Pakistan Bureau of Statistics National Health Accounts
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The health expenditures of the federal government’s civilian part are shown in Table 25 as “un-regionalized/federal”. They include vertical programs on health running across the country. Due to a lack of data, they cannot be disaggregated by province. Since the disaggregated data on private health insurance is not available, this is included in the “un-regionalized/federal” category. ICT means expenditure in the Islamabad area which is separate from the federal government.
- Out-of-Pocket Health Expenditure Survey
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4.1 Introduction
In the compilation of, NHA the OOP health expenditure s are the most crucial component of private
health expenditure to measure because of two reasons. First, it is empirically the largest source of health care
financing in the developing countries. Second, it is challenging to measure as most households do not remem-
ber the health the expenditure particularly with regard to out-patients and other functions like self -medication
etc. The survey’s results actually depend on the recall quality (as an out-patient etc.) and the proper record
(as in-patient& delivery cases) of the households and on the way to ask.
In Pakistan, the predominant survey on expenditures of private households is the Household Inte-
grated Economic Survey (HIES). It is pertinent to mention here that “module on consumption regarding Health”
before launching the HIES 2018 -19 was reviewed from the Health A ccounts perspective and observed that
module on Health included in HIES 2018-19 questionnaire is incomprehensive to capture OOP health expendi-
ture as per the requirement of National Health Accounts (NHA).
OOP health expenditure questionnaire covers all im portant indicators which ensure detailed OOP
health expenditure data as per the requirement of NHA classifications. Data obtained through OOP health
expenditure questionnaire would hopefully be comparable both across countries and over time. NHA section
is indeed grateful to PSLM section for inclusion the OOP health expenditure questionnaire (one page ques-
tionnaire) as a permanent feature/section of the HIES. The three advantages of this approach are as follows:
• The recall period is the last 3 month for Inpatient, out-patients, unrelated to illness & self-medication,
considering that this is the maximum period the households can comprehensively remember their
expenditures on health services. In the previous rounds of NHA, the recall period of OOP survey was
only one month.
• Additional questions could be included.
• The personal characteristics of the respective members of the household (age, sex, status and the
like) could be connected by linking the OOP survey data with the HIES data, thus minimizing the
additional response burden for the households
The idea was to raise the recall period by twelve in order to arrive at expenditures for the whole year
health care functions’ recall period is three months. The HIE S questionnaire remained unchanged and still
included the question of annual expenditure on health. The comparison of both results (HIES as well as a
dedicated questionnaire for OOP health expenditure ) was considered to enable the assessment of the (as-
sumed) underreporting of OOP through HIES.
It is worth mentioning here that an exercise on OOP health expenditures, obtained from two different
sources namely-HIES data and NHA’s OOP special survey data, has been carried out and observed that OOP
health expenditures based on HIES data are understated as compared to NHA OOP special survey data .
Actually, the HIES questionnaire includes questions on health expenditures which from the health Accounts
perspective are incomprehensive to capture OOP health expenditures.
Given the same average deficiency in 2005 -06, 2007-08, 2009-10, 2011-12, 2013-14, and 2015-16
the results for OOP expenditures of the sixth rounds of NHA were enhanced accordingly. Table 26 shows the
OOP health expenditure for 2019-20 & 2021-22 at the national and provincial levels. OOP health expenditure
for 2019-20 & 2021-22 have been estimated by extrapolating forward the data of OOP health expenditure
2018-19 obtained through a dedicated questionnaire for OOP health expenditure included as a permanent
section in the HIES 2018-19 questionnaire.
Pakistan Bureau of Statistics National Health Accounts
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4.2
Questionnaire and method:
The reference period for the HIES and OOP health expenditure survey was 2018-19. The last round
of the HIES covers 24,809 households. It provides important information on household income, savings, lia-
bilities, and consumption expenditure and consumption patterns at national and provincial level with urban/ru-
ral breakdown.
The universe for HIES 2018-19 consists of all the urban and rural areas of the four provinces of Paki-
stan excluding Ex-FATA and military restricted areas. The population of excluded areas constitutes about 2%
of the total population. Two stage stratified random sampling scheme was adopted. All enumeration blocks
selected have been treated as Primary Sampling Units (PSU’s). Households as defined within the PSUs are
considered as Secondary Sampling Units (SSUs).
Pakistan Bureau of Statistics (PBS) has developed its own area sampling frame for both Urban and
Rural domains. Each city/town is divided into enumeration blocks. Sampling frame updated through Population
and Housing Census 2017. Each enumeration block is comprised of 200 to 250 households on average with
well-defined boundaries and maps.
Per capita annual OOP health expenditures in the FY 2021-22 were 4,334 Rupees. The population
(projected) of Pakistan in 2021-22 was 227.0 million. Population for Pakistan and provinces/areas has been
obtained from the Population and Housing Census 2017 for estimation of OOP expenditures at the regional
level.
4.3
Main findings of the survey for 2021-22
The OOP health expenditures for 2019-20 & 2021-22 including reimbursement figures, estimated at
the national level by the OOP survey are Rs.650 billion & Rs.984 billion respectively. The table below gives
the breakup of the gross OOP by region/province.
Punjab has the highest share (53%) of the total OOP health spending, followed by Sindh (23%). KP
has 17% share while Baluchistan has just 6% share of the total OOP health spending.
Table 26: Gross Out of Pocket Health Expenditures in 2019-20 & 2021-22 by region (Million Rs.)
Province/Area
2019-20
2021-22
% Share
Pakistan
803,192
983,716
100
Punjab
425,692
521,369
53
Sindh
184,734
226,255
23
KP
136,543
167,232
17
Baluchistan
48,191
59,023
6
ICT
8,032
9,837
1
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Table 27: Out of Pocket health expenditure by type of health care 2021-22 in %
Province
Inpatient
Outpatient
Unrelated to illness
Self-medication
Total
Pakistan
19.54
73.17
5.79
1.50
100.00
Punjab
13.66
77.46
7.16
1.72
100.00
Sindh
33.26
60.01
5.30
1.43
100.00
KP
24.25
72.01
2.68
1.06
100.00
Baluchistan
26.14
69.06
3.57
1.23
100.00
Analysis of the OOP survey (HIES 2018-19) data reveals that in Pakistan, around 73% of the total
OOP expenditures are incurred on outpatient services while around 20% of total OOP spending is incurred on
inpatient care for their illness, and 5.79% of total OOP spending goes to Unrelated to illness and just 1.5%
expenditures reflects Self-medication which includes all those people who are taking medicines without con-
sultation/prescription, or all those people who are taking medicines for long-lasting diseases like diabetes and
high blood pressure that was already prescribed by doctors.
Further analysis of data on the type of health care by provinces reflects that percentage share of
outpatient is highest in Punjab (77.46%) followed by KP (72.01%), Baluchistan (69.06%) and the lowest share
is of Sindh (60.01%). For the Inpatient services, the highest share is of Sindh (33.26%) and the lowest share
is of Punjab (13.66%).
Table 28: Out of Pocket health expenditure by urban & rural 2021-22 in %
Province
Urban
Rural
Total
Pakistan
58.89
41.11
100.00
Punjab
54.84
45.16
100.00
Sindh
39.58
60.42
100.00
KP
83.52
16.48
100.00
Balochistan
67.81
32.19
100.00
In table 28, the pattern of households OOP health expenditure is explained among urban and rural
areas. It shows that the level of OOP health expenditure in urban areas is higher as compared to rural areas
in Pakistan and provinces as well. Urban percentage share of OOP health expenditures in Pakistan is 58.89%
while in rural areas it is 41.11%. Analysis of OOP health expenditure data with regard to provinces shows that
in urban areas, the highest share is of KP (83.52%) and the lowest share is of Sindh (39.58%).
Table 29: Out of Pocket health expenditure by gender 2021-22 in %
Type of Care
Male
Female
Total
Pakistan
47.16
52.84
100.00
Punjab
46.16
53.84
100.00
Sindh
49.01
50.99
100.00
KP
48.55
51.45
100.00
Balochistan
46.63
53.37
100.00
Pakistan Bureau of Statistics National Health Accounts
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Table 29 shows the pattern of households’ OOP health expenditure by sex at the national
and provincial levels. Analysis of the OOP survey reflects that in Pakistan female OOP spending percent-
age share (53%) on all types of health care access is higher than males (47%). The same pattern can be
seen in provinces.
Table 30: OOP expenditures of private households 2021-22 by category and provinces in %
OOP Expenditure categories
Pakistan
Punjab
Sindh
KP
Baluchistan
Transportation costs
7.71
7.99
6.46
8.12
6.18
Parchi and admission fees
1.47
1.17
1.70
1.97
2.41
Doctors fee
12.97
13.51
14.08
11.02
10.18
Medicines/Vaccine
50.63
53.74
42.76
49.60
39.76
Medical Supplies
2.43
1.87
2.77
3.78
1.94
Diagnostic tests
8.22
7.99
8.78
8.31
8.96
Cost of surgery
7.10
4.76
10.55
9.90
14.34
Medical Durables
0.42
0.29
0.92
0.36
0.58
Food
2.06
1.84
2.53
2.33
1.84
Tips
0.23
0.21
0.26
0.23
0.21
Accompanying person cost
0.55
0.50
0.37
0.91
0.26
Other
6.21
6.13
8.82
3.47
13.34
Total Expenditure
100.00
100.00
100.00
100.00
100.00
Analysis of the OOP survey also reflects that in Pakistan 50.63% of the total OOP spending are in- curred on “Medicine/Vaccine”, 12.97% and 8.22% on Doctor’s fee and Diagnostic tests respectively and 7.7% of the total OOP spending are incurred on Transportation costs.
Further analysis of OOP data with regard to provinces indicates that OOP spending on “Medicine/Vac- cine” is highest in Punjab (53.74%) followed by KP (49.60%), Sindh (42.76%), while the lowest share is in Baluchistan (39.76%). The second highest spending for all the provinces is on Doctor’s fees and then the Diagnostic tests. The reason behind high OOP spending on medicine is that, in private clinics, doctors take the charges including medicine and the value reported in the medicine cost.
The third highest spending for all the provinces is Diagnostic tests. While the fourth highest spending for all the provinces is transportation costs. The high share of transportation costs highlights that health care facilities often are far away to the population. The OOP expenditure on the category ‘cost of surgery’ in Balu- chistan is 14.34% which is significantly higher than other provinces. The elevated expenditure on the 'cost of surgery' category can be attributed to the insufficient facilities and substandard services provided by public healthcare institutions in Baluchistan.
The lowest share is of tips because mostly tips are given in the hospitals at the time of new born in Pakistan. Expenditures on accompanying person incur mostly in the cases of inpatient. KP has the highest percentage share of expenditures incurred on accompanying person.