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Examining Equity in Out-Of-Pocket Expenditures and Utilization of Healthcare Services in Malawi

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Examining Equity in Out-Of-Pocket Expenditures and Utilization of Healthcare Services in Malawi AN ABSTRACT OF THE DISSERTATION OF Ruth Hope Mwandira for the degree of Doctor of Philosophy in Public Health presented on May 31, 2011. Title: Examining Equity in Out-of-Pocket Expenditures and Utilization of Healthcare Services in Malawi Abstract approved: _______________________________________________________________ Chunhuei Chi Best international health practice requires that all people benefit equally from health care services regardless of their socio-economic status and that healthcare payments be based on ability to pay. Although recent household surveys in Malawi show progress in a number of health indicators population averages, many inequalities in health outcomes still exist or are widening among households stratified by socioeconomic and geographical location variables. Inequalities in out-of-pocket expenditures (OOPEs) for healthcare and how they influence utilization of healthcare services are of particular interest to policy makers as they ultimately affect overall health of households. The rationale for this study is that analysis of inequities in healthcare between socioeconomic groups can help to unmask intra-group and between groups’ inequities hidden in national population averages. The study’s three main papers examined equity in households’ out-of-pocket healthcare payments and utilization of medical care. The study adopted the widely used economic frameworks and techniques developed by O’Donnell et al (2008) for analyzing health equity using household data. These economic frameworks focus on the notion of equal treatment for equal need and that payment for healthcare should be according to ability to pay. The Malawi Integrated Household Survey 2(2005) (MIHS2) was the main dataset used in the analysis. The MIHS2 is currently the only dataset that presents inequalities in healthcare expenditures at the household level in Malawi. However, the MIHS2 report does not examine the extent to which these inequalities are inequities. It is in this context that the first study focused on assessing, first, the progressivity of OOPEs for healthcare and second, the redistributive effect of OOPEs for healthcare as a source of finance in the Malawi health system. The progressivity results indicate that OOPEs for healthcare are relatively regressive in Malawi with the poor shouldering the highest financial burden relative to their ability to pay. The study found no evidence of redistributive effect of OOPEs on income inequalities in Malawi. The second study focused on linking OOPEs to use of healthcare using the recommended two-part model (Probit and OLS). The concentration indices were decomposed into contributing factors after standardizing for health need factors, which include age, sex, self-assessed health, chronic illness and disabilities. Probability of use of healthcare and OOPEs were both found to be concentrated among the non-poor while the poor who have higher health need have less use of healthcare. The last study assessed the socioeconomic factors associated with horizontal equity in use of medical facilities and predicted use using logistic regression. General medical facilities use was found to be more concentrated among the non-poor despite the poor having a higher health need. The results showed no significant inequalities in use of public medical facilities and self-treatment between the poor and the non-poor. Overall, inequalities in healthcare utilization and out-of-pocket healthcare expenditures in Malawi are mainly influenced by socioeconomic factors, which are non-need factors than health need factors. Inequalities due to non-need factors suggest presence of inequities, which are avoidable and unjust. This study can help policy makers have a better understanding of the possible effects of OOPEs and help in explaining the factors contributing to inequities in medical care utilization in Malawi. Such information is necessary so that highest priority should be given to the health problems or challenges disproportionately affecting households with varying levels of socioeconomic privilege. ©Copyright by Ruth Hope Mwandira May 31, 2011 All Rights Reserved Examining Equity in Out-of-Pocket Expenditures and Utilization of Healthcare Services in Malawi by Ruth Hope Mwandira A DISSERTATION submitted to Oregon State University in partial fulfillment of the requirements for the degree of Doctor of Philosophy Presented May 31, 2011 Commencement June 2012 Doctor of Philosophy dissertation of Ruth Hope Mwandira presented on May 31, 2011. APPROVED: ____________________________________________________________ Major Professor, representing Public Health ___________________________________________________________ Chair of the Department of Public Health ____________________________________________________________ Dean of the Graduate School I understand that my dissertation will become part of the permanent collection of Oregon State University libraries. My signature below authorizes release of my dissertation to any reader upon request. _______________________________________________________ Ruth Hope Mwandira, Author ACKNOWLEDGEMENTS The completion of this dissertation could not have been possible without the support of some key people. First, I would like to thank God Almighty for divine intervention. I would like to express my sincere gratitude to my Major Professor, Dr. Chunhuei Chi for his unwavering guidance and mentorship throughout the dissertation process. His dedication and commitment to his students is unsurpassed. Special thanks go to Dr Peter Tony Lachenbruch for his statistical guidance and editing the drafts. I am also grateful to the other members of my committee, Dr. Sunil Khanna, Dr Ellen Smit and the Graduate Council Representative Dr. Kate MacTavish. I am deeply grateful to my family who patiently supported me throughout this long journey. Special thanks go to my husband Chimwemwe (Sr), for his love, encouragement and endurance of my absence, but more so for being there for me. Thanks to all my dear children: Khama, Linda, Lily and Chimwemwe (Jr) for their support and love. I cannot forget to thank all friends who supported me in one way or the other to make my stay possible and an unforgettable experience in Corvallis, Oregon: Wilma Hull (special thanks), Daphne, Jean, Lizzie, Alicia, Scholastique, Steve, Ray and Nancy William and many others too many to mention. To Michael McGowen in Corvallis, Willie Kachaka from Malawi National Statistical Office and World Bank officials in Malawi (Dr Chale) and Washington DC, thanks for helping with data preparation and statistical help with the economic frameworks. I would like to acknowledge the support of American Association of University Women, Philanthropy Educational Organization and World Bank MMMF scholarship awards, the Thayer Raymond Fellowship for research award and the OSU Public Health department Graduate Teaching Assistantship. Your financial support helped me to realize my dream. This is for the women of Malawi. You can do it! Thank you all. CONTRIBUTION OF AUTHORS Ruth Hope Mwandira has conceptualized the study, drafted, and conducted all data analyses presented. Dr. Chunhuei Chi guided all aspects of this research, provided editorial comments, suggestions on the analysis and interpretation of findings. Dr. Peter Tony Lachenbruch provided editorial comments and suggestions on the structure and some of the statistics in Manuscript 2 and 3. TABLE OF CONTENTS Page Chapter 1: Introduction…………………………………………………………...1 Background …................................................................................................... 2 Statement of the problem and motivation…..................................................... .4 Purpose of study ………………………………………………………………6 Research questions …………………………………………………………….6 Significance of study …………………………………………………………11 Analytical and Theoretical frameworks….........................................................13 Overview of the healthcare system in Malawi ……………………………… 19 Overview of the Methodology ……………………………………………… 24 Chapter 2: Manuscript 1 ………………………………………………………… 32 Examining the progressivity of out-of-pocket expenditures for healthcare for for households in Malawi Chapter 3: Manuscript 2 ………………………………………………………… 87 Examining socioeconomic factors influencing equity in out-of-pocket expenditures and utilization of healthcare in Malawi Chapter 4: Manuscript 3 ……………………………………………………….. 150 Assessing the socioeconomic factors influencing equity in utilization of medical care in Malawi Chapter 5: Conclusions and Recommendations….……………………………. 205 Limitations …................................................................................................ .212 Recommendations for future research ……………………………………... 214 Bibliography …………………………………………………………………… 217 Appendices ……………………………………………………………………. .229 LIST OF FIGURES Figure Page 2.1. Example of concentration curve of health payments and Lorenz curve………….50 2.2. Average annual OOPEs for healthcare by consumption quintiles in Malawi in 2004/05………………………………………………………………………….. 66 2.3. OOPEs for healthcare as a percent of gross income by quintiles in Malawi in 2004/05…………………………………………………………………………68 2.4. Concentration curves for OOPEs for healthcare and Lorenz curve……………….69 2.5. Contribution of various funding sources to per capita total expenditure on health in US$ in Malawi……………………………………………………………….....74 3.1. Simple model explaining horizontal inequity………..............................................109 3.2. Concentration curves of probability of use of
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