Abstract
BackgroundMonitoring financial protection is a key component in achieving Universal Health Coverage, even for health systems that grant their citizens access to care free-of-charge. Our study investigated out-of-pocket expenditure (OOPE) on curative healthcare services and their determinants in rural Malawi, a country that has consistently aimed at providing free healthcare services.MethodsOur study used data from two consecutive rounds of a household survey conducted in 2012 and 2013 among 1639 households in three districts in rural Malawi. Given our explicit focus on OOPE for curative healthcare services, we relied on a Heckman selection model to account for the fact that relevant OOPE could only be observed for those who had sought care in the first place.ResultsOur sample included a total of 2740 illness episodes. Among the 1884 (68.75%) that had made use of curative healthcare services, 494 (26.22%) had incurred a positive healthcare expenditure, whose mean amounted to 678.45 MWK (equivalent to 2.72 USD). Our analysis revealed a significant positive association between the magnitude of OOPE and age 15–39 years (p = 0.022), household head (p = 0.037), suffering from a chronic illness (p = 0.019), illness duration (p = 0.014), hospitalization (p = 0.002), number of accompanying persons (p = 0.019), wealth quartiles (p2 = 0.018; p3 = 0.001; p4 = 0.002), and urban residency (p = 0.001).ConclusionOur findings indicate that a formal policy commitment to providing free healthcare services is not sufficient to guarantee widespread financial protection and that additional measures are needed to protect particularly vulnerable population groups.
Highlights
Monitoring financial protection is a key component in achieving Universal Health Coverage, even for health systems that grant their citizens access to care free-of-charge
Albeit not a weakness of our methodological approach per se since we purposely focused exclusively on estimating the financial protection afforded by the formal free healthcare system, the reader needs to consider that our of-pocket expenditure (OOPE) values represent lower-bound estimates of total OOPE in Malawi
Appraising findings from our study in relation to the broader literature on sub-Saharan African (SSA) indicates that OOPE for formal healthcare services in Malawi is relatively low compared with what is observed in other settings
Summary
Monitoring financial protection is a key component in achieving Universal Health Coverage, even for health systems that grant their citizens access to care free-of-charge. The concept of UHC sits at the core of Sustainable Development Goal 3 [2] It reminds the international community of the basic human right to health, and calls upon nations to implement health systems that secure access to quality care while ensuring financial protection against the cost of illness. Malawi is an example of a country that resisted the push to finance healthcare provision through the application of user fees. After independence it implemented a free healthcare system (financed primarily by a combination of government and donor funds) to ensure that access to health services in public facilities would not be conditional upon user charges [7,8,9]. In 2004, the government of Malawi further refined free healthcare provision with the introduction of an explicit Essential Health Package (EHP), clearly stipulating which services were to be provided free of charge at point of use in public and in contracted private health facilities [10, 11]
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