Out-of-Pocket Expenditure on Delivery Care in Public and Private Health Sectors – A Study in a Rural District of Pakistan
Keywords:
Delivery care, out-of-pocket expenditure, public health sector, private health sector, Pakistan.
Abstract
Pakistan witnessed a significant improvement in maternal health outcomes during the past two decades. However, persistent urban-rural and socio-economic inequalities exist in access to maternal healthcare services across the country. The objective of this study was to estimate out-of-pocket expenditure (OOPE) on delivery care by women in the public and private health sectors in RajanPur district. This was a cross-sectional study conducted, among 368 randomly selected mothers who had childbirths from 1st October to 31st December 2020. The study applied multi-stage random sampling technique to select the study participants. The results showed that about two-thirds of mothers preferred public hospitals for most recent delivery. The percentage of cesarean deliveries conducted in private hospitals (43.8%) was 4.7 times higher than in public hospitals (9.3%). About 99% of mothers incurred OOPE during delivery care, and the mean OOPE incurred during delivery care was PKR 2840 (US$ 17.75) in public hospitals and PKR 25596 (US$159.9) in private hospitals. OOPE on cesarean delivery in private hospitals (PKR 39654.7, US$247.8) was 2.5 times higher than the public hospitals (PKR16111.9, US$100.69), whereas OOPE incurred on normal delivery care in private hospitals (PKR14339, US$89.62) was 9.5 times higher than OOPE in public hospitals(PKR 1501.4, US$9.38).To conclude, the findings and recommendations drawn from the research would provide some insights to health policymakers and planners in developing an integrated and viable maternal healthcare program in Pakistan.
Downloads
Download data is not yet available.
References
Acharya, J., Kaehler, N., Marahatta, S. B., Mishra, S. R., Subedi, S., & Adhikari, B. (2016). Hidden Costs of hospitalbased delivery from two tertiary hospitals in western Nepal. Plos One, 11(6), e0157746. https://doi.org/10.1371/journal.pone.0157746
Ansari, M. S., Manzoor, R., Siddiqui, N., & Ahmed, A. M. (2015). Access to comprehensive emergency obstetric and newborn care facilities in three rural districts of Sindh province, Pakistan. Health Research Policy and Systems, 13(1), https://doi.org/10.1186/s12961-015-0042-7
ADB (2012). Asian Development Bank. Available athttps://www.adb.org/sites/default/files/publication/29704/ado2012.pdf
Berer, M. (2012). Maternal mortality or women’s health: time for action. Reproductive Health Matters, 20(39), 5-10. https://doi.org/10.1016/s0968-8080(12)39632-8
Chhetri, S., Shah, R., & Rajbanshi, L. (2020). Factors associated with utilization of complete postnatal care service in Baglung Municipality, Nepal. Int J Reprod Med, 2892751. https://doi.org/10.1155/2020/2892751
Goli, S., Rammohan, A., & Moradhvaj. (2018). Out-of-pocket expenditure on maternity care for hospital births in Uttar Pradesh, India. Health Economics Review, 8(5), https://doi.org/10.1186/s13561-018-0189-3
Gopalan, S. S., & Durairaj, V. (2012). Addressing maternal healthcare through demand side financial incentives: Experience of Janani Suraksha Yojana program in India. BMC Health Services Research, 12, 319.
Govil, D., Purohit, N., Gupta, S. D., & Mohanty, S. K. (2016). Out-of-pocket expenditure on prenatal and natal care post Janani Suraksha Yojana: a case from Rajasthan, India. Journal of Health, Population and Nutrition, 35(1), doi: https://doi.org/10.1186/s41043-016-0051-3
Issac, A., Chatterjee, S., & Srivastava, A., & Bhattacharyya, S. (2016). Out of pocket expenditure to deliver at public health facilities in India: a cross sectional analysis.Reproductive Health, 13(99). https://doi.org/10.1186/s12978-016-0221-1
Khan, A., & Zaman, S. (2010). Costs of vaginal delivery and caesarean section at a tertiary level public hospital in Islamabad, Pakistan. BMC Pregnancy Childbirth, 10(2), https://doi.org/10.1186/1471-2393-10-2
Krishnamoorthy, Y., Ganesh, K., Sakthivel, M., & Priyan, S. (2020). Costs incurred and determinants of out-of-pocket payments for child delivery care in India: Evidence from a nationally representative household survey. Int J Health Plann Manage, 35(1), e167-e177. doi: https://doi.org/10.1002/hpm.2953.
Kyei-Nimakoh, M., Carolan-Olah, M. & McCann, T.V. (2017). Access barriers to obstetric care at health facilities in sub-Saharan Africa—a systematic review. Syst Rev 6, 110. https://doi.org/10.1186/s13643-017-0503-x
Malik, A. M., & Syed, S. M. (2012). Socio-economic determinants of household out-of-pocket payments on healthcare in Pakistan. Int J Equity Health, 4(11), 51. https://doi.org/10.1186/1475-9276-11-51
Mansuri, G., Sami, M.F., Ali, M., Doan, H.T.T., Javed, B., & Pandey, P. (2018). When water becomes a hazard: A diagnostic report on the state of water supply, sanitation and poverty in Pakistan and its impact on child stunting (English). WASH Poverty Diagnostic Series. Washington, D.C.: World Bank Group.
Merga, M., Debela, T. F., & Alaro, T. (2019). Hidden costs of hospital-based delivery among women using public hospitals in bale zone, Southeast Ethiopia. Journal of Primary Care & Community Health, 10, https://doi.org/10.1177/2150132719896447
MICS (2017-2018), Punjab Survey findings report, Multiple Indicator Cluster survey. available on https://www.unicef.org/pakistan/media/3121/file/Multiple%20Indicator%20Cluster%20Survey%202017-18%20-%20Punjab.pdf
Mirabedini, S. A., Fazl, E., Hashemi, S. M., Asiabar, S., Rezapour, A., Azami-Aghdash, S., & Amnab, H. (2017). Out-of-pocket and informal payments in Iran's health care system: A systematic review and meta-analysis. Medical Journal of the Islamic Republic of Iran, 31(1), 401-409. https://doi.org/10.14196/mjiri.31.70
Mohanty, S. K., & Srivastava, A. (2013). Out-of-pocket expenditure on institutional delivery in India.Health Policy and Planning, 28(3), 247–262, https://doi.org/10.1093/heapol/czs057
Mohanty, S. K., Kim, R, Khan, P. K., & Subramanian, S. V. (2018). Geographic variation in household and catastrophic health spending in India: Assessing the relative importance of villages, districts, and states. Milbank Q., 96(1), 167–206.
Myint, A. N. M., Liabsuetrakul, T., Htay, T., & Wai, M.M, Sundby, J., & Bjertness, E. (2018). Impoverishment and catastrophic expenditures due to out-of-pocket payments for antenatal and delivery care in Yangon Region, Myanmar: a cross-sectional study. BMJ Open, 8(11),
National Institute of Population Research and Training (2013) Bangladesh Demographic & Health survey 2011. Dhaka, Bangladesh and Calverton, Maryland, USA: NIPORT, Mitra and Associates, and ICF International. Retrieved from: https://dhsprogram.com/pubs/pdf/fr265/fr265.pdf
Noreen, S. (2017) Determinants of Demand for Maternal Health Care Services: A Survey Study of Bahawalpur District. (Doctoral thesis) The Islamia University of Bahawalpur.
Pakistan Bureau of Statistcis PBS Government of Paksitan (2018). 7th population and Housing census 2022. Retrived from https://www.pbs.gov.pk/
Pomeroy, A., Koblinsky, M. M., & Alva, S. (2014). Who gives birth in private facilities in Asia? A Look at Six Countries. Health Policy and Planning, 29, 38-47.
Prinja, S., Bahuguna, P., Gupta, R., Sharma, A., Rana, S. K., & Kumar, R. (2015). Coverage and financial risk protection for institutional delivery: How universal is provision of maternal health care in India? Plos One, 10(9), e0137315. https://doi.org/10.1371/journal.pone.0137315
Qureshi, R.N., Sheikh, S., Khowaja, A.R., Hoodbhoy, Z., Zaidi, S., Sawchuck, D., Vidler, M., Bhutta, Z.A., & Dadeslzen, P. (2016) Health care seeking behaviours in pregnancy in rural Sindh, Pakistan: a qualitative study. Reproductive Health, 13(1), 34.
Rahman, M.M., Gilmour, S., Saito, E., Sultana, P., & Shibuya, K. (2013). Health-related financial catastrophe, inequality and chronic illness in Bangladesh. PLoS One, 8(2), e56873. https://doi.org/10.1371/journal.pone.0056873
Rehman, A., Adnan, M., Mahmood, H., Hassan, M., & Humayun, A. (2017). Maternal health care expenditure among women in rural areas of Pakistan. Annals of King Edward Medical University, 23(2). doi: https://doi.org/10.21649/akemu.v23i2.1587
Riaz, A., Zaidi, S., & Khowaja, A. R. (2015). Perceived barriers to utilizing maternal and neonatal health services in contracted-out versus government-managed health facilities in the rural districts of Pakistan. International Journal of Health Policy and Management, 4(5), 279-284. doi: https://doi.org/10.15171/ijhpm.2015.50
Razumowsky, A. I. (2022). Distance education: A ruin of health. Amazonia Investiga, 11(50), 290-298. https://doi.org/10.34069/AI/2022.50.02.27
Sarkar, A. R., Sultana, M., Ali, N., & Akram, R. (2018). Cost comparison and determinants of out-of-pocket payments on child delivery care in Bangladesh. International Journal of Health Planning and Management, 33(9693), https://doi.org/10.1002/hpm.2615
Sharma, S., Verma, P. B., Viramgami, A. P., Vala, M.C., & Lodhiya, K. K. (2018). Analysis of out-of-pocket expenditure in utilization of maternity care services in urban slums of Rajkot City, Gujarat. Indian J Community Med, 43, 215-9
Sidney, K., Salazar, M., Marrone, G., Diwan, V., DeCosta, A., & Lindholm, L. (2016) Out-of-pocket expenditures for childbirth in the context of the Janani Suraksha Yojana (JSY) cash transfer program to promote facility births: who pays and how much? Studies from Madhya Pradesh, India. Int J Equity Health 15, 71. https://doi.org/10.1186/s12939-016-0362-4
Sughra, M., Fatima, F., Marrium, M., & Abbas, K. (2018). Maternal health expenditures and health seeking behavior among lowest wealth quintile of the rural population in an under developed district of the Punjab, Pakistan. Int J Reprod Contracept Obstet Gynecol, 7, 2579-82.
Srivastava, N. M., Awasthi, S., & Agarwal, G.G. (2009). Care-seeking behavior and out-of-pocket expenditure for sick new-borns among urban poor in Lucknow, Northern India: A prospective follow-up study. BMC Health Serv Res, 61, 9.
Tellis, S. B., Rent, P. D., & Dmello, M. K. (2018). Utilization of antenatal care and out of pocket expenditure on delivery care in Dakshina Kannada. Int J Community Med Public Health, 5(8), 3553-3558
World Bank (2014). World Bank Data. Available from: https://datahelpdesk.worldbank.org/knowledgebase/articles/906522-data-updates-and-errata
WHO (2015) WHO statement on caesarean section rates: Department of Reproductive Health and Research World Health Organization: https://apps.who.int/iris/bitstream/handle/10665/161442/WHO_RHR_15.02_eng.pdf
WHO (2018) World Health Statistics: World Health Organization. Geneva.https://apps.who.int/iris/rest/bitstreams/1137482/retrieve
WHO, UNICEF (2013) Trends in maternal Mortality: 1990 to 2013. Estimates by WHO, UNICEF, UNFPA, The World Bank. Geneva: https://apps.who.int/iris/handle/10665/112697
WHO (2019) World Health Statistics -2019: World Health Organization, Genevahttps://www.who.int/data/gho/data/themes/theme-details/GHO/world-health-statistics
World Bank (2019). Pakistan overview: Available from https://www.worldbank.org/en/country/pakistan/overview
WHO (2021) Maternal deaths decline slowly with vast inequalities worldwide (updated 2021). https://www.who.int/news/item/19-09-2019-maternal-deaths-decline-slowly-with-vast-inequalities-worldwide
WHO & World Bank (2019). Global Monitoring Report on Financial Protection in Health. International Bank for Reconstruction and Development.https://www.who.int/publications/i/item/9789240003958
WHO (2017) World Health Organization. Maternal Health. retrieved from https://www.who.int/health-topics/maternal-health#tab=tab_1?
Ansari, M. S., Manzoor, R., Siddiqui, N., & Ahmed, A. M. (2015). Access to comprehensive emergency obstetric and newborn care facilities in three rural districts of Sindh province, Pakistan. Health Research Policy and Systems, 13(1), https://doi.org/10.1186/s12961-015-0042-7
ADB (2012). Asian Development Bank. Available athttps://www.adb.org/sites/default/files/publication/29704/ado2012.pdf
Berer, M. (2012). Maternal mortality or women’s health: time for action. Reproductive Health Matters, 20(39), 5-10. https://doi.org/10.1016/s0968-8080(12)39632-8
Chhetri, S., Shah, R., & Rajbanshi, L. (2020). Factors associated with utilization of complete postnatal care service in Baglung Municipality, Nepal. Int J Reprod Med, 2892751. https://doi.org/10.1155/2020/2892751
Goli, S., Rammohan, A., & Moradhvaj. (2018). Out-of-pocket expenditure on maternity care for hospital births in Uttar Pradesh, India. Health Economics Review, 8(5), https://doi.org/10.1186/s13561-018-0189-3
Gopalan, S. S., & Durairaj, V. (2012). Addressing maternal healthcare through demand side financial incentives: Experience of Janani Suraksha Yojana program in India. BMC Health Services Research, 12, 319.
Govil, D., Purohit, N., Gupta, S. D., & Mohanty, S. K. (2016). Out-of-pocket expenditure on prenatal and natal care post Janani Suraksha Yojana: a case from Rajasthan, India. Journal of Health, Population and Nutrition, 35(1), doi: https://doi.org/10.1186/s41043-016-0051-3
Issac, A., Chatterjee, S., & Srivastava, A., & Bhattacharyya, S. (2016). Out of pocket expenditure to deliver at public health facilities in India: a cross sectional analysis.Reproductive Health, 13(99). https://doi.org/10.1186/s12978-016-0221-1
Khan, A., & Zaman, S. (2010). Costs of vaginal delivery and caesarean section at a tertiary level public hospital in Islamabad, Pakistan. BMC Pregnancy Childbirth, 10(2), https://doi.org/10.1186/1471-2393-10-2
Krishnamoorthy, Y., Ganesh, K., Sakthivel, M., & Priyan, S. (2020). Costs incurred and determinants of out-of-pocket payments for child delivery care in India: Evidence from a nationally representative household survey. Int J Health Plann Manage, 35(1), e167-e177. doi: https://doi.org/10.1002/hpm.2953.
Kyei-Nimakoh, M., Carolan-Olah, M. & McCann, T.V. (2017). Access barriers to obstetric care at health facilities in sub-Saharan Africa—a systematic review. Syst Rev 6, 110. https://doi.org/10.1186/s13643-017-0503-x
Malik, A. M., & Syed, S. M. (2012). Socio-economic determinants of household out-of-pocket payments on healthcare in Pakistan. Int J Equity Health, 4(11), 51. https://doi.org/10.1186/1475-9276-11-51
Mansuri, G., Sami, M.F., Ali, M., Doan, H.T.T., Javed, B., & Pandey, P. (2018). When water becomes a hazard: A diagnostic report on the state of water supply, sanitation and poverty in Pakistan and its impact on child stunting (English). WASH Poverty Diagnostic Series. Washington, D.C.: World Bank Group.
Merga, M., Debela, T. F., & Alaro, T. (2019). Hidden costs of hospital-based delivery among women using public hospitals in bale zone, Southeast Ethiopia. Journal of Primary Care & Community Health, 10, https://doi.org/10.1177/2150132719896447
MICS (2017-2018), Punjab Survey findings report, Multiple Indicator Cluster survey. available on https://www.unicef.org/pakistan/media/3121/file/Multiple%20Indicator%20Cluster%20Survey%202017-18%20-%20Punjab.pdf
Mirabedini, S. A., Fazl, E., Hashemi, S. M., Asiabar, S., Rezapour, A., Azami-Aghdash, S., & Amnab, H. (2017). Out-of-pocket and informal payments in Iran's health care system: A systematic review and meta-analysis. Medical Journal of the Islamic Republic of Iran, 31(1), 401-409. https://doi.org/10.14196/mjiri.31.70
Mohanty, S. K., & Srivastava, A. (2013). Out-of-pocket expenditure on institutional delivery in India.Health Policy and Planning, 28(3), 247–262, https://doi.org/10.1093/heapol/czs057
Mohanty, S. K., Kim, R, Khan, P. K., & Subramanian, S. V. (2018). Geographic variation in household and catastrophic health spending in India: Assessing the relative importance of villages, districts, and states. Milbank Q., 96(1), 167–206.
Myint, A. N. M., Liabsuetrakul, T., Htay, T., & Wai, M.M, Sundby, J., & Bjertness, E. (2018). Impoverishment and catastrophic expenditures due to out-of-pocket payments for antenatal and delivery care in Yangon Region, Myanmar: a cross-sectional study. BMJ Open, 8(11),
National Institute of Population Research and Training (2013) Bangladesh Demographic & Health survey 2011. Dhaka, Bangladesh and Calverton, Maryland, USA: NIPORT, Mitra and Associates, and ICF International. Retrieved from: https://dhsprogram.com/pubs/pdf/fr265/fr265.pdf
Noreen, S. (2017) Determinants of Demand for Maternal Health Care Services: A Survey Study of Bahawalpur District. (Doctoral thesis) The Islamia University of Bahawalpur.
Pakistan Bureau of Statistcis PBS Government of Paksitan (2018). 7th population and Housing census 2022. Retrived from https://www.pbs.gov.pk/
Pomeroy, A., Koblinsky, M. M., & Alva, S. (2014). Who gives birth in private facilities in Asia? A Look at Six Countries. Health Policy and Planning, 29, 38-47.
Prinja, S., Bahuguna, P., Gupta, R., Sharma, A., Rana, S. K., & Kumar, R. (2015). Coverage and financial risk protection for institutional delivery: How universal is provision of maternal health care in India? Plos One, 10(9), e0137315. https://doi.org/10.1371/journal.pone.0137315
Qureshi, R.N., Sheikh, S., Khowaja, A.R., Hoodbhoy, Z., Zaidi, S., Sawchuck, D., Vidler, M., Bhutta, Z.A., & Dadeslzen, P. (2016) Health care seeking behaviours in pregnancy in rural Sindh, Pakistan: a qualitative study. Reproductive Health, 13(1), 34.
Rahman, M.M., Gilmour, S., Saito, E., Sultana, P., & Shibuya, K. (2013). Health-related financial catastrophe, inequality and chronic illness in Bangladesh. PLoS One, 8(2), e56873. https://doi.org/10.1371/journal.pone.0056873
Rehman, A., Adnan, M., Mahmood, H., Hassan, M., & Humayun, A. (2017). Maternal health care expenditure among women in rural areas of Pakistan. Annals of King Edward Medical University, 23(2). doi: https://doi.org/10.21649/akemu.v23i2.1587
Riaz, A., Zaidi, S., & Khowaja, A. R. (2015). Perceived barriers to utilizing maternal and neonatal health services in contracted-out versus government-managed health facilities in the rural districts of Pakistan. International Journal of Health Policy and Management, 4(5), 279-284. doi: https://doi.org/10.15171/ijhpm.2015.50
Razumowsky, A. I. (2022). Distance education: A ruin of health. Amazonia Investiga, 11(50), 290-298. https://doi.org/10.34069/AI/2022.50.02.27
Sarkar, A. R., Sultana, M., Ali, N., & Akram, R. (2018). Cost comparison and determinants of out-of-pocket payments on child delivery care in Bangladesh. International Journal of Health Planning and Management, 33(9693), https://doi.org/10.1002/hpm.2615
Sharma, S., Verma, P. B., Viramgami, A. P., Vala, M.C., & Lodhiya, K. K. (2018). Analysis of out-of-pocket expenditure in utilization of maternity care services in urban slums of Rajkot City, Gujarat. Indian J Community Med, 43, 215-9
Sidney, K., Salazar, M., Marrone, G., Diwan, V., DeCosta, A., & Lindholm, L. (2016) Out-of-pocket expenditures for childbirth in the context of the Janani Suraksha Yojana (JSY) cash transfer program to promote facility births: who pays and how much? Studies from Madhya Pradesh, India. Int J Equity Health 15, 71. https://doi.org/10.1186/s12939-016-0362-4
Sughra, M., Fatima, F., Marrium, M., & Abbas, K. (2018). Maternal health expenditures and health seeking behavior among lowest wealth quintile of the rural population in an under developed district of the Punjab, Pakistan. Int J Reprod Contracept Obstet Gynecol, 7, 2579-82.
Srivastava, N. M., Awasthi, S., & Agarwal, G.G. (2009). Care-seeking behavior and out-of-pocket expenditure for sick new-borns among urban poor in Lucknow, Northern India: A prospective follow-up study. BMC Health Serv Res, 61, 9.
Tellis, S. B., Rent, P. D., & Dmello, M. K. (2018). Utilization of antenatal care and out of pocket expenditure on delivery care in Dakshina Kannada. Int J Community Med Public Health, 5(8), 3553-3558
World Bank (2014). World Bank Data. Available from: https://datahelpdesk.worldbank.org/knowledgebase/articles/906522-data-updates-and-errata
WHO (2015) WHO statement on caesarean section rates: Department of Reproductive Health and Research World Health Organization: https://apps.who.int/iris/bitstream/handle/10665/161442/WHO_RHR_15.02_eng.pdf
WHO (2018) World Health Statistics: World Health Organization. Geneva.https://apps.who.int/iris/rest/bitstreams/1137482/retrieve
WHO, UNICEF (2013) Trends in maternal Mortality: 1990 to 2013. Estimates by WHO, UNICEF, UNFPA, The World Bank. Geneva: https://apps.who.int/iris/handle/10665/112697
WHO (2019) World Health Statistics -2019: World Health Organization, Genevahttps://www.who.int/data/gho/data/themes/theme-details/GHO/world-health-statistics
World Bank (2019). Pakistan overview: Available from https://www.worldbank.org/en/country/pakistan/overview
WHO (2021) Maternal deaths decline slowly with vast inequalities worldwide (updated 2021). https://www.who.int/news/item/19-09-2019-maternal-deaths-decline-slowly-with-vast-inequalities-worldwide
WHO & World Bank (2019). Global Monitoring Report on Financial Protection in Health. International Bank for Reconstruction and Development.https://www.who.int/publications/i/item/9789240003958
WHO (2017) World Health Organization. Maternal Health. retrieved from https://www.who.int/health-topics/maternal-health#tab=tab_1?
Published
2022-08-30
How to Cite
Akhtar, S., Ahmed, Z., Nair, K. S., Mughal, Y. H., & Mehmood, A. (2022). Out-of-Pocket Expenditure on Delivery Care in Public and Private Health Sectors – A Study in a Rural District of Pakistan. Amazonia Investiga, 11(54), 121-136. https://doi.org/10.34069/AI/2022.54.06.12
Issue
Section
Articles
.gif)
