Abstract
Background: Access to appropriate and affordable healthcare is needed to achieve better health outcomes in Africa. However, access to healthcare remains low, especially among the poor. In Zambia, poor access exists despite the policy by the government to remove user fees in all primary healthcare facilities in the public sector. The paper has two main objectives: (i) to examine the factors associated with healthcare choices among sick people, and (ii) to assess the determinants of the magnitude of out-of-pocket (OOP) payments related to a visit to a health provider. Methods: This paper employs a multilevel multinomial logistic regression to model the determinants of an individual’s choice of healthcare options following an illness. Further, the study analyses the drivers of the magnitude of OOP expenditure related to a visit to a health provider using a two-part generalised linear model. The analysis is based on a nationally representative healthcare utilisation and expenditure survey that was conducted in 2014. Results: Household per capita consumption expenditure is significantly associated with increased odds of seeking formal care (odds ratio [OR] = 1.12, P = .000). Living in a household in which the head has a higher level of education is associated with increased odds of seeking formal healthcare (OR = 1.54, P = .000) and (OR = 1.55, P = .01), for secondary and tertiary education, respectively. Rural residence is associated with reduced odds of seeking formal care (OR = 0.706, P = .002). The magnitude of OOP expenditure during a visit is significantly dependent on household economic well-being, distance from a health facility, among other factors. A 10% increase in per capita consumption expenditure was associated with a 0.2% increase in OOP health expenditure while every kilometre travelled was associated with a K0.51 increase in OOP health expenditure. Conclusion: Despite the removal of user fees on public primary healthcare in Zambia, access to healthcare is highly dependent on an individual’s socio-economic status, illness type and region of residence. These findings also suggest that the benefits of free public healthcare may not reach the poorest proportionately, which raise implications for increasing access in Zambia and other countries in sub-Saharan Africa.
Highlights
Expanded access to healthcare is well-recognised as critical to achieving better health outcomes and economic development in sub-Saharan Africa.[1]
A further 30% opted for self-medication, while 10% did not seek for healthcare
A total of 80% of patients who visited public primary healthcare facilities on an outpatient basis reported not having incurred any medical, travel or any other healthcare-related OOP expenses. This finding confirms that implementation of user fee removal policy has been routinized in the Zambian public health system
Summary
Expanded access to healthcare is well-recognised as critical to achieving better health outcomes and economic development in sub-Saharan Africa.[1]. The role of OOP payments in influencing access has been a subject of growing academic and policy interest.[1,4,5,6] Since the early 2000s, several African countries have abolished user fees in an effort to reduce financial barriers to access to needed healthcare, especially for the poor.[7,8,9,10] User fees were considered to pose a significant barrier to access to appropriate health services The government of Zambia abolished user fees on outpatient primary healthcare services, firstly in 2006 in rural areas, and extended the policy to urban areas in 2012 The goal of this policy was to increase utilisation and access to health services in both rural and urban primary healthcare facilities.[11,12] Despite a notable increase in utilisation of public health services following the removal of user fees as reported in studies,[7,13] a number of questions remain unanswered. Our study is based on a nationally representative household-based health expenditure and utilisation survey conducted in 2014
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