2012年-世界发展银行全球_Health_Equity_and_Financial_Protection_in_Pakistan_33页_1mb

Summary of the Health Equity and Financial Protection Report - Pakistan

Core Content

This report examines health equity and financial protection in Pakistan, focusing on inequalities in health outcomes, health behaviors, and health care utilization, as well as the distribution of government health spending and the impact of out-of-pocket payments on household financial well-being.

Main Findings

1. Health Inequalities

• Ill health is more concentrated among the poor in Pakistan, as evidenced by child health indicators:
  • Infant mortality rate: 9.6% (lowest quintile) vs. 5.5% (highest quintile), with a concentration index of -0.106***
  • Under-five mortality rate: 11.5% (lowest quintile) vs. 6.0% (highest quintile), with a concentration index of -0.098***
• Fever is more prevalent among the better-off, although this may be due to underreporting in poorer populations.
• For adult health outcomes, some conditions are more concentrated among the poor, while others are more common among the wealthy:
  • Obesity among non-pregnant women, asthma, and poor self-assessed health status are more concentrated among the poor.
  • Non-road traffic accidents and diabetes are more common among the better-off.
• Health behaviors:
  • Insufficient intake of fruits and vegetables and insufficient physical activity are more concentrated among the poor.
  • Smoking and concurrent partnerships show mixed results, with no statistically significant differences.

2. Health Care Utilization Inequalities

• Health care utilization is generally higher among the better-off:
  • Childhood immunization, medical treatment of ARI, skilled antenatal care, and skilled birth attendance are more concentrated among the wealthy.
  • Contraceptive prevalence among women is slightly more concentrated among the poor, but not statistically significant.
• Adult preventive care:
  • TB screening is low across all quintiles, with only cervical cancer screening being statistically significant and more concentrated among the wealthy.
  • Breast cancer screening is also low and not significant.
• Adult curative care:
  • Outpatient care is more concentrated among the better-off, while inpatient care utilization is not significantly pro-rich or pro-poor.

3. Benefit Incidence of Government Spending

• Government spending on health is mildly pro-rich for outpatient care.
• Using the constant unit cost method, government spending on all services is not found to be significantly pro-rich or pro-poor.
• Outpatient hospital care subsidies mainly benefit the wealthy, while inpatient care subsidies are not significantly pro-rich or pro-poor.
• Overall, government subsidies are neither pro-rich nor pro-poor.

4. Financial Protection and Out-of-Pocket Payments

• Out-of-pocket (OOP) payments are the largest source of health financing in Pakistan, accounting for 56.8% of total health expenditures in 2009.
• OOP payments are highly correlated with household income, with the average richest households paying 5 times more than the average poorest households.
• Catastrophic OOP payments are concentrated among the wealthy, especially when compared to total household consumption.
• OOP payments contribute to impoverishment, increasing the poverty rate by 6% (using the $2.00/day measure) and 17% (using the $1.25/day measure).
• OOP payments also increase the depth of poverty by 16% (using the $2.00/day measure) and over 25% (using the $1.25/day measure).

Key Information

• Health financing mix (2005-2009): Government spending accounts for 32.8% of total health spending, with 67.2% coming from the private sector. Of this, 84.5% is from out-of-pocket payments.
• Health expenditure as share of GDP: 2.62% in 2009.
• Government health expenditure per capita: US$7.39 (current) and US$20.56 (PPP-adjusted).
• Health system structure:
  • Health services are decentralized following the 18th Amendment of 2010.
  • The Federal Government plays a supportive and coordinating role, while provincial governments manage health care delivery.
• Health care delivery system:
  • Primary care is delivered through Basic Health Units, Rural Health Centers, Maternal and Child Health Centers, and Dispensaries.
  • Secondary and tertiary care are provided through referral facilities and major hospitals, respectively.
  • Specialized health care is provided to active and retired servicemen by the Army Medical Corp.
• Payment mechanisms:
  • User fees are common in both public and private facilities.
  • Informal payments are widespread, with 96% of people who access health care making such payments.
• Risk-pooling:
  • There is no specific social insurance system for health.
  • Private insurance accounts for 0.2% of total health expenditures in 2009 but is growing rapidly.

Conclusion

The report highlights significant inequalities in health outcomes and care utilization, with the poor generally bearing a higher burden of ill health and less access to health services. Out-of-pocket payments are a major contributor to financial strain and impoverishment, especially for the poorest households. While government spending on health is not significantly pro-rich or pro-poor, it is mildly pro-rich for outpatient care. The decentralization of the health system and the limited availability of risk-pooling mechanisms underscore the challenges in achieving equity and financial protection in Pakistan's health sector.