Out-of-pocket expenditures associated with double disease burden in Pakistan: a quantile regression analysis.

BACKGROUND: Pakistan is currently experiencing a double burden of disease. Families with members having both communicable and noncommunicable diseases are at a greater risk of impoverishment due to enormous out-of-pocket payments. This study examines the percentile distribution of the determinants of the out-of-pocket expenditure on the double disease burden. METHOD: The study extracted a sample of 6,775 households with at least one member experiencing both communicable and noncommunicable diseases from the Household Integrated Economic Survey 2018-19. The dataset is cross-sectional and nationally representative. Quantile regression was used to analyze the association of various socioeconomic factors with the OOP expenditure associated with double disease burden. RESULTS: Overall, 28.5% of households had double disease in 2018-19. The households with uneducated heads, male heads, outpatient healthcare, patients availing public sector healthcare services, and rural and older members showed a significant association with the prevalence of double disease. The out-of-pocket expenditure was higher for depression, liver and kidney disease, hepatitis, and pneumonia in the upper percentiles. The quantile regression results showed that an increased number of communicable and noncommunicable diseases was associated with higher monthly OOP expenditure in the lower percentiles (10th percentile, coefficient 312, 95% CI: 92-532), and OOP expenditure was less pronounced among the higher percentiles (75th percentile, coefficient 155, 95% CI: 30-270). The households with older members were associated with higher OOP expenditure at higher tails (50th and 75th percentiles) compared to lower (10th and 25th percentiles). Family size was associated with higher OOPE at lower percentiles than higher ones. CONCLUSION: The coexistence of communicable and noncommunicable diseases is associated with excessive private healthcare costs in Pakistan. The results call for addressing the variations in financial costs associated with double diseases.

Nutritional inequalities among under-five children: a geospatial analysis of hotspots and cold spots in 73 low- and middle-income countries.

BACKGROUND: Child undernutrition is a severe health problem in the developing world, which affects children's development in the long term. This study analyses the extent and patterns of under-five child undernutrition using Demographic and Health Surveys (DHS) for 73 low- and middle-income countries (LMICs). METHODS: First, we mapped the prevalence of undernutrition in the developing world. Second, using the LISA (a local indicator of spatial association) technique, we analyzed the geographical patterns in undernutrition to highlight the localized hotspots (regions with high undernutrition prevalence surrounded by similar other regions), cold spots (regions with low undernutrition prevalence surrounded by similar other regions), and outliers (regions with high undernutrition surrounded by low undernutrition and vice versa). Third, we used Moran's I to find global patterns in child undernutrition. RESULTS: We find that South Asia has the highest under-five child undernutrition rates. The intra-country nutritional inequalities are highest in Burundi (stunting), Kenya (wasting), and Madagascar (underweight). The local indicator of spatial association (LISA) analysis suggests that South Asia, Middle East and North Africa (MENA) region, and Sub-Saharan Africa are undernutrition hotspots and Europe and Central Asia and Latin America, and the Caribbean are undernutrition cold spots (regions with low undernutrition surrounded by similar other regions). Getis Ord-Gi* estimates generally support LISA analysis. Moran's I and Geary's C gave similar results about the global patterns of undernutrition. Geographically weighted regressions suggest that several socioeconomic indicators significantly explain child undernutrition. CONCLUSIONS: We found a significant within and across country variation in stunting, wasting and underweight rates among the under-five children's population. The geospatial analysis also suggested that stunting, wasting, and underweight patterns exhibit clear regional patterns, underscoring the need for coordinated interventions at the regional level.

Impact of high-risk fertility behaviours on underfive mortality in Asia and Africa: evidence from Demographic and Health Surveys.

BACKGROUND: Maternal age < 18 or > 34 years, short inter-pregnancy birth interval, and higher birth order are considered to be high-risk fertility behaviours (HRFB). Underfive mortality being disproportionately concentrated in Asia and Africa, this study analyses the association between HRFB and underfive mortality in selected Asian and African countries. METHODS: This study used Integrated Public Microdata Series-Demographic and Health Surveys (IPUMS-DHS) data from 32 countries in sub-Saharan Africa, Middle East, North Africa and South Asia from 1986 to 2017 (N = 1,467,728). Previous evidence hints at four markers of HRFB: women's age at birth of index child < 18 or > 34 years, preceding birth interval < 24 months and child's birth order > 3. Using logistic regression, we analysed change in the odds of underfive mortality as a result of i) exposure to HRFB individually, ii) exposure to any single HRFB risk factor, iii) exposure to multiple HRFB risk factors, and iv) exposure to specific combinations of HRFB risk factors. RESULTS: Mother's age at birth of index child < 18 years and preceding birth interval (PBI) < 24 months were significant risk factors of underfive mortality, while a child's birth order > 3 was a protective factor. Presence of any single HRFB was associated with 7% higher risk of underfive mortality (OR 1.07; 95% CI 1.04-1.09). Presence of multiple HRFBs was associated with 39% higher risk of underfive mortality (OR 1.39; 95% CI 1.36-1.43). Some specific combinations of HRFB such as maternal age < 18 years and preceding birth interval < 24 month significantly increased the odds of underfive mortality (OR 2.07; 95% CI 1.88-2.28). CONCLUSION: Maternal age < 18 years and short preceding birth interval significantly increase the risk of underfive mortality. This highlights the need for an effective legislation to curb child marriages and increased public investment in reproductive healthcare with a focus on higher contraceptive use for optimal birth spacing.

Behavioral factors associated with utilization of healthcare services among elderly in Pakistan: evidence from a nationally representative survey.

BACKGROUND: In Pakistan, health system is facing unprecedented challenges to deal with the healthcare demand of the growing ageing population. Using conceptual framework, this study aims to analyze the factors associated with the utilization of healthcare services in private and public hospitals by the elderly population. METHODS: This study used a sample of 5319 individuals aged 60 and above extracted from the Pakistan Social and Living Standards Measurement Survey 2014-15. We followed the Anderson's Behavioral model of healthcare utilization. The behavioral factors, including predisposing, enabling and need factors, associated with the use of healthcare care were analyzed using exploratory data analysis and binary logistic regressions. The utilization of healthcare service in the study refers to the visits to private and government hospital. RESULTS: Out of total 5319 participants around three-fourth or 72.4% of participants visited private hospitals for their healthcare needs. Multivariate analysis showed that older age-group (80 years and above) and participants from urban were 1.35 and 1.53 times more likely to avail healthcare service in private hospitals, respectively. The elderly persons from Khyber Pakhtunkhwa were three times (AOR: 3.29, 95%CI 2.5-4.8) more likely to visit government hospitals than their peers in Punjab. Participants who attended school (AOR: 1.21, 95%CI 0.82-1.31) were more likely to utilize healthcare service in private hospitals. Elders from rich (AOR: 1.04, 95%CI 0.84-1.13) and richest (AOR: 1.29, 95%CI 0.89-1.87) wealth quintiles were more likely to use healthcare in private hospitals. The likelihood of the utilization of healthcare service in private hospitals was 1.7 times higher for three or more consulting visits than the single visit, and 1.5 times higher in the public hospital. CONCLUSIONS: Our findings underscore a dire need for expanding the outreach of healthcare services for the elderly population. It calls for effective implementation of policies which aim at improving equitable access to private healthcare services, and upgrading of government hospitals Moreover, the knowledge generated through this research may be employed to make social protection programs more responsive to age-related healthcare needs, and focused on caregiving for elderly living without spouse.