Out-of-Pocket Expenditure on Chronic Non-Communicable Diseases in Sub-Saharan Africa: The Case of Rural Malawi

Abstract

In Sub-Saharan Africa (SSA) the disease burden of chronic non-communicable diseases (CNCDs) is rising considerably. Given weaknesses in existing financial arrangements across SSA, expenditure on CNCDs is often borne directly by patients through out-of-pocket (OOP) payments. This study explored patterns and determinants of OOP expenditure on CNCDs in Malawi. We used data from the first round of a longitudinal household health survey conducted in 2012 on a sample of 1199 households in three rural districts in Malawi. We used a two-part model to analyze determinants of OOP expenditure on CNCDs. 475 respondents reported at least one CNCD. More than 60% of the 298 individuals who reported seeking care incurred OOP expenditure. The amount of OOP expenditure on CNCDs comprised 22% of their monthly per capita household expenditure. The poorer the household, the higher proportion of their monthly per capita household expenditure was spent on CNCDs. Higher severity of disease was significantly associated with an increased likelihood of incurring OOP expenditure. Use of formal care was negatively associated with the possibility of incurring OOP expenditure. The following factors were positively associated with the amount of OOP expenditure: being female, Alomwe and household head, longer duration of disease, CNCDs targeted through active screening programs, higher socio-economic status, household head being literate, using formal care, and fewer household members living with a CNCD within a household. Our study showed that, in spite of a context where care for CNCDs should in principle be available free of charge at point of use, OOP payments impose a considerable financial burden on rural households, especially among the poorest. This suggests the existence of important gaps in financial protection in the current coverage policy.

The economic burden of chronic non-communicable diseases in rural Malawi: an observational study

“…Poorest households faced the highest risk of catastrophic spending due to CNCDs. These findings, which rely on direct costs for CNCDs aggregated at the household level, support findings from our previous work, which pointed at the regressivity of individual out-of-pocket expenditure on CNCDs [45]. These findings are also consistent with prior analyses of catastrophic spending, which included chronic conditions as an explanatory variable in models targeting the overall economic burden due to ill health in SSA [14, 15] and in LMICs more in general [28, 39, 42, 50, 51].…”

Determinants of Healthcare Utilisation and Out-of-Pocket Payments in the Context of Free Public Primary Healthcare in Zambia

“…Literature shows that in Africa, the decision to seek formal care or self-medicate can be dependent on the type of perceived illness. 45,46 It is important to bear in mind the survey did not ask about severity of the illness. Nonetheless, we would recommend that this issue be subject to further investigation in future studies.…”

“…44,46 Similarly, in a setting such as Zambia where there is no widespread health insurance, formal sector employment status provides a more effective means to afford healthcare payments. In terms of the influence of provider type, a visit to hospitals is associated with higher OOP payments largely because of more advanced treatment and longer distances (on average a patient resides nearer a health post or health centre than a hospital).…”

“…In fact, it has been demonstrated that even in the context of free health services at the point of care, geographical barriers to (and invariably the cost of) access remain an issue. 46 The finding that private facilities and higher level public facilities are associated with higher OOP payments might reflect either better quality or higher user fees or both, at these facilities. …”

Overdependence on For-Profit Pharmacies: A Descriptive Survey of User Evaluation of Medicines Availability in Public Hospitals in Selected Nigerian States

“…However, public health facilities are often characterized by inadequacy of supplies including medicines [2]. Medicines account for 20–60% of health spending in developing countries [3, 4, 5], and up to 90% of the population in developing countries purchase medicines through out-of-pocket payments [6, 7, 8, 9], which has impoverishing effects on the people [10]. Medicines make up the largest family expenditure item after food [11] because they are expensive [12], but offer a simple solution to many health problems, provided they are available [13].…”