Volume 11 - Issue 54
/ June 2022
121
https:// www.amazoniainvestiga.info ISSN 2322- 6307
DOI: https://doi.org/10.34069/AI/2022.54.06.12
How to Cite:
Akhtar, S., Ahmed, Z., Sreekantan Nair, K., Mughal, Y.H., & Mehmood, A. (2022). Out-of-Pocket Expenditure on Delivery Care in
Public and Private Health Sectors – A Study in a Rural District of Pakistan. Amazonia Investiga, 11(54), 121-136.
https://doi.org/10.34069/AI/2022.54.06.12
Out-of-Pocket Expenditure on Delivery Care in Public and Private
Health Sectors – A Study in a Rural District of Pakistan
Perbelanjaan Luar Poket untuk Penjagaan Penghantaran di Sektor Kesihatan Awam dan
Swasta – Kajian di Daerah Luar Bandar Pakistan
Received: June 7, 2022 Accepted: July 12, 2022
Written by:
Sohail Akhtar51
https://orcid.org/0000-0002-3882-3200
Zafar Ahmed52
https://orcid.org/0000-0002-6609-7314
Kesavan Sreekantan Nair53
https://orcid.org/0000-0002-2664-2621
Yasir Hayat Mughal54
https://orcid.org/0000-0001-8862-4608
Asim Mehmood55
https://orcid.org/0000-0003-2343-7283
Abstract
Pakistan witnessed a significant improvement in maternal health outcomes during the past two decades.
However, persistent urban-rural and socio-economic inequalities exist in access to maternal healthcare
services across the country. The objective of this study was to estimate out-of-pocket expenditure (OOPE)
on delivery care by women in the public and private health sectors in RajanPur district. This was a cross-
sectional study conducted, among 368 randomly selected mothers who had childbirths from 1st October to
31st December 2020. The study applied multi-stage random sampling technique to select the study
participants. The results showed that about two-thirds of mothers preferred public hospitals for most recent
delivery. The percentage of cesarean deliveries conducted in private hospitals (43.8%) was 4.7 times higher
than in public hospitals (9.3%). About 99% of mothers incurred OOPE during delivery care, and the mean
OOPE incurred during delivery care was PKR 2840 (US$ 17.75) in public hospitals and PKR 25596
(US$159.9) in private hospitals. OOPE on cesarean delivery in private hospitals (PKR 39654.7, US$247.8)
was 2.5 times higher than the public hospitals (PKR16111.9, US$100.69), whereas OOPE incurred on
normal delivery care in private hospitals (PKR14339, US$89.62) was 9.5 times higher than OOPE in public
hospitals(PKR 1501.4, US$9.38).To conclude, the findings and recommendations drawn from the research
would provide some insights to health policymakers and planners in developing an integrated and viable
maternal healthcare program in Pakistan.
Keywords: Delivery care, out-of-pocket expenditure, public health sector, private health sector, Pakistan.
Abstrak
Pakistan menyaksikan peningkatan ketara dalam hasil kesihatan ibu sepanjang dua dekad yang lalu. Walau
bagaimanapun, ketidaksamaan bandar-luar bandar dan sosio-ekonomi yang berterusan wujud dalam akses
kepada perkhidmatan penjagaan kesihatan ibu di seluruh negara. Objektif kajian ini adalah untuk
menganggarkan perbelanjaan out-of-pocket (OOPE) untuk penjagaan bersalin oleh wanita dalam sektor
51
Faculty of Medicine and Health Sciences UNIMAS, Universiti Malaysia Sarawak, Malaysia. Department of Health Informatics,
College of Public Health and Health Informatics, Qassim University, Saudi Arabia.
52
Faculty of Medicine and Health Sciences UNIMAS, Universiti Malaysia Sarawak, Malaysia.
53
Department of Health Administration, College of Public Health and Health Informatics, Qassim University, Saudi Arabia.
54
Department of Health Administration, College of Public Health and Health Informatics, Qassim University, Saudi Arabia.
55
Department of Health Informatics, Faculty of Public Health and Tropical Medicine, Jazan University, Saudi Arabia.
122
kesihatan awam dan swasta di daerah Rajan Pur. Ini adalah kajian keratan rentas yang dijalankan, antara
368 ibu yang dipilih secara rawak yang bersalin dari 1 Oktober hingga 31 Disember 2020. Kajian ini
menggunakan teknik persampelan rawak berbilang peringkat untuk memilih peserta kajian. Keputusan
menunjukkan bahawa kira-kira dua pertiga daripada ibu memilih hospital awam untuk bersalin terbaharu.
Peratusan bersalin secara cesarean yang dijalankan di hospital swasta (43.8%) adalah 4.7 kali lebih tinggi
daripada di hospital awam (9.3%). Kira-kira 99% ibu mengalami OOPE semasa penjagaan bersalin, dan
purata OOPE yang ditanggung semasa penjagaan bersalin ialah PKR 2840 (US$ 17.75) di hospital awam
dan PKR 25596 (US$159.9) di hospital swasta. OOPE untuk bersalin secara caesar di hospital swasta (PKR
39654.7, AS$247.8) adalah 2.5 kali lebih tinggi daripada hospital awam (PKR16111.9, AS$100.69),
manakala OOPE ditanggung untuk penjagaan bersalin biasa di hospital swasta (PKR14339, AS$89.62 kali)
lebih tinggi daripada OOPE di hospital awam (PKR 1501.4, AS$9.38). Sebagai kesimpulan, penemuan dan
cadangan yang diperoleh daripada penyelidikan itu akan memberikan beberapa pandangan kepada
penggubal dasar kesihatan dan perancang dalam membangunkan program penjagaan kesihatan ibu yang
bersepadu dan berdaya maju di Pakistan.
Kata kunci: Penjagaan penghantaran, perbelanjaan di luar poket, sektor kesihatan awam, sektor kesihatan
swasta, Pakistan
Introduction
Maternal health is considered a significant public
health challenge in most developing countries
(WHO, 2015). About 295 000 women in the
world died owing to reasons associated with
pregnancies and delivery in 2017 (WHO, 2017).
There is a lack of adequate healthcare services for
millions of women in developing countries,
which results in poor overall health in women
(WHO, UNICEF, 2013). Besides, there are many
barriers, including physical distance, out-of-
pocket expenditures (OOPEs), and familial
influences. (Riaz et al., 2015). Whereas poor
functionality of health centers in rural areas is
another significant barrier.
Pakistan has a population of 200 million in 2017,
with 61% living in rural areas (PBS, 2018).
Health indicators for Pakistan are by no means
satisfactory. The country has an under-five
mortality rate of 74.9 per 1000 live births against
the global average of 39 (WHO, 2019). The
MMR of 178 per 100,000 live births is the
highest among the neighboring countries. (WHO,
2019. According to the World Bank, 29.5 %
population lives below the poverty line (World
Bank, 2019).It is estimated that 80% of the poor
population in Pakistan lives in rural areas.
(Mansuri et al., 2018).The poor, particularly in
rural areas with lower incomes, poor sanitary
living conditions, and low access to public
healthcare, are likely to have high morbidity and
mortality rates but tend to have lower utilization
of healthcare services than those who are better
off (WHO, 2021). They also spend higher
proportions of their incomes on healthcare that
they access (WHO & World Bank, 2019).
Uncertainty related to health and the catastrophic
nature of health expenditures often renders even
non-poor households into cycles of poverty
(WHO, 2018; WHO & World Bank, 2019).
In rural areas of Pakistan, there is limited
availability of healthcare facilities. So achieving
equity in health is one of the significant goals to
improve the poor's well-being and survival in
rural areas. However, achieving equity is far
from reality, particularly with rapid privatization
that has taken healthcare beyond the reach of the
poor. Even though these services were fraught
with issues in terms of access and quality, the
poor could still find it difficult to access health
care services, including maternal and postnatal
services. Due to reasons like lack of access and
distance to government health facilities followed
by an inadequate supply of medicines and
diagnostic facilities in public healthcare
facilities, especially in rural areas, people seek
treatment in the private sector, which is the
dominant source of care, including maternal and
child health services (Pomeroy, Koblinsky&
Alva, 2014). The existing studies and reports in
different districts in Pakistan have revealed that
the private sector provides about 80% of all
outpatient contacts (PBS, 2018; Rehman et al.,
2017). Even sudden and catastrophic
expenditures can push families below the poverty
line (ADB, 2012; WHO & World Bank, 2019).
Expenditure on drugs accounted for a substantial
percentage of household expenditure in general
and health care expenditure in particular.
The past decade witnessed a significant
improvement in maternal health outcomes in
Pakistan. Although all provinces in Pakistan have
made progress in improving the maternal
mortality rate (MMR), infant mortality rate
(IMR), and under-five mortality rate (U5MR),
Akhtar, S., Ahmed, Z., Sreekantan Nair, K., Mughal, Y.H., Mehmood, A. / Volume 11 - Issue 54: 121-136 / June, 2022
Volume 11 - Issue 54
/ June 2022
123
https:// www.amazoniainvestiga.info ISSN 2322 - 6307
the progress in Punjab province is slow. The
Government of Punjab has taken several
initiatives to improve the maternal and child
health indicators, including integration of Lady
Health Workers (LHWs), Maternal, Newborn
and Child Health (MNCH) program, nutrition
program, and strengthening emergency obstetric
services. Still, the available reports reveal low
utilization of maternal health services in rural
areas (Riaz et al., 2015; Rehman et al., 2017).
Low utilization of maternal health services could
be due to a lack of availability accessibility of
appropriate maternal health services at affordable
costs. Also, in the case of maternal health
services, socio-economic factors play a
paramount role (Pomeroy, Koblinsky & Alva,
2014; Riaz, et al., 2015). Moreover, the
unavailability of lady doctors in rural areas has
been a big hurdle in availing maternal and
postnatal services. Thus, maternal health care
utilization is primarily influenced by
accessibility, availability, and affordability
factors. Therefore, it is important to understand
the utilization pattern of maternal care services
and OOPEs incurred by the rural community
while seeking these services from public and
private healthcare facilities.
There appears to be limited information on
OOPEs associated with the utilization of delivery
care in Pakistan. To the best of the researcher's
knowledge, and based on an extensive literature
review, a detailed study has not been conducted
to understand the OOPE on delivery care among
rural women in Punjab province. Against this
background, the present research has focused on
estimating OOPE on the utilization of delivery
services in a rural district of the province. Thus,
the present research was undertaken in RajanPur,
predominantly a rural district, and has recorded
the province's lowest maternal and child health
indicators (MICS, 2017-2018).
Review of Literature
The concept of OOPE has been defined by
researchers and institutions in different contexts.
In the health sector, the World Bank defines
OOPE as "any direct outlay by households,
including gratuities and in-kind payments to
health practitioners and suppliers of
pharmaceuticals, therapeutic appliances, and
other goods and services whose primary intent is
to contribute to the restoration or enhancement of
the health status of individuals or population
groups. It is a part of the private health
expenditure" (World Bank, 2014). Despite
policies by developing countries to provide free
access to maternity care, it seems that households
often have to pay out of pocket, whether formally
or informally (Berer, 2012). Particularly in
maternal healthcare, it is even more significant
(Srivastava et al., 2009). Many studies in India
(Goli et al., 2018; Tellis et al., 2018; Mohanty &
Srivastava, 2013; Govil et al., 2016; Issac et al.,
2016) showed that OOPE of women availing
maternal health carefrom the public sector has
increased over a period of time. Mirabedini et al.
(2017), through their systematic review in Iran,
showed the predominance of OOPE and informal
payments in the health system. Bangladesh
Patient Exit Survey (National Institute of
Population Research and Training, 2013)
revealed that almost 75% of outpatients, and
more than 90% of inpatients associated with
maternal and child health care, reported spending
a major share of OOPE on travel costs to the
facility. In Pakistan, a study in Sindh province by
Ansari et al. (2015) showed that 82% of women
who utilized maternal health care in public health
facilities and 96% who used the private facilities
incurred OOPE. The study found that almost
55% of users of public facilities and 71% of
private health facilities could not afford this
expenditure.
Many studies have shown that indirect
expenditures of hospital-based delivery care are
much higher than direct costs. Evidence shows
that even in many countries where maternal
health services are free to women, indirect costs
such as transportation become an important
factor influencing the utilization of these
services. (Kyei-Nimakoh, et al., 2017). The
major constraints are related to poorly located
health facilities and an inadequate number of
facilities delivering maternal health care. As a
result, the women in rural areas have to incur
huge indirect costs, including transport expenses.
A study in Nepal (Acharya et al., 2016) showed
that indirect costs are seven times ($268) higher
than that of the hospital costs ($38). In this study,
indirect expenditure of delivery services included
expenses on transportation, food,
communication, laundry services, and fuel. It
also includes expenditure incurred on childcare,
clothes/women, and accessories like a thermos
flask, buckets, mug, soap, mat, toothpaste, oil,
and toilet papers. This also includes loss of wages
during the hospital stay (Acharya et al., 2016). A
study in Ethiopia revealed the median direct
medical cost of institutional delivery was $
10.80, while the direct nonmedical cost was
$10.31. From the direct medical costs, the
median cost of a drug during institutional
delivery was $10.94. The study also revealed that
the median loss of wages was about $39.82,
while the median loss of wages for caregivers
124
except husband was around $2007.29 during the
institutional deliveries in Ethiopia. (Merga et al.,
2019).
Sharma et al. (2018), in a study of OOPE on
maternal care in urban slums of India, used both
direct and indirect expenditures. Direct
expenditure comprised of expenditures incurred
on registration, medicines, consumables, hospital
bed, laboratory investigations, anesthesia and
surgery if any, food, gifts to attendants, drugs,
and supplies, and transportation; whereas
indirect expenditure included the cost of the
mother and caretakers in terms of loss of daily
wages. However, a study based on the
Bangladesh Demographic and Health Survey
2014 did not demarcate the direct and indirect
expenditures separately (Sarkar et al., 2018).The
study included, along with all expenditures
incurred in the hospital as direct medical cost,
also included expenditures on travel, food,
lodging, hiring of an "aya," and even tip‐giving
were all major components of child delivery
costs. An earlier study on OOPE in Bangladesh
(Rahman et al., 2013) also did not differentiate
between direct and indirect expenditures. The
study included charges incurred on registration,
doctor's consultation, medicines, diagnostic tests,
transportation, and other associated costs.
Another study on OOPE on delivery care in
Bangladesh by Noreen (2017) demarcated direct
and indirect expenditures. In this study, direct
expenditure consists of travel costs, consultation
fees, hospitalization charges, and purchases of
drugs and supplies, whereas indirect costs
included the opportunity costs of time lost due to
caesarean section delivery, which accounted for
a substantial proportion of total caesarean section
delivery costs.
A study based on the national family health
survey 2015-16 of India did not provide the
details of items included in direct and indirect
expenditures (Krishnamoorthy et al., 2020). In a
study in Myanmar, Myint et al. (2018) included
expenses on all related healthcare services
received during delivery care, namely hospital
costs, investigation fees, drugs, consultation fees,
food, living, transportation, and other related
costs in estimating OOPE, but no differentiation
of direct and indirect expenditures was
provided.Malik and Syed (2012) in Pakistan,
using national survey data, did not make any
demarcation between direct and indirect OOPE.
The authors included expenditures on medicines,
equipment supplies, fees paid to doctors,
traditional healers, etc. Hospitalization including
doctors' fees, laboratory tests, X-ray charges, etc.
Dental/optical care and all other expenses on
healthcare not classified elsewhere were also
included. Another study in Pakistan by Khan and
Zaman (2010) estimated OOPE on delivery care
in tertiary hospitals, included both direct and
indirect expenditure components together. The
components of OOPE included expenditure
incurred on food, transport, drugs, tests, blood
transfusion, informal caregiver's time cost,
hospital charges, and informal payments like tips
and bribes.
A study by Tellis et al. (2018) in India collected
both direct and indirect expenditures. Direct
expenditure included expenses incurred on
registration, consultation, bed charges,
investigations, medication, and blood
transfusion, whereas indirect expenditure
includes food, transport, and wage loss faced by
the respondents. However, expenditures incurred
on companions in terms of food, transport,
accommodation, and wage loss were calculated
separately. Few studies conducted in India
showed that informal payments for getting
delivery care services consisting of gifts and tips
for services to form a major share of indirect
expenditures. (Issac et al., 2016; Gopalan and
Durairaj, 2012; Mohanty & Srivastava, 2013).
One such study shows that tips for getting
services, which 86% of women had to incur,
included tips to avail government ambulance and
bribes either in cash or kind (distributing sweets)
to facility staff for their services (Issac et al.
2016).
Material and Methods
This was a cross-sectional study conducted in
Rajanpur district in Pakistan, which is
predominantly a rural district in the province of
Punjab. and the research applied descriptive and
analytical techniques. All mothers who had
childbirth in healthcare facilities (public and
private) in the district from 1st October to 31st
December 2020 were the population of the study.
The sample size for the study was calculated
using the formula: n = z2pq / d2; where z = 1.96
at 95% confidence interval, p = 0.59 (this is the
proportion of institutional delivery in rural areas
as per Pakistan Demographic and Health Survey
2017-2018), q = (1-p) = 0.41, d = acceptable error
5%= 0.05. The sample size thus calculated was
368 (approximately).
A multi-stage random sampling technique was
followed to select the participants in the study.
As a first step, a total number of 3 BHUs were
selected from each of the six Rural Health
Centres (RHCs) for this study. Secondly, the
number of mothers who had institutional
Volume 11 - Issue 54
/ June 2022
125
https:// www.amazoniainvestiga.info ISSN 2322 - 6307
deliveries in each of the selected BHU areas
during three months, i.e., 1stOctober –
31stDecember 2020, was collected from the
Chief Executive Officer (Health), RajanPur. As
per the list, there were 2362 institutional
deliveries reported during this period in all the 18
BHUs selected for the study. BHU- wise list of
mothers with their names and addresses were
collected with the assistance of the LHWs in the
concerned BHUs. It was decided to select 25
mothers randomly from the list received from
each BHU, making a total number of 450
mothers from 18 BHUs. This was done keeping
in view the non-availability of household
members or incomplete responses. Interviews
were conducted with the selected participants
with the assistance of LHWs who were in charge
of the selected village areas. Although efforts
were made to contact 450 mothers, however, due
to the non-availability of male members in the
family and non-cooperation or non-response
from the participants; only 408 mothers from
were contacted and interviewed. After scrutiny of
all data collected through the interview
schedules, it was found that 368 interview
schedules were fully completed in all respects,
and they were used in the analysis yielding a
response rate of 82%.
Participants of the study included the women
residents of the selected BHU area, aged 15-49
years, who had delivered within three months,
i.e. 1st October – 31st December 2020 in a
healthcare facility in the district and were willing
to participate in the study. They should be present
at the study area during data collection.Primary
data for the study was collected using a locally
translated structured interview schedule, which
was initially developed in English. The interview
schedule was prepared based on the validated
study instruments used by earlier studies on
maternal healthcare utilization in Pakistan
(Noreen, 2017) and similar studies in other
countries (Chhetri et al., 2020; Issac et al., 2016;
Rahman et al., 2013).
Initial section of the interview schedule
contained different questions related to various
socioeconomic characteristics of mothers,
second section dealt with details of delivery care
such as mode of delivery, outcome of delivery,
place of delivery, distance to the healthcare
facility, reasons for seeking care from the private
healthcare facilities and perception about public
healthcare facilities. The third section contained
details of OOPE incurred on delivery care by the
mothers under direct medical expenditure and
non-medical expenditure, respectively.
Disaggregated information on each category of
expenditure was included in this section. Direct
medical expenditureincluded details of costs
incurred on diagnostic procedures, cost on
medicines and supplies, cost incurred on surgery,
hospital charges and other costs such as blood
transfusions. Direct non-medical expenditure
included cost on referral transport, food
expenditure for mother and accompanying
person and accommodation of accompanying
person.
Primary data collected through the interview
schedule was entered into SPSS software
version-25 and was analyzed using qualitative
and quantitative techniques. The ethical
clearance for this study was obtained from the
Medical Ethics Committee, Faculty of Medicine
and Health Sciences, UNIMAS.
Results
Socio-economic characteristics
The mean age of mothers in the study was
approximately 28.3 years, with more than 60% of
them between 20 to 30 years’ age group. Of
them, 59.5% did not have any schooling, 16%
had primary schooling, 16.57% had secondary
level schooling, and 7.88% had higher secondary
and above qualification. A majority of mothers
(85.6%) were housewives, 7.8% of them were
working in the government or private sector,
3.8% were contract wage earners and 2.7% were
self-employed. The household income of the
respondents revealed that almost 54% of them
had lower than 10000 PKR. Only a negligible
number of households (3 nos.) was covered by
any health insurance scheme.
126
Table 1.
Socio-economic and demographic characteristics of mothers.
Variables
Number (n=368)
Percentage
Age group of women
Below 25 years
141
38.31
26 – 35 years
174
47.28
36 years and above
53
14.40
Education of Women
No formal education
219
59.51
Primary level
59
16.03
Secondary level
61
16.57
Higher secondary and above
29
7.88
Occupation of women
Housewife
315
85.60
Working (government and private)
29
7.88
Daily wage earners
14
3.80
Self employed
10
2.72
Monthly Household Income
Below 10000 PKR
200
54.34
Between 100001- 30000 PKR
119
32.34
Between 300001-60000 PKR
49
13.32
Source: SPSS Data Analysis Files by author
Utilization of Delivery Care
Table 2 presents the description on utilization of
delivery care by mothers included in the study.
The data shows that normal deliveries constituted
79.3%, while deliveries done through caesarian
section constituted 20.7% of deliveries. While
most (99.5%) of mothers delivered a single baby,
less than 1% had twins. While 67% of mothers
preferred the public healthcare facilities for most
recent delivery, 33% preferred private healthcare
facilities.
Table 2.
Delivery profile of mothers included in the study.
Delivery details
Responses
Numbers
%
Mode of the recent
delivery
1-Normal
Caesarean -2
292 76
79.3 20.7
The outcome of recent
delivery? (In terms of number of
children)
1-Single 2-Twins
366 2
99.5 0.5
The outcome of recent
delivery? (in terms of alive or
dead)
1-Live birth (currently
alive) 2-Stillbirth
360
8
97.8
2.2
Place of most recent
delivery?
1-Public health
facilities 2-Private health
facilities
247
121
67.0
33.0
Source: spss data analysis files by author.
Table 3 presents the details of normal and
caesarean deliveries conducted in both public
and private health care instititons. Cross
tabulation results show that out of 247 deliveries
conducted at the public healthcare facilities, 224
deliveries (90.68%) were normal and 23
deliveries (9.32%) were conducted through
cesarean procedures. However, out of 121
Volume 11 - Issue 54
/ June 2022
127
https:// www.amazoniainvestiga.info ISSN 2322 - 6307
deliveries conducted at private healthcare
facilities, only 68 deliveries (56.2%) were performed normally and 53 deliveries (43.80%)
were conducted through caesarean procedures.
Table 3.
Normal and caesarean deliveries in public and private hospitals.
Place of Delivery
Normal
Caesarean
Total
Public Sector
No.
224
23
247
%
90.68%
9.32%
(100%)
Private Sector
No
68
53
121
%
56.20%
43.80%
(100%)
Total
No
292
76
368
%
100%
100%
(100%)
Thus, the percentage of cesarean deliveries
conducted in the private healthcare facilities is
almost 4.7 times higher than the percentage of
cesarean deliveries conducted in public
healthcare facilities. Of the 76 caesarean
deliveries reported in the study, 53 (69.7%) were
conducted in the private hospitals and out of 292
normal deliveries reported in the study, 224
(76.7%) were performed in public hospitals.
Direct Medical Expenditures on Delivery
Care
Public Healthcare Facilities
In the study, 247 (67.12%) out of 368 mothers
availed delivery care from the public healthcare
facilities. Table 4 gives a detailed break-up of
direct medical expenditures incurred by mothers
who had childbirths in public healthcare
facilities. Expenditure incurred in public
healthcare facilities broadly includes costs
incurred on diagnostic tests, drugs & supplies
and surgery charges.
Table 4.
Direct medical expenditures on delivery care in the public healthcare facilities (in PKR)
Expenditure
Head
N (211)
2000 &
below
2001-
4000
4001-
6000
6001-
8000
8001-
10000
Above
10000
Mean
Diagnostic
tests
86
(100%)
81 (94.2%)
4 (4.6%)
1 (1.2%)
0
0
0
394.0
Drugs & other
supplies
201 (100%)
169 (84.0%)
11 (5.5%)
7 (3.5%)
1 (0.5%)
8 (3.9%)
5 (2.5%)
1269.6
Surgery
08 (100%)
0
0
0
1 (12.5%)
3 (37.5%)
4 (50%)
10777.8
Total OOPE
211 (100%)
176 (83.4%)
11 (5.2%)
6 (2.8%)
3 (1.4%)
1 (0.5%)
14 (6.6%)
2043.09
Source: SPSS Data Analysis Files by author
The analysis revealed that 211 (85.42%) mothers
out of 247 who had deliveries at public healthcare
facilities incurred some amount as OOPE. Out of
these 211 mothers who had incurred OOPE, 86
(40.8%) of them paid for diagnostic tests, 201
(95.2%) incurred expenditure on purchase of drugs
and other supplies from private pharmacies, and 8
of them (3.8%) had incurred charges on surgery
performed in the hospitals. A majority of mothers
(94.2%) incurred OOPE below PKR 2000 for
diagnostic tests (94.2%) and drugs/supplies (84%).
On an average, mothers incurred PKR 394 on
diagnostic tests, PKR 1269.6 on purchase of drugs
and supplies and PKR 10777.8 as surgery charges.
Thus, the study showed that mothers had incurred
PKR 2043.09 as direct medical expenditures while
availing delivery care from the public healthcare
facilities.
Private Healthcare Facilities
In the study, 121(32.9%) out of 368 mothers availed
delivery care from private healthcare facilities.
Table 5 provides a detailed break-up of direct
medical expenditures incurred by the mothers who
had availed delivery care in private healthcare
facilities.
128
Table 5.
Direct medical expenditures on delivery care in private healthcare facilities (in PKR)
Expenditure
Head
N = 121
< 2000
2001-
4000
4001-
6000
6001-
8000
8001-
10000
>10001
Mean
Diagnostic
charges
121
111 (91.7%)
3 (2.5%)
7 (5.8%)
0
0
0
1707.4
Drugs &
other
supplies
121
32 (26.4%)
43 (35.5%)
26 (21.5%)
3 (2.5%)
13 (10.7%)
4 (3.3%)
4450.4
Surgery
53
0
0
1 (1.8%)
0
2 (3.50)
50 (87.7%)
18596.5
Hospital
charges
121
1 (0.8%)
6 (5.0%)
36 (29.8%)
23 (19.0%)
24 (19.8%)
31 (25.6%)
9227.3
Total
OOPE
121
0
2 (1.7%)
1 (0.8%)
12 (9.9%)
15 (12.4%)
91 (75.2%)
23471.9
Source: SPSS Data Analysis Files by author
The study showed that all mothers who had
delivered at the private healthcare facilities
(N=121) incurred OOPE on diagnostic tests,
drugs & supplies, and hospital charges. However,
53 (43.8%) mothers incurred surgery charges. A
majority of mothers (91.7%) who availed
delivery care in private healthcare facilities
incurred PKR 2000 or below for diagnostic
procedures. Further analysis revealed that on an
average, mothers incurred PKR 1707.4 on
diagnostic tests, PKR 4450.4 on purchase of
drugs and supplies, PKR 18596.5 on surgery
related expenditure, PKR 9227.3 as hospital
charges. Thus, the study revealed that families of
mothers who had their child birth at private
healthcare facilities incurred a mean direct
OOPE of PKR 23471.9.
Direct Non- Medical Expenditure on Delivery
Care
PublicHealthcare Facilities
Table 6 gives a detailed break-up of direct non-
medical expenditures incurred by the families on
delivery care in public healthcare facilities. The
categories of non-medical expenditures include
transport costs from home to hospitals, back to
home from the hospitals, and expenditures
incurred on food for mothers and accompanied
persons during the stay in hospital.
Table 6.
Non- medical expenditure on delivery care in public healthcare facilities (in PKR)
Expenditure
Head
N = 211
< 2000
2001-4000
>4001
Mean ±SD
Transport costs
from home to
hospital
(pregnant
woman for
delivery)
90
90 (100%)
0
0
197.10
Transport costs
from hospital to
home (mother
and neonate after
delivery)
211
210 (99.6%)
1 (0.4%)
0
470.1
Referral
transport cost
03
2(66.7)
0
1 (33.3)
3000.0
Transport costs
of accompanying
persons
06
0
5 (83.3%)
1 (16.6%)
866.7
Volume 11 - Issue 54
/ June 2022
129
https:// www.amazoniainvestiga.info ISSN 2322 - 6307
Food
expenditure for
mothers
192
183 (95.3%)
8 (4.7%)
737.0
Food
expenditure for
accompanying
persons
57
52 (91.2%)
5 (8.8%)
0
593.7
Total OOPE
(Mean)
211
202 (95.7%)
7 (3.3%)
2 (0.9)
821.4
Source: SPSS Data Analysis Files by author
The results revealed that 211 mothers (85.4%)
who sought delivery care in public healthcare
facilities reported that they incurred direct non-
medical expenditure in the form of costs on
transport from home to hospitals, from hospital
to home, and purchase of food items for mothers
and accompanying persons. Of the 211 mothers
who reported of incurring OOPE on non-medical
expenditure, 90 (42.6%) mothers incurred
expenditure on arranging transport from home to
hospital and they incurred OOPE up to 2000
PKR. This means a majority of mothers had
availed ambulance services provided by health
department in the district, although a few of them
travelled by other means of transportation.
Whereas, most of the mothers i.e., 210 mothers
(99.5%) have reported that their family had to
arrange transport facilities to go back home and,
in the process, they incurred a significant
amount. Only 3 mothers have reported of
incurring additional costs of transport owing to
referral of the case to higher facility. Expenditure
on food is another component of direct non-
medical expenditure as 192 mothers (91%) who
had their child birth at public health facilities
incurred costs on food purchased for mothers,
and another 57 mothers (27%) reported of
incurring additional costs of food purchased for
bystanders in the hospital.
Further analysis revealed that on an average,
mothers had incurred PKR197.10 as cost of
transport from home to hospital, PKR 470 as cost
of transport from hospital to home, PKR 3000 for
arranging referral transport, PKR 866.7 as
transport costs of accompanying persons in the
hospital, PKR 737 and PKR 593.7 as cost of food
for mother and accompanied persons
respectively. Thus, the study revealed that
mothers who had delivered at public healthcare
facilities have incurred a mean OOPE of 821.4
PKR.
Private Healthcare Facilities
Table 7 gives a detailed break-up of direct non-
medical expenditures incurred by the mothers on
delivery care in the private sector health
facilities. The categories of non-medical
expenditures include transport costs from home
to hospitals, cost of transport from the hospitals
to home, food expenditures on mothers and
accompanied persons in the hospital.
Table 7.
Non- medical expenditures on delivery care in private healthcare facilities (in PKR)
Expenditure Head
N = 121
1-2000
2001-4000
>4001
Mean
Transport costs
from home to
hospital (pregnant
woman for
delivery)
120
116 (96.6)
4 (3.3)
0
981.8
Transport costs
from hospital to
home (mother and
neonate after
delivery)
121
117 (96.7)
4 (3.3)
0
1024.0
Referral transport
costs
02
1(50%)
1(50%)
0
2650.0
130
Transport costs of
accompanying
persons
15
15 (100.0)
0
0
866.7
Food expenditure
for mothers
120
97 (80.8%)
23 19.2%)
0
1504.5
Food expenditure
for accompanied
90
66 (73.3%)
24 (26.6%)
0
1211.9
Total OOPE
(Mean)
121
86(71.1)
28(23.1)
7(5.8)
2124.4
Source: SPSS Data Analysis Files by author
Results reveal that all mothers (N=121) who
sought delivery care in private healthcare
facilities reported of incurring direct non-medical
expenditures in the form of costs on transport
from home to hospitals, from hospital to home,
and purchase of food items for mothers and
accompanying persons. Out of 121 mothers who
reported of incurring OOPE on non-medical
expenditure, 120 (99.2%) mothers incurred
below PKR 2000 as cost of transport to reach
hospital. Whereas, all mothers incurred costs on
arranging transport facilities to go back home.
Only 2 mothers incurred additional costs for
transport due to emergency referral to higher
facility. While 120 respondents (99.2%) reported
that they incurred expenditure on purchase of
food items for mothers, and 90 mothers (74.4%)
reported of incurring additional costs for
purchasing food for accompanying persons in the
hospital. The study revealed that on an average
mother incurred PKR 981.8 as cost of transport
from home to hospital, PKR 1024 as cost of
transport from hospital to home, PKR 2650 for
arranging referral transport, PKR 866.7 as cost of
transport for accompanying persons, PKR 1504.5
and PKR 1211.9 as cost of food items for mother
and accompanying persons respectively. Overall,
the study revealed that mothers who had
delivered at private healthcare facilities have
incurred a mean OOPE of PKR 2124.4 as direct
non-medical expenditure, which is quite higher
compared to the non-medical OOPE of mothers
(PKR.821.4) who had delivered at public
healthcare facilities.
Mean OOPE on Delivery Care
A comparison of average OOPE incurred by the
mothers who had delivered in public and private
hospitals are presented in table 8.
Table 8.
MeanOOPE on delivery care in public and private healthcare facilities (average in PKR)
Expenditure Head
Public Sector
Private Sector
Direct Medical Expenditures
Diagnostic charges
394.0
1707.4
Drugs & other supplies
1269.6
4450.4
Surgery
10777.8
18596.5
Hospital charges
0
9227.3
Total (Mean)
2013.09 (71.02%)
23471.9 (91.70%)
Direct Non-Medical Expenditures
Home-Hospital
197.10
981.80
Hospital-Home
470.10
1024.0
Referral
3000.0
2650.0
Transport for accompanying
persons
866.7
866.7
Food items for mothers
737.0
1504.5
Food items for accompanied
593.7
1211.9
Total (Mean)
821.4 (28.97%)
2124.4 (8.29%)
Grand Total
2834.50
25596.3
Home-Hospital
197.10
981.80
Source: SPSS Data Analysis Files by author
Volume 11 - Issue 54
/ June 2022
131
https:// www.amazoniainvestiga.info ISSN 2322 - 6307
Mean direct medical expenses incurred by
mothers who delivered in public healthcare
facilities (which includes diagnostic tests, drugs,
and surgery charges) was PKR 2013.09, and
mothers who delivered at private healthcare
facilities (which includes diagnostic tests, drugs,
surgery and other hospital charges) was PKR
23471.9. Mean direct non-medical expenses
incurred by the mothers who delivered at public
healthcare facilities (which includes transport
expenses to the hospital and back home,
expenses on food items purchased for mothers
and bystanders) was PKR 821.4, whereas mean
direct non-medical expenses for mothers who
delivered at private healthcare facilities was PKR
2124.1. The study reveal that mean average
OOPE for mothers who availed delivery care
from the public healthcare facilities was PKR
2834.50, whereas OOPE incurred by mothers
who sought delivery care in the private
healthcare facilities was PKR 25596.3. Thus, the
study shows that OOPE on delivery care at
private hospitals is almost 9 times higher
compared to public hospitals.
Figure 1. Proportion of Mean Direct Medical Expenditure Vs. Non-medical Expenditure on Delivery Care
Source: SPSS Data Analysis Files & Excel file by author
Fig 1 shows that mean direct medical expenditure
for delivery care in the public healthcare facilities
comprises 71.02% of total OOPE; whereas this
component constitutes 91.70% of total OOPE on
delivery care in the private healthcare facilities.
While direct non-medical expenditure comprises
28.97% of delivery care in the public healthcare
facilities, this component forms only 8.29% of
delivery care in the private healthcare facilities.
Mean OOPE on Normal and Caesarean
Deliveries
Average (Mean) OOPE on normal and caesarean
deliveries in public and private sector hospitals
are presented in table 9. Mean direct medical
expenditure on delivery care included mean
expenses incurred on diagnostics, drugs&
supplies, surgery and hospital charges. Mean
direct non-medical expenditure includes travel
expense from home to hospital and back to home,
transportation charges for mothers,
accompanying persons including referrals. It also
includes costs of food items purchased for
mothers and accompanying persons. It is evident
from the results in table-9 that average direct
medical expense on diagnostic tests conducted in
public sector hospitals for normal delivery is
PKR. 242.1 while in private sector it is PKR
1508.8, which is almost 6 times higher than that
of public sector hospitals. However, much
difference is not observed in average diagnostic
charge for mothers who had cesarean deliveries
in public healthcare facilities (PKR 1957.9), and
private health facilities (PKR 1962.3).Average
expenditure incurred on drugs and other supplies
for normal deliveries in public hospitals is PKR
700 while in private healthcare facilities it is
PKR 3139.7, which is almost 4.5 times higher
than public hospitals. However, mean expense
for cesarean deliveries in public hospital of PKR
7228.6 is higher than mean expense for cesarean
deliveries in private hospitals (PKR 6132.1).
Surgery charges constitutes a major share of
OOPE for cesarean deliveries, especially in the
private hospitals. While only a small fraction of
mothers who had cesarean deliveries at public
hospitals incurred surgery charges, all mothers
who delivered at private hospitals had incurred
surgery charges. Mean charges incurred for
surgery during cesarean deliveries are
PKR10777.8 in public hospitals and PKR
18882.4 in private hospitals. While there were no
hospital charges in public healthcare facilities,
mothers who had delivered in private hospitals
incurred a mean hospital charge of PKR 7845.6
for normal deliveries and PKR 11000.0 for
71.02%
28.97%
Public Hospitals
Direct Medical Expenditure
Direct Non-Medical Expenditure
91,70
%
8,29%
Private Hospitals
Direct Medical Expenditure
Direct Non-Medical Expenditure
132
cesarean deliveries. The analysis also showed
that mean direct medical expenditure for normal
delivery in private hospitals (PKR 12825.0) is
about 14 times higher than mean direct medical
expenditure for normal delivery in public
hospitals (PKR 922). However, mean direct
medical expenditure for cesarean deliveries in
private hospital (PKR 37132.1) is only about 2.6
times higher than mean direct medical
expenditure for cesarean deliveries in public
hospital (PKR 14047.6).
Table 9.
Average OOPE on normal and caesarean deliveries in public and private sector hospitals ( in PKR)
Expenditure Head
Public Sector
Private Sector
Normal
Caesarean
Normal
Caesarean
Direct Medical Expenditures
Diagnostic charges
242.1
1957.9
1508.8
1962.3
Drugs & other
supplies
700.0
7228.6
3139.7
6132.1
Surgery
0
10777.8
16166.7
18882.4
Hospital charges
0
0
7845.6
11000.0
Total OOPE (Mean)
922.0
14047.6
12825.0
37132.1
Direct Non-Medical Expenditures
Transport cost from
home tohospital
166.7
459.5
843.4
1159.4
Transport cost to
home
402.9
1095.2
904.4
1178.3
Referral transport cost
1500.0
7000.0
300.0
5000.0
Transport cost of
accompanying persons
750.0
925.0
600.0
1100.0
Cost of food for
mothers
280.6
1280.4
824.8
2260.4
Cost of food for
accompanying
persons
340.2
623.5
637.6
1816.7
Total OOPE (Mean)
579.4
2064.3
1814.0
2522.6
Grand Total (Mean)
1501.4
16111.9
14339.0
39654.7
Source: SPSS Data Analysis Files by author
With regard to direct non-medical expenses,
mean expenditure for travelling from home to
hospital for normal delivery is PKR166.7 in
public hospitals and PKR 843.4 in private
hospital; mothers who reported cesarean section
in public hospitals incurred an average expense
on travelling PKR 459.5 and PKR 1159.4 in
private hospitals respectively. Mean transport
charges incurred by families while going back to
home from hospitals were higher for both normal
and caesarean deliveries in both public and
private sectors. For normal deliveries, mean
expense incurred by families for going back
home is PKR 402.9 in public hospital and PKR
904.4 in private hospital; and for caesarean
deliveries mean averages are PKR 1095.2 and
PKR 1178.3 in public and private sector hospitals
respectively. Mean expense on arranging referral
transport from public hospital is higher than that
of private hospital for both normal and caesarean
deliveries. On an average, an amount of PKR
1500 and PKR 7000 were incurred on referral
transport by mothers who had normal and
cesarean deliveries respectively in public
hospitals. However, mean expenses on referral
transport in private hospitals are PKR 300.0 for
normal delivery and PKR 5000 for cesarean
deliveries, both are lower compared to public
hospitals. Transportation of accompanying
persons in public sector is PKR 750, while in
private hospitals it is PKR 600; and for cesarean
deliveries mean amount of PKR 925 and PKR
1100 were incurred in public and private
hospitals respectively.
A considerable amount was also incurred on
purchase of food for both mothers and
accompanying persons in hospitals. Expenditure
on food increases with increase in number of
days of hospital admission and families had to
Volume 11 - Issue 54
/ June 2022
133
https:// www.amazoniainvestiga.info ISSN 2322 - 6307
spent a higher amount in the event of cesarean
deliveries. Food expenditure for mothers and
bystanders were higher in private hospitals
probably due to more number of stays compared
to public hospitals. The analysis showed that
mean direct non-medical expenditure for normal
delivery in private hospital (PKR 1814) is almost
3 times higher than mean direct non-medical
expenditure for normal delivery in public
hospital (PKR 579.4). However, mean direct
non-medical expenditure for cesarean delivery in
private hospital (PKR 2522.6) is only PKR 500
higher than direct non-medical expenditure for
cesarean delivery in public hospital (PKR
2064.3). The overall analysis in table 9 shows
that OOPE incurred on normal delivery care in
private hospitals is almost 9.5 times higher than
OOPE incurred on normal delivery care in public
hospitals; whereas OOPE incurred on cesarean
delivery care in private hospitals is almost 2.5
times higher than OOPE incurred on cesarean
delivery care in public hospitals.
Discussion
Although many studies attempted to estimate
OOPE on maternal healthcare utilization using
both primary and secondary data at the
international level, such studies are lacking in the
context of Pakistan. One of the objectives of the
present study was to estimate the OOPE (direct
medical and non-medical costs) on delivery care
by mothers in public and private hospitals in the
RajanPur district. The study showed that 90.2%
of mothers had incurred direct medical expenses
for delivery care in public or private facilities.
This finding is consistent with an earlier study in
three districts of Sindh province, which showed
that 82% and 96% of the women who utilized
public or private health facilities for delivery care
incurred OOPE (Ansari et al., 2015). It also
showed a vast difference in OOPE incurred by
mothers on delivery care in public vs. private
healthcare facilities. The mean OOPE incurred
for delivery in a public hospital is PKR 2834
compared to PKR 25596 in private hospitals. The
present study's findings are consistent with
earlier studies in Pakistan.
Rehman et al., (2017) in a rural district of
Pakistan showed that women incurred on an
average PKR 4000 for delivery care in the public
hospital and PKR 16000 in the private hospital.
Sughra et al. (2018) in the Punjab district of
Pakistan showed that the mean OOPE on
delivery care was PKR 7531 and for the lowest
wealth quintile between PKR 7351 -855. While
the vast difference in OOPE was due to higher
hospital charges, medicine, and surgery fees in
private healthcare facilities, the cost of
transportation contributed to the increased share
of OOPE in public healthcare facilities. More
than two-thirds of women incurred charges on
medicine, cotton pads, syringes, and saline in
public hospitals, which they bought from private
pharmacies. Even countries with universal
availability of maternal health services also incur
huge OOPE, including informal payments
(Sidney et al., 2016). Prinja et al. (2015), in a
study in India, found that OOPE for delivery in
the private sector is about 16 times higher than
that of the public health sector. This is due to the
government's universal availability of free
delivery care facilities through public health
facilities.
Overall, OOPE is higher for the mothers who
have childbirth in private health care facilities
and delivered through cesarean section. These
women incurred high OOPE due to additional
charges on medicine and supplies, diagnostic
services, and blood transfusion in the private
hospitals. Mohanty et al. (2018) showed that
cesarean deliveries in the private sector are
almost US$ 296 higher than normal deliveries. In
Nepal, cesarean delivery is almost 7.5 times
higher than normal deliveries in the private
sector. In Bangladesh, a cesarean section in the
private sector is 3.2 times higher than normal
deliveries (Sarkar et al., 2018). In this study, tips
for getting services in public healthcare facilities
were negligible, although earlier studies have
reported informal payments made by mothers
during delivery care utilization in public
hospitals. For instance, Issac et al. (2016) in India
showed that 86% of the woman had incurred tips
(median value of US$5.25) to avail government
ambulance and bribes in cash or kind to facility
staff for their services such as obtaining a bed in
the postnatal ward. A study by Khan and Zaman
(2010) in a tertiary level public hospital in
Islamabad, Pakistan, estimated that the average
cost to mothers for normal delivery was
PKR7528 and that cesarean delivery was PKR
13678.
The study showed that costs incurred on
transportation account for a significant share of
direct non-medical expenditure. Despite the
availability of a public ambulance scheme in the
district, this was not the vehicle of choice for
many women due to long waiting times, poor
road connectivity, and easy availability of other
modes of transportation within the
neighborhood. However, a majority of the
woman used ambulance facilities for returning
home. A similar study in Pakistan by Ansari et al.
(2015) reported that more than 55% of users in
134
the public sector and 71% of private health sector
users could not afford travel costs, and travel
costs were higher among women who had to
travel more than 5 km distance (Razumowsky,
2022). Qureshi et al (2016) found that poor
transportation and financial problem are
significant barriers to seeking maternal health
services in Pakistan. The government of Pakistan
focused on maternal and child health and created
multiple policies to improve the availability of
maternal and neonatal care services and address
financial barriers related to their utilization.
However, the target of universal health coverage
for delivery care in Pakistan is not yet achieved.
Similar findings have also been highlighted in a
few studies discussing the high OOPE for
institutional deliveries in Pakistan.
Conclusion
The study showed that households incurred a
high OOPE on delivery care in public and private
hospitals. A significant difference in OOPE was
observed between public versus private
hospitals; and normal versus caesarian deliveries,
which demonstrates that health care is expensive
in the private sector. The percentage of cesarean
deliveries conducted in private health sector was
4.7 times higher than cesarean deliveries
performed in public healthcare facilities. The
prevalence of cesarean deliveries in the private
health sector was almost three times the
WHOrecommended norms. OOPE on cesarean
delivery in private hospitals is almost 2.5 times
higher than the public hospitals, whereas OOPE
incurred on normal delivery care in private
hospitals is almost 9.5 times higher than OOPE
in public hospitals.The study also found that
costs incurred on transportation account for a
significant share of direct non-medical
expenditure. Despite the availability of a public
ambulance scheme in the district, this was not the
vehicle of choice for many women. Thus,
findings of this study make some significant
contributions to understanding OOPEs in
utilizing delivery care by women in a rural
district of Pakistan. These findings have policy
implications on the need to implement an
effective regulatory mechanism to control the
costs of care delivered by both public and private
healthcare facilities. There is also a need to
monitor and supervise maternal healthcare
services delivered by the public and private
sectors.
Bibliographic references
Acharya, J., Kaehler, N., Marahatta, S. B.,
Mishra, S. R., Subedi, S., & Adhikari, B.
(2016). Hidden Costs of hospitalbased
delivery from two tertiary hospitals in
western Nepal. Plos One, 11(6), e0157746.
https://doi.org/10.1371/journal.pone.015774
6
Ansari, M. S., Manzoor, R., Siddiqui, N., &
Ahmed, A. M. (2015). Access to
comprehensive emergency obstetric and
newborn care facilities in three rural districts
of Sindh province, Pakistan. Health Research
Policy and Systems, 13(1),
https://doi.org/10.1186/s12961-015-0042-7
ADB (2012). Asian Development Bank.
Available
athttps://www.adb.org/sites/default/files/pub
lication/29704/ado2012.pdf
Berer, M. (2012). Maternal mortality or women’s
health: time for action. Reproductive Health
Matters, 20(39), 5-10.
https://doi.org/10.1016/s0968-
8080(12)39632-8
Chhetri, S., Shah, R., & Rajbanshi, L. (2020).
Factors associated with utilization of
complete postnatal care service in Baglung
Municipality, Nepal. Int J Reprod Med,
2892751.
https://doi.org/10.1155/2020/2892751
Goli, S., Rammohan, A., & Moradhvaj. (2018).
Out-of-pocket expenditure on maternity care
for hospital births in Uttar Pradesh, India.
Health Economics Review, 8(5),
https://doi.org/10.1186/s13561-018-0189-3
Gopalan, S. S., & Durairaj, V. (2012).
Addressing maternal healthcare through
demand side financial incentives: Experience
of Janani Suraksha Yojana program in India.
BMC Health Services Research, 12, 319.
Govil, D., Purohit, N., Gupta, S. D., &
Mohanty, S. K. (2016). Out-of-pocket
expenditure on prenatal and natal care post
Janani Suraksha Yojana: a case from
Rajasthan, India. Journal of Health,
Population and Nutrition, 35(1), doi:
https://doi.org/10.1186/s41043-016-0051-3
Issac, A., Chatterjee, S., & Srivastava, A., &
Bhattacharyya, S. (2016). Out of pocket
expenditure to deliver at public health
facilities in India: a cross sectional
analysis.Reproductive Health, 13(99).
https://doi.org/10.1186/s12978-016-0221-1
Khan, A., & Zaman, S. (2010). Costs of vaginal
delivery and caesarean section at a tertiary
level public hospital in Islamabad, Pakistan.
BMC Pregnancy Childbirth, 10(2),
https://doi.org/10.1186/1471-2393-10-2
Volume 11 - Issue 54
/ June 2022
135
https:// www.amazoniainvestiga.info ISSN 2322 - 6307
Krishnamoorthy, Y., Ganesh, K., Sakthivel, M.,
& Priyan, S. (2020). Costs incurred and
determinants of out-of-pocket payments for
child delivery care in India: Evidence from a
nationally representative household survey.
Int J Health Plann Manage, 35(1),
e167-e177. doi:
https://doi.org/10.1002/hpm.2953.
Kyei-Nimakoh, M., Carolan-Olah, M. &
McCann, T.V. (2017). Access barriers to
obstetric care at health facilities in sub-
Saharan Africa—a systematic review. Syst
Rev 6, 110. https://doi.org/10.1186/s13643-
017-0503-x
Malik, A. M., & Syed, S. M. (2012). Socio-
economic determinants of household out-of-
pocket payments on healthcare in Pakistan.
Int J Equity Health, 4(11), 51.
https://doi.org/10.1186/1475-9276-11-51
Mansuri, G., Sami, M.F., Ali, M., Doan, H.T.T.,
Javed, B., & Pandey, P. (2018). When water
becomes a hazard: A diagnostic report on the
state of water supply, sanitation and poverty
in Pakistan and its impact on child stunting
(English). WASH Poverty Diagnostic Series.
Washington, D.C.: World Bank Group.
Merga, M., Debela, T. F., & Alaro, T. (2019).
Hidden costs of hospital-based delivery
among women using public hospitals in bale
zone, Southeast Ethiopia. Journal of Primary
Care & Community Health, 10,
https://doi.org/10.1177/2150132719896447
MICS (2017-2018), Punjab Survey findings
report, Multiple Indicator Cluster survey.
available on
https://www.unicef.org/pakistan/media/3121
/file/Multiple%20Indicator%20Cluster%20S
urvey%202017-18%20-%20Punjab.pdf
Mirabedini, S. A., Fazl, E., Hashemi, S. M.,
Asiabar, S., Rezapour, A.,
Azami-Aghdash, S., & Amnab, H. (2017).
Out-of-pocket and informal payments in
Iran's health care system: A systematic
review and meta-analysis. Medical Journal of
the Islamic Republic of Iran, 31(1), 401-409.
https://doi.org/10.14196/mjiri.31.70
Mohanty, S. K., & Srivastava, A. (2013). Out-of-
pocket expenditure on institutional delivery
in India.Health Policy and Planning, 28(3),
247–262,
https://doi.org/10.1093/heapol/czs057
Mohanty, S. K., Kim, R, Khan, P. K., &
Subramanian, S. V. (2018). Geographic
variation in household and catastrophic
health spending in India: Assessing the
relative importance of villages, districts, and
states. Milbank Q., 96(1), 167–206.
Myint, A. N. M., Liabsuetrakul, T., Htay, T., &
Wai, M.M, Sundby, J., & Bjertness, E.
(2018). Impoverishment and catastrophic
expenditures due to out-of-pocket payments
for antenatal and delivery care in Yangon
Region, Myanmar: a cross-sectional study.
BMJ Open, 8(11),
National Institute of Population Research and
Training (2013) Bangladesh Demographic &
Health survey 2011. Dhaka, Bangladesh and
Calverton, Maryland, USA: NIPORT, Mitra
and Associates, and ICF International.
Retrieved from:
https://dhsprogram.com/pubs/pdf/fr265/fr26
5.pdf
Noreen, S. (2017) Determinants of Demand for
Maternal Health Care Services: A Survey
Study of Bahawalpur District. (Doctoral
thesis) The Islamia University of
Bahawalpur.
Pakistan Bureau of Statistcis PBS Government of
Paksitan (2018). 7th population and Housing
census 2022. Retrived from
https://www.pbs.gov.pk/
Pomeroy, A., Koblinsky, M. M., & Alva, S.
(2014). Who gives birth in private facilities in
Asia? A Look at Six Countries. Health Policy
and Planning, 29, 38-47.
Prinja, S., Bahuguna, P., Gupta, R., Sharma, A.,
Rana, S. K., & Kumar, R. (2015). Coverage
and financial risk protection for institutional
delivery: How universal is provision of
maternal health care in India? Plos One,
10(9), e0137315.
https://doi.org/10.1371/journal.pone.013731
5
Qureshi, R.N., Sheikh, S., Khowaja, A.R.,
Hoodbhoy, Z., Zaidi, S., Sawchuck, D.,
Vidler, M., Bhutta, Z.A., & Dadeslzen, P.
(2016) Health care seeking behaviours in
pregnancy in rural Sindh, Pakistan: a
qualitative study. Reproductive Health,
13(1), 34.
Rahman, M.M., Gilmour, S., Saito, E.,
Sultana, P., & Shibuya, K. (2013). Health-
related financial catastrophe, inequality and
chronic illness in Bangladesh. PLoS One,
8(2), e56873.
https://doi.org/10.1371/journal.pone.005687
3
Rehman, A., Adnan, M., Mahmood, H.,
Hassan, M., & Humayun, A. (2017).
Maternal health care expenditure among
women in rural areas of Pakistan. Annals of
King Edward Medical University, 23(2). doi:
https://doi.org/10.21649/akemu.v23i2.1587
Riaz, A., Zaidi, S., & Khowaja, A. R. (2015).
Perceived barriers to utilizing maternal and
neonatal health services in contracted-out
versus government-managed health facilities
in the rural districts of Pakistan. International
136
Journal of Health Policy and Management,
4(5), 279-284. doi:
https://doi.org/10.15171/ijhpm.2015.50
Razumowsky, A. I. (2022). Distance education:
A ruin of health. Amazonia Investiga, 11(50),
290-298.
https://doi.org/10.34069/AI/2022.50.02.27
Sarkar, A. R., Sultana, M., Ali, N., & Akram, R.
(2018). Cost comparison and determinants of
out-of-pocket payments on child delivery
care in Bangladesh. International Journal of
Health Planning and Management, 33(9693),
https://doi.org/10.1002/hpm.2615
Sharma, S., Verma, P. B., Viramgami, A. P.,
Vala, M.C., & Lodhiya, K. K. (2018).
Analysis of out-of-pocket expenditure in
utilization of maternity care services in urban
slums of Rajkot City, Gujarat. Indian J
Community Med, 43, 215-9
Sidney, K., Salazar, M., Marrone, G., Diwan, V.,
DeCosta, A., & Lindholm, L. (2016) Out-of-
pocket expenditures for childbirth in the
context of the Janani Suraksha Yojana (JSY)
cash transfer program to promote facility
births: who pays and how much? Studies
from Madhya Pradesh, India. Int J Equity
Health 15, 71.
https://doi.org/10.1186/s12939-016-0362-4
Sughra, M., Fatima, F., Marrium, M., &
Abbas, K. (2018). Maternal health
expenditures and health seeking behavior
among lowest wealth quintile of the rural
population in an under developed district of
the Punjab, Pakistan. Int J Reprod Contracept
Obstet Gynecol, 7, 2579-82.
Srivastava, N. M., Awasthi, S., & Agarwal, G.G.
(2009). Care-seeking behavior and out-of-
pocket expenditure for sick new-borns among
urban poor in Lucknow, Northern India: A
prospective follow-up study. BMC Health
Serv Res, 61, 9.
Tellis, S. B., Rent, P. D., & Dmello, M. K.
(2018). Utilization of antenatal care and out
of pocket expenditure on delivery care in
Dakshina Kannada. Int J Community Med
Public Health, 5(8), 3553-3558
World Bank (2014). World Bank Data. Available
from:
https://datahelpdesk.worldbank.org/knowled
gebase/articles/906522-data-updates-and-
errata
WHO (2015) WHO statement on caesarean
section rates: Department of Reproductive
Health and Research World Health
Organization:
https://apps.who.int/iris/bitstream/handle/10
665/161442/WHO_RHR_15.02_eng.pdf
WHO (2018) World Health Statistics: World
Health Organization.
Geneva.https://apps.who.int/iris/rest/bitstrea
ms/1137482/retrieve
WHO, UNICEF (2013) Trends in maternal
Mortality: 1990 to 2013. Estimates by WHO,
UNICEF, UNFPA, The World Bank.
Geneva:
https://apps.who.int/iris/handle/10665/11269
7
WHO (2019) World Health Statistics -2019:
World Health Organization,
Genevahttps://www.who.int/data/gho/data/th
emes/theme-details/GHO/world-health-
statistics
World Bank (2019). Pakistan overview:
Available from
https://www.worldbank.org/en/country/pakis
tan/overview
WHO (2021) Maternal deaths decline slowly
with vast inequalities worldwide (updated
2021). https://www.who.int/news/item/19-
09-2019-maternal-deaths-decline-slowly-
with-vast-inequalities-worldwide
WHO & World Bank (2019). Global Monitoring
Report on Financial Protection in Health.
International Bank for Reconstruction and
Development.https://www.who.int/publicati
ons/i/item/9789240003958
WHO (2017) World Health Organization.
Maternal Health. retrieved from
https://www.who.int/health-topics/maternal-
health#tab=tab_1?