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Year : 2018  |  Volume : 31  |  Issue : 3  |  Page : 846-849

Out-of-pocket health expenditure in rural population

Family Medicine Department, Faculty of Medicine, Menoufia University, Shebin Elkom, Menoufia, Egypt

Date of Submission26-Mar-2017
Date of Acceptance29-May-2017
Date of Web Publication31-Dec-2018

Correspondence Address:
Basma S Ibrahem
Family Medicine Department, Faculty of Medicine, Menoufia University, Shebin Elkom, Menoufia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mmj.mmj_223_17

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The aim of this study was to distinguish between the different determinants of out-of-pocket (OOP) health expenditure in rustic Egypt.
OOP well-being expenditure represents 60% of total health expenditures in Egypt. Numerous families in Egypt depend on OOP to fund healthcare services. This specifically impacts their entrance to quality well-being administrations. Creating knowledge about the determinants of OOP is a need to configuration polices that shield family units from impoverishment.
Patients and methods
The study was a cross-sectional one that was directed in country zone, lower Egypt, from September 2015 to October, 2016. The calculated sample size was 380 participants selected by means of systematic random sampling. They were divided according to the health expenditure in last medicinal services required in the recent weeks into the OOP and the non-OOP group. A predesigned questionnaire was utilized to recognize different determinants of OOP well-being use (e.g., age, sex, and health status).
An overall 85% of studied shared members had OOP costs over the most recent 4 weeks for healthcare. There was a statistically significant difference (P < 0.001) between displaying OOP and being a woman in childbearing age, living in high socioeconomic level, having chronic disease, absence of health insurance coverage, poor perception of health, and private care.
OOP health expenditure is more predominant in specific gatherings of population and is affected by basic determinants. Tending to such determinants ought to have a noteworthy impact on getting legitimate medicinal services and thus in the expectations for everyday comforts.

Keywords: finance, health, impoverishment, out-of-pocket

How to cite this article:
Farahat TM, Shaheen HM, Khalil NA, Ibrahem BS. Out-of-pocket health expenditure in rural population. Menoufia Med J 2018;31:846-9

How to cite this URL:
Farahat TM, Shaheen HM, Khalil NA, Ibrahem BS. Out-of-pocket health expenditure in rural population. Menoufia Med J [serial online] 2018 [cited 2020 Feb 24];31:846-9. Available from: http://www.mmj.eg.net/text.asp?2018/31/3/846/248732

  Introduction Top

The way a health framework is financed influences the execution of its different elements of stewardship, asset creation and administration arrangement, and at last the accomplishment of health framework objectives of well-being change, appropriate responsiveness, and reasonable monetary commitments[1]. The Egyptian healthcare might be best depicted as multifaceted and disconnected subsequently of the different levels of administrative offices and private associations that shape this arrangement of care[2].

Out-of-pocket (OOP) expenditure is the principal mean of financing healthcare in Egypt. Households are more overburdened with OOP compared with the vast majority of other lower center wage nations[3].

OOP is any direct payment by households to health experts, pharmaceuticals, examinations, and different administrations with basic purpose to share the reclamation or support of the well-being status of people or populace gatherings. It is a piece of private health expenditure[4]. OOP health expenditure could cause financial catastrophe to households, pushing them into poverty[5]. Moreover, dependence on OOP may build disparities in access to human services[6].

OOP expenditures constituted 49% of total national healthcare expenditure. Households paid an average of 6% of their total expenditure on healthcare services. Seven to 13% of households faced catastrophic health expenditures and poverty rates increased by up to 20% after healthcare expenditure was accounted for. It was also found that lower income and rural households faced greater risk of experiencing higher OOP health expenditure[7].

Knowledge about the determinants of OOP expenditure on health is vital from a health policy perspective to design the interventions or system changes that ensure accessible and financially protective health services to all people[7]. This study aimed to distinguish the different determinants of OOP health expenditure in rustic Egypt.

  Patients and Methods Top

Ethics: The study design was reviewed and formally approved by the Ethics Committee of Faculty of Medicine, Menoufia University, on 9 August 2015. Communications were made with the university and health professions to be oriented with the objectives and procedures of the study. Moreover, permissions were obtained to conduct the study. All participants were informed about the nature of study and those who consented were included in the study.

This study was a cross-sectional one and was carried out during the period from the 1 September 2015 to the end of September 2016 in rural area, lower Egypt. In this study, the sample size was calculated using EPI calc. program, version 12, considering 0.60 (WHO Anthro 2005) as the proportion of the population positive for the health conditions that will require payments[8], with a power of 80%, confidence interval (CI) of 95%, and 0.05 as the absolute sampling error that can be tolerated. Hence, the sample size was 344 households and then it was increased to 380 to round the figure. The sample size was collected through systematic random sample technique; every 13th house was selected (number of total households (5090) over the calculated sample size, 380) until the completion of calculated sample. The university hospital was chosen as starting points. Coordination with social workers within the hospital to guide the walk inside the study area.

The study unit included households, with the informant being either a male or female member who was older than 18 years old and available at the time of study. If there was more than one household in a house, a single household was selected by means of simple random sampling. The participants were sorted out according to health expenditure in last healthcare needed to the OOP and the non-OOP group. They were interviewed using a predesigned questionnaire that was divided into sections. The first section included identification data (age, sex, education, and occupation) and assessment of socioeconomic standard according to the scoring system of Fahmy et al.[9]. The second section included questions about health status description and, finally, health service utilization in last healthcare needed that was structured based on World Health Survey, Short Questionnaire, Rotation D (WHO Evidence and Information for Policy). This part included questions about determinants of OOP expenditure that included health insurance coverage, self-rating of health in the last 4 weeks, presence of chronic disease, and the type of facility where medical care was sought (governmental, private, excluding self-treatment) and the reasons for choosing this type of care.

Statistical analysis

The data were tabulated and analyzed using IBM Corp. released 2011. IBM SPSS statistics for Windows (version 20.0; IBM Corp., Armonk, New York, USA).

Two types of statistics were performed: descriptive statistics and analytic statistics, which included the χ2-test that was used to study the association between two qualitative variables. Odds ratio (OR) was calculated. A P value of less than 0.05 was considered statistically significant. A logistic regression was performed.

  Results Top

The share of OOP health expenditure in the last 4 weeks was 85%, whereas 15% of the participants had no OOP [Figure 1]. There was a statistically significant difference between the OOP and the non-OOP group as regards age grouping in relation to sex; OOP was high in women between 18 and 40 years of age (96%, P < 0.001), whereas in men the highest prevalence of OOP was observed in those between 40 and 60 years of age (93.8%, P < 0.001). OOP was prevalent in high socioeconomic standards (P < 0.001, with OR = 17.01); middle socioeconomic group was considered as a reference [Table 1]. Patients with chronic diseases were significantly more prevalent in the OOP group as about 94% of them paid OOP for health (P < 0.001) with OR (95% CI) of 3.42 (1.32–8.87); absence of chronic disease was considered as a reference group. Moreover, self-perception of illness by patients has a significant relationship with OOP as it is more prevalent with poorer self-perception of health (99.4%, P < 0.001), with an OR (95% CI) of 0.03 (0.004–0.22); perception of good health was considered as a reference group [Table 1]. Seeking care from private sector was significantly higher in the OOP group (P < 0.001), with an OR (95% CI) of 5.36 (2.77–10.35); governmental care was considered as a reference group. There was a statistically significant difference between the OOP and the non-OOP group as regards health insurance coverage as those not covered were more prevalent in the OOP group (88%, P < 0.001) [Table 1]. Logistic regression showed that the high socioeconomic status was associated with an increased likelihood of exhibiting OOP more than middle status (OR = 25 and 95% CI = 3.1–210) followed by the presence of chronic diseases (OR = 6.6 and 95% CI = 2.2–20) and seeking private care (OR = 0.03 and 95% CI = 1.05–6.3). However, participants in good health were less likely to exhibit OOP than those in poor health status by percent of 0.03 (OR = 0.03 and 95% CI = 0.003–0.21) [Table 2].
Figure 1: Frequency and percentage of out-of-pocket (OOP) payments in last healthcare needed.

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Table 1: Determinants of out-of-pocket expenditure

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Table 2: Binary logistic regression for prediction of out-of-pocket in health

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  Discussion Top

This study showed that most respondents of the study community had OOPs for healthcare consumption and this is nearly consistent with the results of national health account[3], which revealed that the vast majority of Egypt's health spending 72% came directly from household OOP payments. The study by Onwujekwe et al.[10] in southeast Nigeria also concluded that OOPs is the most common type of payment mechanism for healthcare consumption. The plausibility of this finding could be attributed to rural families having fewer choices of health facilities and preferring to use private clinics. OOPs were more prevalent among women in childbearing age; this is consistent with the findings of Whitehead et al.[11], who concluded that women spend more per capita compared with men for all types of outpatient and inpatient services. This may be attributed to lower insurance coverage for women as well as higher utilization rates for health services overall, especially private providers. This is in line with a Tanzanian study, which reported the prevalence of high informal payments and increased need for health service utilization among younger women and their children[7]. On the contrary, the findings of Onwujekwe et al.[10] showed that women were less likely compared with men to use OOPs in Udi district in Nigeria.

OOP health expenditures were more prevalent among participants of high socioeconomic standard. This is in agreement with the study by Geitona et al.[12], who concluded that those in the highest income quintile spent significantly more than those in the lowest income quintile. Chronic disease patients face relatively high OOP expenditure. These results are in line with Rashad and Sharaf[5], who explored catastrophic and impoverishing effects of OOP health expenditure in Egypt and concluded that chronic disease is a key risk factor not only for OOPs but also for catastrophic health payments. Moreover, Heltberg and Lund[13] stated that an additional financial burden over chronic disease patients is expected.

Self-reported health status, as a measure of healthcare need, is an important contributor to healthcare utilization and health spending. This result is consistent with Geitona et al.[12] and Mugisha et al.[14], who concluded that decision concerning whether to seek care and the amount of expenditure depend on the perception of seriousness of the illness.

OOPs expenditures were more common in private facilities than in governmental ones, and this is consistent with National Health Account[3], and analysis based on Household Health Expenditure and Utilization Survey data concluded that the vast majority of private sector funds come directly from households as OOP expenditure.

As regards health insurance coverage as one of the determinants of OOPs, those not covered by insurance system were more prevalent in the OOP group. This is in line with McWilliams et al.[15], who supported the hypothesis that previously uninsured adults used health services more intensively and required OOPs for care. However, Barakat and Halawa[1] concluded that having insurance does not always protect families from high OOP healthcare spending.

A logistic regression was performed to ascertain the effects of different determinants on the likelihood that participants have OOP. The probability increased in high socioeconomic status, presence of chronic disease, and private facilities. The probability decreased with good perception of health. Sex has no effect on the OOP probability in that model.

  Conclusion Top

OOP health expenditure is more predominant in specific gatherings of population and affected by basic determinants. Tending to such determinants ought to have a noteworthy impact in getting legitimate medicinal services and thus in the expectations for everyday comforts.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Barakat A, Halawa EF. Household costs of seeking outpatient care in Egyptian children with diarrhea: a cross-sectional study. Pan Afr Med J 2013;14:42.  Back to cited text no. 1
Haley DR, Bég SA. The road to recovery: Egypt's healthcare reform. Int J Health Plann Manage 2012; 27:e83–e91.  Back to cited text no. 2
Ministry of Health, Egypt, and Health Systems 20/20. National Health Accounts 2007/2008: Egypt Report. Bethesda, MD: Health Systems 20/20 Project, Abt Associates Inc.; 2010. Available from: https://www.hfgproject.org/wp-content/uploads/2015/02/National-Health-Accounts-2007-2008_Egypt-Report.pdf. [Last accessed on 2017 Nov 03].  Back to cited text no. 3
Kirigia JM, Preker A, Carrin G, Mwikisa C, Diarra-Nama AJ. An overview of health financing patterns and the way forward in the WHO African Region. East Afr Medl J 2006; 83:1–28.  Back to cited text no. 4
Rashad AS, Sharaf MF. Catastrophic economic consequences of healthcare payments: effects on poverty estimates in Egypt, Jordan, and Palestine. Am J Econ 2015; 3:216–234.  Back to cited text no. 5
Xu K, Evans DB, Carrin G, Aguilar-Rivera AM, Musgrove P, Evans T. Protecting households from catastrophic health spending. Health Aff 2007; 26:972–983.  Back to cited text no. 6
Brinda EM, Andrés RA, Enemark U. Correlates of out-of-pocket and catastrophic health expenditures in Tanzania: results from a national household survey. BMC Int Health Hum Rights 2014; 14:5.  Back to cited text no. 7
Handousa H, Sayed HA, El Araby A, Hamed R, Sobhy H, Al Zanaty F. Key development challenges facing Egypt. Cairo: Situation Analysis Taskforce; 2010. p. 73. Available from: http://www.eg.undp.org/content/dam/egypt/./2010_Sit%20Analysis_KDCFE_English.pdf. [Last accessed on 2017 Mar 25].  Back to cited text no. 8
Fahmy SI, Nofal LM, Shehata SF, El Kady HM, Ibrahim HK. Updating indicators for scaling the socioeconomic level of families for health research. J Egypt Public Health Assoc 2015; 90:1–7.  Back to cited text no. 9
Onwujekwe OE, Uzochukwu BSC, Obikeze EN, Okoronkwo I, Ochonma OG, Onoka CA, et al. Investigating determinants of out-of-pocket spending and strategies for coping with payments for healthcare in southeast Nigeria. BMC Health Serv Res 2010; 10:10–67.  Back to cited text no. 10
Whitehead M, Dahlgren G, Evans T. Equity and health sector reforms: can low-income countries escape the medical poverty trap? Lancet 2001; 358:833–836.  Back to cited text no. 11
Geitona, M, Zavras, D, Kyriopoulos, J. Determinants of healthcare utilization in Greece: implications for decision-making. Eur J Gen Pract 2007; 13:144–150.  Back to cited text no. 12
Heltberg R, Lund N. Shocks, coping, and outcomes for Pakistan's poor: health risks predominate. J Dev Stud 2009; 45:889–910.  Back to cited text no. 13
Mugisha F, Kouyate B, Gbangou A, Sauerborn R. Examining out-of-pocket expenditure on health care in Nouna, Burkina Faso: implications for health policy. Trop Med Int Health 2002; 7:187–196.  Back to cited text no. 14
McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Use of health services by previously uninsured Medicare beneficiaries. N Engl J Med 2007; 357:143–153.  Back to cited text no. 15


  [Figure 1]

  [Table 1], [Table 2]


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