Background Monitoring financial protection is a key component in achieving Universal Health Coverage, even for health systems that grant their citizens access to care free-of-charge. Our study investigated out-of-pocket expenditure (OOPE) on curative healthcare services and their determinants in rural Malawi, a country that has consistently aimed at providing free healthcare services. Methods Our study used data from two consecutive rounds of a household survey conducted in 2012 and 2013 among 1639 households in three districts in rural Malawi. Given our explicit focus on OOPE for curative healthcare services, we relied on a Heckman selection model to account for the fact that relevant OOPE could only be observed for those who had sought care in the first place. Results Our sample included a total of 2740 illness episodes. Among the 1884 (68.75%) that had made use of curative healthcare services, 494 (26.22%) had incurred a positive healthcare expenditure, whose mean amounted to 678.45 MWK (equivalent to 2.72 USD). Our analysis revealed a significant positive association between the magnitude of OOPE and age 15–39 years ( p = 0.022), household head ( p = 0.037), suffering from a chronic illness ( p = 0.019), illness duration ( p = 0.014), hospitalization ( p = 0.002), number of accompanying persons ( p = 0.019), wealth quartiles ( p 2 = 0.018; p 3 = 0.001; p 4 = 0.002), and urban residency ( p = 0.001). Conclusion Our findings indicate that a formal policy commitment to providing free healthcare services is not sufficient to guarantee widespread financial protection and that additional measures are needed to protect particularly vulnerable population groups.

中文翻译：

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“免费”医疗保健系统中寻求医疗保健和自付费用的决定因素：马拉维农村的证据。

背景技术监控财务保护是实现全民健康覆盖的关键组成部分，即使对于允许公民免费获得医疗服务的卫生系统而言。我们的研究调查了马拉维农村地区用于医疗保健服务的自付费用（OOPE）及其决定因素，马拉维一直致力于提供免费的医疗服务。方法我们的研究使用了2012年和2013年对马拉维农村三个地区的1639户家庭进行的连续两轮住户调查的数据。鉴于我们对OOPE的关注主要在于提供治愈性医疗服务，因此我们依靠Heckman选择模型来说明以下事实：只有最初寻求护理的患者才能观察到相关的OOPE。结果我们的样本共包括2740个疾病发作。在1884年（68。75％的人使用了治愈性医疗保健服务，其中494人（26.22％）的医疗保健支出为正，平均为678.45兆瓦克（折合2.72美元）。我们的分析显示，OOPE的大小与15-39岁的年龄（p = 0.022），户主（p = 0.037），患有慢性病（p = 0.019），病程（p = 0.014）之间存在显着的正相关，住院（p = 0.002），陪同人数（p = 0.019），财富四分位数（p 2 = 0.018; p 3 = 0.001; p 4 = 0.002）和城市居住地（p = 0.001）。结论我们的发现表明，提供免费医疗服务的正式政策承诺不足以保证广泛的财务保护，还需要采取其他措施来保护特别脆弱的人群。