Spatiotemporal variation and socioeconomic factors of financial hardships of out-of-pocket health expenditure in Pakistan

Background: Financial hardships of out-of-pocket health expenditure (OPHE) is a growing concern for health policy makers in many low and middle-income countries. Spatiotemporal variation between Pakistan’s four provinces over 2001-2015 is discussed, which would help comparing existing health services delivery and financial risk protection plans. Aims: In this paper, we estimate financial hardship of OPHE in Pakistan. Methods: We use the data sets of the household integrated economic surveys 2001-02, 2005-06, 2010-11 and 2015-16. We estimate OPHE share in household total and non-subsistence expenditure, catastrophic headcount at the threshold of OPHE ≥ 10% of total expenditure or OPHE ≥ 25% of non-subsistence expenditure. We estimate impoverishment of OPHE using national poverty lines. Finally, we explore socioeconomic factors of financial hardships of OPHE. Results: Over the years, catastrophic headcount and impoverishment of OPHE had decreased at national level (–1.3% points) and in the provinces of Sindh (-7.8% points) and Khyber Pukhtoonkhawa (KPK), (–2.8% points). The province of KPK and the year 2005-06 witnessed the highest incidence of financial catastrophe (26.89% points) and impoverishment (4.8% points) of OPHE. Households in rural areas, in the middle and rich quintiles and those headed by a male were more likely to encounter financial catastrophe and impoverishment due to OPHE. Conclusion: Inter-provincial variation in financial hardships of OPHE provide aide to provincial level priority setting. The high impact of OPHE in the non-poor, in rural areas, and in KPK calls for enhanced targeting of financial risk protection plans.