time. In addition, because the recall period for outpatient care was only three months, it is not possible to investigate outpatient utilization rates. Instead, we could only estimate the percentage of care sought in either the public or private sectors among those who sought outpatient care.
We have also drawn limited conclusions on the reasons for utilizing healthcare, as approximately half of the encounters for inpatient and outpatient care were classified as ‘other’ for the variable on type of disease, and other categories were labelled poorly, such as one which was classified as “women’s issues”. It was unclear whether there is any overlap between the diseases categorized as other and the current categories. As a result, we can make limited conclusions on the disease specific utilization and related OOP expenditures.
Lastly, this analysis is based on data collected prior to the implementation of social health protection programs in Pakistan. These results for OOP expenditures and its determinants for inpatient care may have changed after the implementation of the programs, but this is not expected to have a large impact on the overall results since both the utilization and OOP expenditures were mostly for outpatient care, which is not covered in the social health protection programs. An important area of future research would be to replicate the analysis using the out-of-pocket expenditure dataset to be published by Pakistan Bureau of Statistics in mid-2020 and assess the impact of the programs.