Study sample characteristics
Characteristics of the study sample and their health encounters are shown in Table 1. Of the 7,878 people who had an illness within one year of interview, the highest percentage of people who sought care were 41 to 60 years old for outpatient encounters (25.3%), and 21 to 40 years old for inpatient/delivery encounters (47.4%). When utilization was examined by household wealth, the highest percentage of people who sought care were in the wealthiest quintile for both inpatient (28.3%) and outpatient (22.5%) visits, while the lowest percentage was in the poorest quintile for both types of visits (16.3% for outpatient, 12.5% for inpatient). Approximately half of the respondents lived in Punjab (49.1% for outpatient, and 57.6% for inpatient), and most respondents lived in rural areas (61.8% for outpatient, and 69.3% for inpatient). Most (85.9%) of the care sought took place in an outpatient setting. The results suggest a preference for private providers for both outpatient and inpatient care (84.6% and 68.5%, respectively).
Table 1. Characteristics of the study sample and their health encounters
Bivariate analysis
As shown in Figures 1 and 2, the province of residence and illness type were associated with care sector choice. Residents of Punjab and Sindh provinces had higher private sector outpatient care utilization at 70% and 82% respectively, compared to KP and Balochistan provinces, where this figure was much lower at 58% and 54%, respectively. Approximately 90% of utilization for communicable diseases and chronic conditions was for outpatient care, with over 70% of encounters occurring at private sector facilities. Accidents and injuries had a relatively higher percentage of outpatient utilization (61%) compared to inpatient utilization (39%). Approximately 52% of outpatient and 20% of inpatient encounters were for illnesses classified as “Other”, and over 80% of outpatient encounters for these illnesses were at private sector health facilities.
Figure 1. Type of provider accessed by province
Figure 2. Type of provider accessed by disease category
Table 2 presents the distribution of healthcare encounters by provider type and type of care. Most outpatient encounters occurred with a private doctor/clinic (69.4%), followed by public tertiary care (12%), and private hospitals (8.3%). Most inpatient encounters occurred at private hospitals (51.7%), public tertiary care hospitals (27.8%), and with a private doctor/clinic (8.3%). It is worth noting that traditional modes of care were also consulted; 5.3% and 7.5% of those who sought medical care chose traditional healers for outpatient and inpatient care, respectively.
Table 2. Type of healthcare provider accessed by type of care
Table 3 shows average annualized expenditure (in 2013 PKR)[3] for outpatient and inpatient care by sector of care. Although the average outpatient expenditures in the public and private sectors were similar (PKR 10,440 in the public sector and 10,395 in the private sector), there were differences in individual expenditure components. For example, outpatient expenditures on doctors’ fees were significantly higher (p < 0.001) in the private sector, where the mean expenditure on doctors’ fees was PKR 2,110 compared to PKR 29 in the public sector. Expenditures on supplies and medical durables were also higher in the private sector than in the public sector (PKR 550 vs. PKR 300, respectively, p=0.04). Other categories of medical expenditures for outpatient care, such as spending on medicines and diagnostic tests, were not significantly different between the public and private sectors. Like outpatient care, the average inpatient expenditures in the public and private sectors were similar, but differences were observed when expenditure components were examined. Private sector inpatient encounters led to significantly higher expenses on the following categories of medical expenditures: parchi/admission fee, doctors’ fees, and operation theater/intervention room charges (all p-values <0.001). The average expenditure on inpatient admission fees was PKR 889 in the private sector compared to PKR 63 in the public sector. Expenditures on doctors’ fees and operation theater expenses were PKR 3,646 and PKR 3,294, respectively, in the private sector compared to PKR 581 and PKR 883, respectively, in the public sector. Among non-medical expenditures for inpatient encounters, expenditure on tips was significantly higher in the private sector (PKR 74) than in the public sector (PKR 35, p=0.01).
Table 4 shows the differences in expenditure composition per visit or admission by type and sector of care. In the outpatient setting, medicines and vaccines accounted for about three quarters of public sector OOP expenditures (75.4%); other major drivers of public sector OOP expenditures were diagnostic tests (9.7%) and transportation (8.3%). Medicines and vaccines were also major drivers of expenditures for private sector outpatient visits, but their share of total OOP expenditures (51.9%) was not as large as in the public sector. Instead, doctors’ fees (20.3%) and diagnostic tests (10.2%) collectively accounted for almost 31% of all private sector outpatient OOP expenditures. We observed similar patterns for inpatient care: public sector expenditures were driven by medicines and vaccines (48%), supplies and medical durables (20.6%), and diagnostic tests (11.1%), while private sector OOP expenditures were driven by medicines and vaccines (35.7%), doctors’ fees (18.3%), and operation theater or room charges (16.5%).
Table 3. Average annualized expenditure (PKR) for outpatient and inpatient by sector of care
Table 4. Expenditure composition per admission or visit by type and sector of care
Multivariable models
Factors associated with sector of care
We examined the factors associated with the sector where care was sought among those who sought medical care. Because we anticipated that the factors would differ for those who sought inpatient care or delivery assistance compared to those who sought outpatient care, we analyzed the data on sector of care separately based on the type of care. The regression results are presented in Table 5.
Table 5. Marginal effects from logistic regression modelling: factors associated with choosing a private sector provider vs. a public sector provider stratified by type of care
Among patients who accessed outpatient care (n=6,724), females were 2.5 percentage points (pp) less likely than males to choose care from a private sector provider (p=0.02). In addition, the choice of sector also appeared to follow a wealth gradient, where patients in the richest quintile was 7.5 pp (p<0.001) more likely, and the richer quintile 5.8 pp (p=0.001) more likely than those in the poorest quintile to choose private sector care. There were no statistically significant differences in sector of care for patients in middle and poor wealth quintiles compared to the poorest. We also observed that the likelihood of seeking outpatient care from the private sector was negatively correlated with household size. Those living in households with more than four members were less likely to choose private sector providers than those in households with one to four members (marginal effect range -6.0 pp to -5.0 pp, all p-values <0.05). Finally, we found that private sector care was more likely to be sought for some illness types than others. For example, compared to communicable diseases, accidents and injuries were less likely to be treated in the private sector, whereas other illnesses were more likely to be treated in the private sector.
The patterns observed among those who accessed outpatient care were quite different from the patterns observed among those who accessed inpatient and delivery care. Notably, in contrast to those who accessed outpatient care, gender, wealth, and household size were not associated with sector of care. In addition, patients living in a rural region who accessed inpatient care were 11.8 percentage points more likely to seek private care than those in urban areas (p=0.001). Finally, the only illness type that was significantly associated with seeking private inpatient care was other female reproductive health concerns (marginal effect 18.4 pp, p=0.01). No statistically significant differences were observed for the remaining illness type categories.
Factors associated with out-of-pocket (OOP) expenditures
Table 6. Factors associated with OOP expenditures stratified by type of care
The results from the GLM on OOP expenditures stratified by type of care accessed are presented in Table 6. Among individuals who accessed outpatient care, patient age was positively associated with OOP expenditures and appeared to follow a gradient with increasing age. Compared to patients age 0 to 5 years, expenditures for patients age 6 to 20 years were, on average, PKR 1,750 higher, expenditures for patients age 21 to 40 years PKR 5,033 higher, expenditures for patients, age 41 to 60 years PKR 8,093 higher, and expenditures for patients over 60 years old PKR 7,374 higher (all p-values ≤0.001). OOP expenditures for outpatient care differed by wealth quintiles. Compared to the poorest wealth quintile, patients in the poorer, middle, richer, and richest quintiles spent PKR 1,573, PKR 3,387, PKR 4,335, and PKR 7,302 more on outpatient care (all p-values ≤0.001). Rural residents spent PKR 1,455 more than their urban counterparts (p=0.01). Additionally, compared to people living in Punjab province, people who lived in Sindh and KP provinces spent less, on average, for outpatient care (PKR 4,665 and PKR 4,394 respectively, both p-values <0.001). People in the largest households (13 or more members) spent PKR 3,388 less on average than those in households with 1 to 4 members (p=0.01). There were no differences in OOP expenditures between private and public sector care.
Among individuals who accessed inpatient care, we found that OOP expenditures on private sector provider were PKR 6,657 higher than expenditures on public sector providers (p<0.001). Expenditures for females were PKR 4,636 less than for males (p=0.05). Compared to patients age 0 to 5 years, OOP expenditures were only significantly different among patients age 21 to 40 years (PKR 11,412, p=0.002). Similar to expenditures on outpatient care, expenditures on inpatient care followed a wealth gradient. Compared to the poorest wealth quintile, patients in the middle, richer, and richest quintiles spent PKR 4,471, PKR 7,423, and PKR 22,537 more on inpatient care (all p-values ≤0.001). Geography was also associated with expenditures in the inpatient care model. Rural residents spent PKR 3,297 more than their urban counterparts (p=0.03), while residents of Sindh and Balochistan spent PKR 3,136 and PKR 8,524 less than Punjab residents (both p-values <0.05). Household size was also associated with OOP expenditures. Households with 5 to 8 members and 9 to 12 members spent PKR 5,581 and PKR 9,167 less than households with 1 to 4 members, respectively (both p-values <0.05). Finally, expenditures for inpatient care related to accident or injury was PKR 13,215 higher than for inpatient care related to communicable diseases (p=0.003).
[3] The exchange rate at the time was 1 USD = 106.8 PKR