Health Policy and Planning Advance Access originally published online on December 5, 2008
Health Policy and Planning 2009 24(1):1-17; doi:10.1093/heapol/czn043
The effect of wealth status on care seeking and health expenditures in Afghanistan
1 Johns Hopkins University Bloomberg School of Public Health, Baltimore, USA.
2 Ministry of Public Health, Kabul, Afghanistan.
* Corresponding author. Laura C Steinhardt, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Suite E8132 Baltimore, MD, USA, 21205. Tel: +1 (410) 955-5000. Fax: +1 (410) 614-1419. E-mail: lsteinha{at}jhsph.edu
This paper analyses the effect of wealth status on care-seeking patterns and health expenditures in Afghanistan, based on a national household survey conducted within public health facility catchment areas. We found high rates of reported care-seeking, with more than 90% of those ill seeking care. Sick individuals from all wealth quintiles had high rates of care-seeking, although those in the wealthiest quintile were more likely to seek care than those from the poorest (odds ratio 2.2; 95% CI 1.6, 3.0). The nearest clinic providing the government's Basic Package of Health Services (BPHS) was the most commonly sought first provider (53% overall), especially for relatively poor households (62% in poorest vs. 42% in least poor quintile, P < 0.0001). Sick individuals from wealthier quintiles used hospitals and for-profit private providers more than those in poorer quintiles. Multivariate analysis showed that wealth quintile was the strongest predictor of seeking care, and of going first to private providers. More than 90% of those seeking care paid money out-of-pocket. Mean (median) expenditures among those paying for care in the previous month were 873 Afghanis (200 Afghanis), equivalent to US$17.5 (US$4). Expenditures were lowest at BPHS clinics and highest at private providers. Financing care through borrowing money or selling assets/land (‘any distress’ financing) was reported in nearly 30% of cases and was almost twice as high among households in the poorest versus the least poor quintile (P < 0.0001). Financing care through selling assets/land (‘severe distress’ financing) was less common (10% overall) and did not differ by wealth status. These findings indicate that BPHS facilities are being used by the poor who live close to them, but further research is needed to assess utilization among populations in more remote areas. The high out-of-pocket health expenditures, particularly for private sector services, highlight the need to develop financial protection mechanisms in Afghanistan.
Key Words: Illness, care seeking, provider, health expenditures, equity, Afghanistan
Accepted for publication 23 September 2008.