Equity Shortfalls & Failure of The Welfare State: Community Willingness to Pay for Health Care at Government Facilities in Jehlum (Pakistan)

Tayyeb Imran Masud, Nasir Farooq*, Abdul Ghaffar**

Health Services Academy, Islamabad, Pakistan, *Department of Community Medicine, Ayub Medical College, Abbottabad, **Global Forum for Health Research, Geneva, Switzerland

Background: The question of willingness to pay is very crucial in planning for services. In Pakistan, the long-term issues of sustainability of health systems particularly, allocation of finances have routinely been addressed by planners with insufficient data and unclear goals. This study was conducted with the objectives to determine the demand for health care services in the community; at first level care facilities and community level and determine the willingness of the community (Willingness to pay) to participate in cost sharing mechanisms for provision of primary health care in fee for service and prepayment mechanisms. Methods: A cross sectional stratified household interview survey of 600 households was carried out in urban and rural areas of district Jehlum, to address the financial sustainability of government health care interventions at the community level and to explore the question of willingness to pay for health care and their ability to participate in the cost sharing mechanisms. Results: In response to willingness to pay at a Government facility to obtain health care 437 (72.7%) of the households expressed their willingness to pay for health care. In 72% of the cases, cost was not considered as a barrier in seeking care and only 19% of the cases considered cost as a partial barrier; the rest said that cost prohibited seeking care. A majority across all strata is willing to pay for consultation and medicines at public sector facilities, although the responses from the low income groups exhibit a slight decrease in the willingness to pay. The willingness to pay is marginally affected by income, place of residence and/or cost of the treatment incurred. Conclusion: The findings of this study suggest that the community is willing to pay for health care at the public sector facilities if payment can ensure provision of essential curative services and medications at improved quality levels.

Key Words: Health Expenditures, Equity, Cost sharing, Health Services Needs and Demands 


INTRODUCTION     

A welfare state strives to guarantee to its citizens health care. The emergence of the New World Order, riding on the crest of the wave of market economy changed many of the realities that were previously taken as granted. In a uni-polar world dominated by the market forces, the real politics has changed and the time has come for the lesser-developed nations to review the current state of affairs and carefully plot out the future courses of action available.1 Up to the early 1980’s, in the less developed countries, health care used to be donor driven with the UN family and International Donors playing a major role. The policies and interventions in the health care arena were under the control of health professionals with a view to achieve the ultimate objectives of providing health care. The “effectiveness of interventions” played a major role in determining the flow of funds. This scenario changed with the emergence of the Bretton Woods institutions in the late eighties as a major player in health sector financing. The 1993 World Development report2 is a major policy document, which has decisively transformed the time-honored traditions and beliefs of health care. Issues of efficiency and performance were brought to the forefront by the economists at the IMF and World Bank.3 The World Health Organization has followed it up with a Health Systems Performance report4, and a report by the commission on Macroeconomics and Health  which shifts the focus of discussion from egalitarian provision of all services to all the population to a more pragmatic approach of equitable distribution of possible services. The major shift is from “health professionals” providing “effective” solutions to health care problems to “economists” planning “efficient” solutions.5 The methodology of Burden of Disease, in priority setting, has revolutionized the historic traditions of identification of interventions first and then putting them high on the priority list.

These developments have added further burden on the already under performing health systems like Pakistan. The question of sustainability of health care service provision is a burning issue in the policy making and health care financing arena. In Pakistan, the long-term issues of sustainability of health systems particularly, human resource development and allocation of finances have routinely been addressed by planners with the short-term gains in mind and the result is that in the WHO 2000 report, Pakistan ranks quite low in health systems performance indicators.

The question of resource distribution, compounded with the desire to provide health care for all, is challenging in all countries whether they are developed or less developed. In the National Health Policy, the government of Pakistan has duly recognized that alone it cannot bear the cost of providing health care to the nation and different mechanisms have been suggested for resource mobilization. Among these is granting autonomy to various teaching hospitals, strengthening of district hospitals, developing public private partner-ships and privatization of primary level health facilities.6,7

The paucity of information on equitable allocation of resources predicts the actual situation of available literature on the subject. The willingness to pay has not been documented for the different initiatives of alternative financing strategies and the level of participation/ability is yet to be addressed in Pakistan.

This study was carried out at the first level care facility to address the financial sustainability of government health care interventions at the community level.

This study was undertaken to explore the question of willingness to pay for health care from the communities’ perspective and their ability to participate in the cost sharing mechanisms. The objectives of the study were to determine the demand for health care services in the community; at first level care facilities and community level and to determine the willingness of the community (Willingness to pay) to participate in cost sharing mechanisms for provision of primary health care on the following aspects of alternative financing mechanisms: -

(a)           Fee for Service

(b)           Prepayment

MATERIAL AND METHODS

The survey was conducted in November 1998 and the study population was all the households (approx 155,000 households) in District Jehlum of Punjab Province in Pakistan, Jehlum was chosen as it has been at the forefront of implementation of interventions and health care reforms. The survey was cross sectional household  interview survey. Household was defined as all the members of a family living within one compound and using the one kitchen.

For the survey, a multi stage clustering technique was applied in which the Primary Sampling Units were all households in district Jehlum. Three strata were identified as Urban, Semi Urban, and Rural. The staging was done at Ward (Urban areas are divided into municipality wards of 15-20,000 population each) in urban and semi urban areas, and Union Council (Rural areas are divided into Union Councils administratively of approx 15,000 populations each ) and Village Level in the rural area. For sample size calculation, absolute precision (d) was taken as 5 percentage points and expected prevalence (p) was taken at 50% assuming that 50% will be willing to pay. The design effect was taken as 1.5 due to the multi stage sampling methodology. The required sample size came to 577 households; this was rounded out to 600 households. The questionnaire developed by UNICEF for Health Care Demand and Health Expenditures Survey in the Bamako Initiative was modified and adapted for the survey.

In each enumerated household, the head of the family or in case of non-availability the eldest family member, mother, father or wife of head of household were interviewed. The minimum qualification of the survey team was graduate and two medical doctors were supervising the data collection throughout. The question asked was: Would you be willing to pay for health care at the government health facility? For what services and what are your conditions? And what is the maximum amount you would be willing to pay?

A Socio- Economic Score (SES) was constructed for the households and groups were made according to quartiles. The data was analyzed using EPI INFO 6.04 D and MS Excel.

RESULTS

The survey population comprised of 601 households, out of this 72% was in the rural area, 11% in the semi urban area, and 17% in the urban area. The average number of persons in a household was 6.9. The per capita income was Rs 894 (U$18 approx at exchange rate of 1998 Rs 48=U$1) per month and per capita expenditures were Rs 901, the expenditure on food on average comprised of 50% of the total expenditure.

Socio demographic profile

The proportion of under 15 years of age in the population was 42.1% while above 60 years was 6%.. The sex distribution was 105 males to 100 females. The overall adult literacy rate (Adult Literacy Rate: Percentage of persons aged 15 years and over who can read and write (8) ) was 70%, 83% for males and 56% for females. 

Willingness to pay

On the question of willingness to pay at a Government facility to obtain health care 437 (72.7%) of the households indicated their willingness to pay for health care it was 81% in the urban, in the rural population 72%, and in the semi urban 60% were willing to pay at a government facility. Stratification by Income groups and SES revealed that the low Income and SES group had less willingness to pay for health care compared to the middle and high groups (Table 1). The willingness to pay was conditional and availability of medicines was identified as a condition by 89% of the households. For service provision, 71% were willing to pay for medicines and 38% for curative care episodes (Table 2).

 

Table-1:Cross tabulation of Willingness to Pay Health Care at First Level Care Facility

 
Yes (%)

No (%)

Total*

Cost consideration Prevented From Seeking Care

No

118 (76.6)

36 (23.4)

154

In part

22 (53.7)

19 (46.3)

41

Totally

13 (65.0)

7 (35.0)

20

Total

153 (71.2)

62 (28.8)

215

Treatment paid from

Cash At Hand

142 (74.3)

49 (25.7)

191

Household Savings

2(66.7)

1 (33.3)

3

Loan

6 (35.3)

11 (64.7)

17

Assistance From Outside

1(50.0)

1 (50.0)

2

Others

2

0

2

Total

153 (71.2)

62 (28.8)

215

Delay In Seeking Care

0-1 days (No delay)

105 (71.9)

41(28.1)

146

2-3 days

39 (72.2)

15 (27.8)

54

4-7 days

6 (60.0)

4 (40.0)

10

more than 7 days

2 (50.0)

2 (50.0)

4

Total

152 (71.0)

62 (29.0)

214

Stratified by Residence

Urban

82 (80.4)

20 (19.6)

102

Semi Urban

42 (64.6)

23 (35.4)

65

Rural

313 (72.1)

121 (27.9)

434

Total

437 (72.7)

164 (27.3)

601

Income Groups by Quartiles

Low

121 (63.0)

71(37.0)

192

Middle

193 (73.7)

69 (26.3)

262

High