Determinants of healthcare seeking and out-of-pocket expenditures in a "free" healthcare system: evidence from rural Malawi

BackgroundMonitoring financial protection is a key component in achieving Universal Health Coverage, even for health systems that grant their citizens access to care free-of-charge. Our study investigated out-of-pocket expenditure (OOPE) on curative healthcare services and their determinants in rural Malawi, a country that has consistently aimed at providing free healthcare services.MethodsOur study used data from two consecutive rounds of a household survey conducted in 2012 and 2013 among 1639 households in three districts in rural Malawi. Given our explicit focus on OOPE for curative healthcare services, we relied on a Heckman selection model to account for the fact that relevant OOPE could only be observed for those who had sought care in the first place.ResultsOur sample included a total of 2740 illness episodes. Among the 1884 (68.75%) that had made use of curative healthcare services, 494 (26.22%) had incurred a positive healthcare expenditure, whose mean amounted to 678.45 MWK (equivalent to 2.72 USD). Our analysis revealed a significant positive association between the magnitude of OOPE and age 15-39years (p =0.022), household head (p =0.037), suffering from a chronic illness (p =0.019), illness duration (p =0.014), hospitalization (p =0.002), number of accompanying persons (p =0.019), wealth quartiles (p(2)=0.018; p(3)=0.001; p(4)=0.002), and urban residency (p=0.001).ConclusionOur findings indicate that a formal policy commitment to providing free healthcare services is not sufficient to guarantee widespread financial protection and that additional measures are needed to protect particularly vulnerable population groups.