Determinants of Healthcare Utilisation and Out-of-Pocket Payments in the Context of Free Public Primary Healthcare in Zambia

This paper aims to contextualise ‘healthcare access and utilisation’ within its wider social circumstances, including structural factors that shape primary healthcare for marginalised groups. Mainstream theories often neglect complexities among the broader social, institutional and cultural milieus that shape primary healthcare utilisation in reality. A blended critical social framework is presented to highlight the recognition and emancipatory intents surrounding person, family, healthcare practice and society. Using the theoretical contributions of Habermas and Honneth, the framework focuses on power relationships, misrecognition/recognition strategies, as well as disempowerment/empowerment dynamics. To enable causal and structural analysis, we draw on the depth ontology of critical realism. The framework is then applied to the case of rural elderly women’s primary healthcare use in Bangladesh. Drawing on the literature, this article illustrates how a blended critical social perspective reveals the overlapping and complex determinants that affect primary healthcare utilisation, before concluding with the importance of situating healthcare access in sociocultural structures.

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Primary healthcare utilisation and self-rated health among patients with Irritable Bowel Syndrome: What are the impacts of comorbidities, gastrointestinal symptom burden, sense of coherence and stress?

Journal of Psychosomatic Research ◽

10.1016/j.jpsychores.2019.01.015 ◽

2019 ◽

Vol 119 ◽

pp. 1-7 ◽

Cited By ~ 1

Author(s):

Anna-Karin Norlin ◽

Åshild Faresjö ◽

Magnus Falk ◽

Michael P. Jones ◽

Susanna Walter

Keyword(s):

Irritable Bowel Syndrome ◽

Sense Of Coherence ◽

Primary Healthcare ◽

Gastrointestinal Symptom ◽

Symptom Burden ◽

Healthcare Utilisation ◽

Self Rated Health ◽

Irritable Bowel

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Do employer-sponsored health insurance schemes affect the utilisation of medically trained providers and out-of-pocket payments among ready-made garment workers? A case–control study in Bangladesh

BMJ Open ◽

10.1136/bmjopen-2019-030298 ◽

2020 ◽

Vol 10 (3) ◽

pp. e030298

Author(s):

Sayem Ahmed ◽

Abdur Razzaque Sarker ◽

Marufa Sultana ◽

Felix Roth ◽

Rashidul Alam Mahumud ◽

...

Keyword(s):

Health Insurance ◽

Outcome Measures ◽

Case Control Study ◽

Healthcare Providers ◽

Healthcare Utilisation ◽

Healthcare Services ◽

Case Control ◽

Cross Sectional ◽

Out Of Pocket Payments ◽

Control Study

ObjectiveWe estimated the effect of an employer-sponsored health insurance (ESHI) scheme on healthcare utilisation of medically trained providers and reduction of out-of-pocket (OOP) expenditure among ready-made garment (RMG) workers.DesignWe used a case–control study design with cross-sectional preintervention and postintervention surveys.SettingsThe study was conducted among workers of seven purposively selected RMG factories in Shafipur, Gazipur in Bangladesh.ParticipantsIn total, 1924 RMG workers (480 from the insured and 482 from the uninsured, in each period) were surveyed from insured and uninsured RMG factories, respectively, in the preintervention (October 2013) and postintervention (April 2015) period.InterventionsWe tested the effect of a pilot ESHI scheme which was implemented for 1 year.Outcome measuresThe outcome measures were utilisation of medically trained providers and reduction of OOP expenditure among RMG workers. We estimated difference-in-difference (DiD) and applied two-part regression model to measure the association between healthcare utilisation, OOP payments and ESHI scheme membership while controlling for the socioeconomic characteristics of workers.ResultsThe ESHI scheme increased healthcare utilisation of medically trained providers by 26.1% (DiD=26.1; p<0.01) among insured workers compared with uninsured workers. While accounting for covariates, the effect on utilisation significantly reduced to 18.4% (p<0.05). The DiD estimate showed that OOP expenditure among insured workers decreased by −3700 Bangladeshi taka and -1100 Bangladeshi taka compared with uninsured workers when using healthcare services from medically trained providers or all provider respectively, although not significant. The multiple two-part models also reported similar results.ConclusionThe ESHI scheme significantly increased utilisation of medically trained providers among RMG workers. However, it has no significant effect on OOP expenditure. It can be recommended that an educational intervention be provided to RMG workers to improve their healthcare-seeking behaviours and increase their utilisation of ESHI-designated healthcare providers while keeping OOP payments low.

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