Oregon State University
Examining equity in out-of-pocket expenditures and utilization of healthcare services in Malawi.
Degree: PhD, Public Health, 2011, Oregon State University
Best international health practice requires that all people benefit equally from health care
services regardless of their socio-economic status and that healthcare payments be based
on ability to pay. Although recent household surveys in Malawi show progress in a
number of health indicators population averages, many inequalities in health outcomes
still exist or are widening among households stratified by socioeconomic and
geographical location variables. Inequalities in out-of-pocket expenditures (OOPEs) for
healthcare and how they influence utilization of healthcare services are of particular
interest to policy makers as they ultimately affect overall health of households. The
rationale for this study is that analysis of inequities in healthcare between socioeconomic
groups can help to unmask intra-group and between groups' inequities hidden in national
The study's three main papers examined equity in households' out-of-pocket healthcare
payments and utilization of medical care. The study adopted the widely used economic
frameworks and techniques developed by O'Donnell et al (2008) for analyzing health
equity using household data. These economic frameworks focus on the notion of equal
treatment for equal need and that payment for healthcare should be according to ability to
pay. The Malawi Integrated Household Survey 2(2005) (MIHS2) was the main dataset
used in the analysis. The MIHS2 is currently the only dataset that presents inequalities in
healthcare expenditures at the household level in Malawi. However, the MIHS2 report
does not examine the extent to which these inequalities are inequities.
It is in this context that the first study focused on assessing, first, the progressivity of
OOPEs for healthcare and second, the redistributive effect of OOPEs for healthcare as a
source of finance in the Malawi health system. The progressivity results indicate that
OOPEs for healthcare are relatively regressive in Malawi with the poor shouldering the
highest financial burden relative to their ability to pay. The study found no evidence of
redistributive effect of OOPEs on income inequalities in Malawi. The second study
focused on linking OOPEs to use of healthcare using the recommended two-part model
(Probit and OLS). The concentration indices were decomposed into contributing factors
after standardizing for health need factors, which include age, sex, self-assessed health,
chronic illness and disabilities. Probability of use of healthcare and OOPEs were both
found to be concentrated among the non-poor while the poor who have higher health
need have less use of healthcare. The last study assessed the socioeconomic factors
associated with horizontal equity in use of medical facilities and predicted use using
logistic regression. General medical facilities use was found to be more concentrated
among the non-poor despite the poor having a higher health need. The results showed no
significant inequalities in use of public medical facilities and self-treatment between…
Advisors/Committee Members: Chi, Chunhuei (advisor), Lachenbruch, Peter T. (committee member).
to Zotero / EndNote / Reference
APA (6th Edition):
Mwandira, R. (2011). Examining equity in out-of-pocket expenditures and utilization of healthcare services in Malawi. (Doctoral Dissertation). Oregon State University. Retrieved from http://hdl.handle.net/1957/21885
Chicago Manual of Style (16th Edition):
Mwandira, Ruth. “Examining equity in out-of-pocket expenditures and utilization of healthcare services in Malawi.” 2011. Doctoral Dissertation, Oregon State University. Accessed February 19, 2019.
MLA Handbook (7th Edition):
Mwandira, Ruth. “Examining equity in out-of-pocket expenditures and utilization of healthcare services in Malawi.” 2011. Web. 19 Feb 2019.
Mwandira R. Examining equity in out-of-pocket expenditures and utilization of healthcare services in Malawi. [Internet] [Doctoral dissertation]. Oregon State University; 2011. [cited 2019 Feb 19].
Available from: http://hdl.handle.net/1957/21885.
Council of Science Editors:
Mwandira R. Examining equity in out-of-pocket expenditures and utilization of healthcare services in Malawi. [Doctoral Dissertation]. Oregon State University; 2011. Available from: http://hdl.handle.net/1957/21885