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Naz L, Sriram S. Out-of-pocket expenditures associated with double disease burden in Pakistan: a quantile regression analysis. BMC Public Health 2024; 24:801. [PMID: 38486277 PMCID: PMC10938732 DOI: 10.1186/s12889-024-18320-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 03/10/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Pakistan is currently experiencing a double burden of disease. Families with members having both communicable and noncommunicable diseases are at a greater risk of impoverishment due to enormous out-of-pocket payments. This study examines the percentile distribution of the determinants of the out-of-pocket expenditure on the double disease burden. METHOD The study extracted a sample of 6,775 households with at least one member experiencing both communicable and noncommunicable diseases from the Household Integrated Economic Survey 2018-19. The dataset is cross-sectional and nationally representative. Quantile regression was used to analyze the association of various socioeconomic factors with the OOP expenditure associated with double disease burden. RESULTS Overall, 28.5% of households had double disease in 2018-19. The households with uneducated heads, male heads, outpatient healthcare, patients availing public sector healthcare services, and rural and older members showed a significant association with the prevalence of double disease. The out-of-pocket expenditure was higher for depression, liver and kidney disease, hepatitis, and pneumonia in the upper percentiles. The quantile regression results showed that an increased number of communicable and noncommunicable diseases was associated with higher monthly OOP expenditure in the lower percentiles (10th percentile, coefficient 312, 95% CI: 92-532), and OOP expenditure was less pronounced among the higher percentiles (75th percentile, coefficient 155, 95% CI: 30-270). The households with older members were associated with higher OOP expenditure at higher tails (50th and 75th percentiles) compared to lower (10th and 25th percentiles). Family size was associated with higher OOPE at lower percentiles than higher ones. CONCLUSION The coexistence of communicable and noncommunicable diseases is associated with excessive private healthcare costs in Pakistan. The results call for addressing the variations in financial costs associated with double diseases.
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Affiliation(s)
- Lubna Naz
- Department of Economics, School of Economics and Social Sciences, Institute of Business Administration, 75270, Karachi, Pakistan
| | - Shyamkumar Sriram
- Department of Social and Public Health, Ohio University, 45701, Athens, OH, USA.
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Azmat SK, Thom EM, Arshad M, Hamza HB, Aabroo A, Balal A, Awan MA, Rifaq F, Hemachandra N, Qudsia U. A study protocol for integrating outpatient services at the primary health care level as part of the universal health coverage benefit package within the national health insurance program of Pakistan through private health facilities. Front Public Health 2024; 12:1293278. [PMID: 38532967 PMCID: PMC10964903 DOI: 10.3389/fpubh.2024.1293278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 02/20/2024] [Indexed: 03/28/2024] Open
Abstract
Introduction and aim Pakistan has a mixed-health system where up to 60% of health expenditures are out of pocket. Almost 80% of primary healthcare (PHC) facilities are in the private sector, which is deeply embedded within the country's health system and may account for the unaffordability of healthcare. Since 2016, the existing national health insurance program or Sehat Sahulat Program (SSP), has provided invaluable coverage and financial protection to the millions of low-income families living in Pakistan by providing inpatient services at secondary and tertiary levels. However, a key gap is the non-inclusion of outpatient services at the PHC in the insurance scheme. This study aims to engage a private provider network of general practitioners in select union councils of Islamabad Capital Authority (ICT) of Pakistan to improve access, uptake, and satisfaction and reduce out-of-pocket expenditure on quality outpatient services at the PHC level, including family planning and reproductive health services. Methods and analysis A 24-month research study is proposed with a 12-month intervention period using a mixed method, two-arm, prospective, quasi-experimental controlled before and after design with a sample of 863 beneficiary families from each study arm, i.e., intervention and control groups (N = 1726) will be selected through randomization at the selected beneficiary family/household level from four peri-urban Union Councils of ICT where no public sector PHC-level facility exists. All ethical considerations will be assured, along with quality assurance strategies. Quantitative pre/post surveys and third-party monitoring are proposed to measure the intervention outcomes. Qualitative inquiry with beneficiaries, general practitioners and policymakers will assess their knowledge and practices. Conclusion and knowledge contribution PHC should be the first point of contact for accessing health services and appears to serve as a programmatic engine for universal health coverage (UHC). The research aims to study a service delivery model which harnesses the private sector to deliver an essential package of health services as outpatient services under SSP, ultimately facilitating UHC. Findings will provide a blueprint referral system to reduce unnecessary hospital admissions and improve timely access to healthcare. A robust PHC system can improve population health, lower healthcare expenditure, strengthen the healthcare system, and ultimately make UHC a reality.
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Affiliation(s)
- Syed Khurram Azmat
- Marie Stopes Society, Karachi, Pakistan
- AIPH - AAPNA Institute of Public Health, Jinnah Sindh Medical University, Karachi, Pakistan
| | | | | | - Hasan Bin Hamza
- Ministry of National Health Services, Regulations, and Coordination, Islamabad, Pakistan
| | - Atiya Aabroo
- Ministry of National Health Services, Regulations, and Coordination, Islamabad, Pakistan
| | | | - Muhammad Ali Awan
- Marie Stopes Society, Karachi, Pakistan
- AIPH - AAPNA Institute of Public Health, Jinnah Sindh Medical University, Karachi, Pakistan
| | - Faisal Rifaq
- Federal Sehat Sahulat Program, Islamabad, Pakistan
| | | | - Uzma Qudsia
- World Health Organization, Islamabad, Pakistan
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Zafar S, Loo PS, Avais AR, Afghan S, de Savigny D, Muñoz DC, Fruchtman CS. Unveiling Maternal Health Insights During the COVID-19 Pandemic in Pakistan: Using Causal Loop Diagrams to Illuminate and Prevent Unintended Policy Effects. Glob Health Sci Pract 2023; 11:e2100803. [PMID: 37903575 PMCID: PMC10615243 DOI: 10.9745/ghsp-d-21-00803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 09/13/2023] [Indexed: 11/01/2023]
Abstract
The authors explain that using causal loop diagrams can visualize retrospectively the unintended negative consequences of COVID-19 related policies on maternal health and has potential to be used prospectively to foster decision-making to prevent those consequences.
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Affiliation(s)
- Shamsa Zafar
- Fazaia Medical College, Air University, Islamabad, Pakistan
| | - Pei Shan Loo
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Saera Afghan
- Pakistan Institute of Medical Sciences, Islamabad, Pakistan
| | - Don de Savigny
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Daniel Cobos Muñoz
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Carmen Sant Fruchtman
- Swiss Tropical and Public Health Institute, Basel, Switzerland.
- University of Basel, Basel, Switzerland
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Coste M, Bousmah MAQ. Predicting health services utilization using a score of perceived barriers to medical care: evidence from rural Senegal. BMC Health Serv Res 2023; 23:263. [PMID: 36927564 PMCID: PMC10018867 DOI: 10.1186/s12913-023-09192-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 02/16/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Ensuring access to healthcare services is a key element to achieving the Sustainable Development Goal 3 of "promoting healthy lives and well-being for all" through Universal Health Coverage (UHC). However, in the context of low- and middle-income countries, most studies focused on financial protection measured through catastrophic health expenditures (CHE), or on health services utilization among specific populations exhibiting health needs (such as pregnancy or recent sickness). METHODS This study aims at building an individual score of perceived barriers to medical care (PBMC) in order to predict primary care utilization (or non-utilization). We estimate the score on six items: (1) knowing where to go, (2) getting permission, (3) having money, (4) distance to the facility, (5) finding transport, and (6) not wanting to go alone, using individual data from 1787 adult participants living in rural Senegal. We build the score via a stepwise descendent explanatory factor analysis (EFA), and assess its internal consistency. Finally, we assess the construct validity of the factor-based score by testing its association (univariate regressions) with a wide range of variables on determinants of healthcare-seeking, and evaluate its predictive validity for primary care utilization. RESULTS EFA yields a one-dimensional score combining four items with a 0.7 Cronbach's alpha indicating good internal consistency. The score is strongly associated-p-values significant at the 5% level-with determinants of healthcare-seeking (including, but not limited to, sex, education, marital status, poverty, and distance to the health facility). Additionally, the score can predict non-utilization of primary care at the household level, utilization and non-utilization of primary care following an individual's episode of illness, and utilization of primary care during pregnancy and birth. These results are robust to the use of a different dataset. CONCLUSION As a valid, sensitive, and easily documented individual-level indicator, the PBMC score can be a complement to regional or national level health services coverage to measure health services access and predict utilization. At the individual or household level, the PBMC score can also be combined with conventional metrics of financial risk protection such as CHE to comprehensively document deficits in, and progress towards UHC.
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Affiliation(s)
- Marion Coste
- Aix Marseille University, CNRS, AMSE, Marseille, France. .,Aix Marseille University, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France.
| | - Marwân-Al-Qays Bousmah
- Aix Marseille University, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France.,Université Paris Cité, IRD, Inserm, Ceped, Paris, F-75006, France
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Martins RS, Masood MQ, Mahmud O, Rizvi NA, Sheikh A, Islam N, Khowaja ANA, Ram N, Furqan S, Mustafa MA, Aamdani SS, Pervez A, Haider AH, Nadeem S. Adolopment of adult diabetes mellitus management guidelines for a Pakistani context: Methodology and challenges. Front Endocrinol (Lausanne) 2023; 13:1081361. [PMID: 36686436 PMCID: PMC9849674 DOI: 10.3389/fendo.2022.1081361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/16/2022] [Indexed: 01/06/2023] Open
Abstract
Introduction Pakistan has the highest national prevalence of type 2 diabetes mellitus (T2DM) in the world. Most high-quality T2DM clinical practice guidelines (CPGs) used internationally originate from high-income countries in the West. Local T2DM CPGs in Pakistan are not backed by transparent methodologies. We aimed to produce comprehensive, high-quality CPGs for the management of adult DM in Pakistan. Methods We employed the GRADE-ADOLOPMENT approach utilizing the T2DM CPG of the American Diabetes Association (ADA) Standards of Medical Care in Diabetes - 2021 as the source CPG. Recommendations from the source guideline were either adopted as is, excluded, or adapted according to our local context. Results The source document contained 243 recommendations, 219 of which were adopted without change, 5 with minor changes, and 18 of which were excluded in the newly created Pakistani guidelines. One recommendation was adapted: the recommended age to begin screening all individuals for T2DM/pre-diabetes was lowered from 45 to 30 years, due to the higher prevalence of T2DM in younger Pakistanis. Exclusion of recommendations were primarily due to differences in the healthcare systems of Pakistan and the US, or the unavailability of certain drugs in Pakistan. Conclusion A CPG for the management of T2DM in Pakistan was created. Our newly developed guideline recommends earlier screening for T2DM in Pakistan, primarily due to the higher prevalence of T2DM amongst younger individuals in Pakistan. Moreover, the systematic methodology used is a significant improvement on pre-existing T2DM CPGs in Pakistan. Once these evidence based CGPs are officially published, their nationwide uptake should be top priority. Our findings also highlight the need for rigorous expanded research exploring the effectiveness of earlier screening for T2DM in Pakistan.
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Affiliation(s)
- Russell Seth Martins
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University, Karachi, Pakistan
| | - Muhammad Qamar Masood
- Section of Endocrinology, Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Omar Mahmud
- Medical College, Aga Khan University, Karachi, Pakistan
| | - Nashia Ali Rizvi
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University, Karachi, Pakistan
| | - Aisha Sheikh
- Section of Endocrinology, Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Najmul Islam
- Section of Endocrinology, Department of Medicine, Aga Khan University, Karachi, Pakistan
| | | | - Nanik Ram
- Section of Endocrinology, Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Saira Furqan
- Section of Endocrinology, Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Mohsin Ali Mustafa
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University, Karachi, Pakistan
| | | | - Alina Pervez
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University, Karachi, Pakistan
| | | | - Sarah Nadeem
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University, Karachi, Pakistan
- Section of Endocrinology, Department of Medicine, Aga Khan University, Karachi, Pakistan
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Forman R, Ambreen F, Shah SSA, Mossialos E, Nasir K. Sehat sahulat: A social health justice policy leaving no one behind. Lancet Reg Health Southeast Asia 2022; 7:100079. [PMID: 37383932 PMCID: PMC10305855 DOI: 10.1016/j.lansea.2022.100079] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Affiliation(s)
- Rebecca Forman
- London School of Economics and Political Sciences, London, UK
| | - Faiza Ambreen
- London School of Economics and Political Sciences, London, UK
| | | | - Elias Mossialos
- London School of Economics and Political Sciences, London, UK
- Imperial College London, London, UK
| | - Khurram Nasir
- London School of Economics and Political Sciences, London, UK
- Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
- Center for Cardiovascular Computational & Precision Health (C3-PH), Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
- Division of Health Equity & Disparities Research, Center for Outcomes Research, Houston Methodist, Houston, TX, USA
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Khalid F, Raza W, Hotchkiss DR, Soelaeman RH. Correction to: Health services utilization and out-ofpocket (OOP) expenditures in public and private facilities in Pakistan: an empirical analysis of the 2013-14 OOP health expenditure survey. BMC Health Serv Res 2021; 21:570. [PMID: 34107923 PMCID: PMC8191127 DOI: 10.1186/s12913-021-06545-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Faraz Khalid
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA. .,Present address: Universal Health Coverage/Health Systems Department, World Health Organization, Regional Office for the Eastern Mediterranean, Monazamet El Seha El Alamia Str, Extension of Abdel Razak El Sanhouri Street, P.O. Box 7608, Nasr City, Cairo, 11371, Egypt.
| | | | - David R Hotchkiss
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA
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Habib SS, Zaidi S. Exploring willingness to pay for health insurance and preferences for a benefits package from the perspective of women from low-income households of Karachi, Pakistan. BMC Health Serv Res 2021; 21:380. [PMID: 33892702 PMCID: PMC8067289 DOI: 10.1186/s12913-021-06403-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/15/2021] [Indexed: 11/16/2022] Open
Abstract
Background Achieving universal health coverage (UHC) and reduction in out of pocket (OOP) expenditures on health, is a critical target of the Sustainable Development Goals (SDG). In low-middle income countries, micro-health insurance (MHI) schemes have emerged as a useful financing tool for laying grounds for Universal Health Coverage. The aim of this study was to provide evidence for designing a feasible health insurance scheme targeted at urban poor, by exploring preferences for an insurance benefits package and co-payments among women from low-income households in Karachi, Pakistan. Methods This was a descriptive cross-sectional study, conducted using household surveys between July–August 2015. A total of 167 female beneficiaries of Benazir Income Support Programme (BISP), a large-scale cash transfer scheme targeted at low-income households, were recruited in Karachi through a mix of convenience and snowball sampling. Hypothetical insurance benefits packages for a prospective health insurance scheme were formulated to capture respondents’ preferences for health insurance benefits package and co-payments. All data was analyzed using Stata (version 13). Results Respondents reporting expenditure on OPD and hospitalization in the last 2 weeks were 93.4 and 11.9% respectively. The highest median expenditure was incurred on medicines. Out of the proposed benefits package, a majority (53%) of the study participants opted for the comprehensive benefits package that provided coverage for emergency care, hospitalization, OPD consultation, diagnostic tests and transportation. For the co-payment plan, 38.9% participants preferred no co-payments that is 100% insurance coverage of medicines followed by hospitalization (25.9%). Nearly half of the respondents (49.4%) chose outpatient consultation for 50% co-payment. A majority of the participants (65.3%) agreed to 100% co-payment for the transportation cost. Conclusion Health insurance schemes can be introduced in urban areas, against collection of micro-payments, to prevent low-income households from facing financial catastrophe. A comprehensive benefits package covering emergency care, hospitalization, OPD consultation, diagnostic tests and transportation, is the most preferred among low-income beneficiaries.
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Affiliation(s)
- Shifa Salman Habib
- Community Health Solutions, 9th Floor, Al-Tijarah Building, Main Shahrah-e-Faisal, Karachi, Pakistan.
| | - Shehla Zaidi
- Department of Community Health Sciences, The Aga Khan University, National Stadium Road, Karachi, Pakistan
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