KARACHI: The out-of-pocket (OOP) expenditure in the health sector in Pakistan is the largest among the regional countries while the people in Punjab and Sindh have the highest ratio among the country’s provinces of paying from their own pockets to get health facilities, said a recent official report.

According to the report, compiled by the provincial health department, spending on the health care, both nationally and across the provinces, is lower than what is in the countries of the region.

Pakistan spends 2.6 per cent of its gross domestic product on health, which is the lowest in South Asian countries with comparative spending of 7.4pc in Afghanistan, 4.2pc in India, 4pc in Sri Lanka and 5.6pc in China.

The OOP expenditure constitutes nearly two-thirds of all expenditure provision in Sindh, 37.7pc, as compared to 32.2pc in Pakistan and is inclusive of the provincial government, district government, medical education, federal allocations and expenditure by military and autonomous agencies on health care.

According to the report, after adjustment for spending on medical education and service delivery by parastatal and military facilities, the share stands at 32pc of the expenditure.

Both provincial and district governments are major sources of public sector funds in Sindh, with the district share being the highest compared to other provinces, probably due to the high concentration of salaried workers in the urban areas.

The report said estimates of philanthropic funding were presumably higher in Sindh than the rest of Pakistan, while contribution by international donors to the health sector was the lowest in Sindh.

It said the OOP expenditure was incurred at both public and private sector facilities. Households in Sindh annually spend 53pc of the OOP on purchase of medicines and 43pc on doctors’ fee and hospitalisation.

A survey conducted by the health department on maternal, newborn and child health in rural Sindh shows a high OOP expenditure for a range of services with Rs300 to Rs600 for antenatal care, Rs1,350 to Rs2,000 for delivery, Rs12,500 to Rs13,500 for C-section and Rs150 to Rs400 on outpatient visits for child illness.

“High OOP forms the major barrier for accessing emergency obstetric care and emergency neonatal services and a contributory factor to accessing pregnancy care and child preventive care check-ups,” said the report.

It referred to a study on chronic care in urban Sindh showing that an average OOP of Rs11,580 was spent on diabetes therapy with the poorest income quintile paying the highest proportionate burden of up to 18pc of the income on ambulatory treatment alone.

The report said a high level of OOP expenditure had grave implications as it led to foregoing of available health care, delaying access until progression of disease to complications and non-compliance with prescribed drug therapy.

The OOP is ‘regressively distributed with the poorer families’ in Sindh bearing a heavier burden for medical care costs. The World Bank’s analysis of a survey data shows that the lowest income quintile spends about 7pc of monthly household income on health care as compared to the average of 5.2pc of households from higher quintile.

“Poorer households in event of emergency and sudden illness are at risk of catastrophic expenditure, which is taken as less than 40pc of non-food spending on health, and can trigger a cycle of debt and poverty,” it said.

The share of OOP spending across Sindh contrasts in its rural and urban areas. Despite having the highest concentration of health providers, the OOP expenditure is lower in the urban areas, which could be attributed to an active philanthropic sector that contributes to medicine provision in public sector hospitals and fee subsidisation at NGO-managed facilities.

It said Sindh had the lowest share of foreign donor contribution with an overall share of 0.1pc in the total health expenditure in the province, which is much less than Khyber Pakhtunkhwa and Balochistan, where donor assistance contributed 5pc and 15.5pc of the total health expenditure, respectively.