الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
A key health system’s goal, according to World Health Organization, is to move towards Universal Health Coverage with equity. Access to healthcare is central in the performance of healthcare systems around the world. Access is an important concept in the study of the organization, financing and delivery of healthcare services. It is also an important political symbol and policy goal. Access to healthcare is the opportunity or ease with which consumers or communities are able to use appropriate services in proportion to their needs.
To attain accessto healthcare, services must be physically accessible, financially affordable and acceptable to people. Unmet need for healthcare and delayed medical care are important indicators of access.About half of total health expenditure in Egypt comes from out-of-pocket at the point of service in public and private facilities. Out-of-pocket payments for healthcare are usually the most inequitable type of financing because they tend to hit the poor the hardest by being a barrier to healthcare or by denying individuals financial protection from catastrophic illness.
This study aims to:
7. To describe socio-demographic and medical characteristics of the users of Family Health facilities and their householdsin Alexandria.
8. To describe the utilization of health services among users of Family Health facilities and their householdsin Alexandria.
9. To measure extent of delayed care and unmet need for health care among users of Family Health facilitiesand their householdsin Alexandria.
10. To identify reasons, determinants and consequences of delayed care and unmet need for health care among users of Family Health facilitiesand their householdsin Alexandria.
11. To estimate out-of-pocket payment for health care among users of Family Health facilities and their householdsin Alexandria.
12. To detect inequities in access and out-of-pocket payment among users of Family Health facilities and their householdsin Alexandria.
The study was conducted at family health facilities (units and centers) affiliated to the Ministry of Health and Population in Alexandria. The study was descriptive cross sectional, and used multistage cluster sample design.
The study sample consisted of 2000 households. Information from households was collected by interviewing users of family health facilities. Family health users were selected at the entrance of the family health facility beside the registration office. The average time taken to conduct the interview was about half an hour.
As regards data collection, a structured interview schedule was designed based on reviewing the questionnaires used in previous studies. Questions in the structured interview schedule were answered for each of household member by respondent. The framework used was based on Andersen Behavioral Model of Health Service Use with modifications. Access was measured using four types of outcome dependent variables, namely, unmet need for healthcare,delayed medical care, utilization rates, and out-of-pocket payment. The independent explanatory variables were the predisposing, enabling, health status/need factors.The designed schedule included various sections: predisposing socio-demographic characteristics (age, sex, marital status, education, occupation, household size), enabling characteristics (monthly income, health insurance, possessions of household, usual source of care), health status measures(sickness in last four weeks, chronic disease, charlson- comorbity score), utilization and out-of-pocket payment of outpatient and inpatient services, coping strategies, and unmet need and delayed medical care (frequency, reasons, consequences).Wealth index was constructed using principal component analysis. Household members’ quintiles of share of household income and wealth index were developed. Household burden of out-of-pocket payment for outpatient visits was calculated as a percentage of total household monthly expenditure. Six multiple binary logistic regression models were applied to identify determinants of use of outpatient services, use of outpatient services by ill individuals (use/need), use of inpatient services, catastrophic household burden of out-of-pocket payment for outpatient services, unmet need and delayed medical care.
The study revealed the following findings:
Part A: characteristics of users of family health facilities and their household members
1. Predisposing socio-demographic characteristics
• The greater proportions of respondents were females (97.2%), from 30-<40 years (32.6%), married (91.1%), and related to household head as wife/husband (86.0%), while the greater proportions of total household members were females (50.2%), less than 10 years old (30.0%), married (45.2%), and related to household head as sons or daughters (49.6%).
• The greater proportion of respondents attained no education (32.4%), and were only housewives (87.6%), while the greater proportion of total household members attained primary/preparatory education (32.6%), and was working (33.0%).
• The greater proportions of households were composed of 1-4 members (58.5%), had 1-2 children (50.2%), and had no elderly in the household (88.6%).
2. Enabling characteristics
• The mean household monthly income among households was 1372.81 LE, while the mean household monthly expenditure among households was 1321.04 LE, and the mean share of household income per member was 317.61 LE for total household members.
• The majority of household members did not have any type of health insurance (70.2%), and greater proportion of insured household members was affiliated to Health Insurance Organization (89.2 %).
• The highest percentage of insured household members benefited from health insurance in the previous twelve months (62.3%), while the most frequent reason for not using the insurance in insured individuals in previous twelve months were ”low quality service” (44.0%)
• The majority of household members had usual source of care (66.7%), and highest percentage of total household members with usual source of care used family health facilities as their usual source of care (27.9%), while that the most frequent reasons of choosing certain providers or facilities as a usual source of care were ”knowing that care available will help to get better”(38.5%).
3. Health status/ need characteristics
• The health status of the greater proportion of household members was assessed by respondents as being average (34.8%), while lowest percentage of household members was ill during last four weeks preceding the study (48.7%), smaller proportion of household members suffered from chronic diseases and conditions (18.9%), and the majority of household members had charlson-comorbidity index score of 0 (86.4%)
Part B: Use and out-of-pocket payment of healthcare services
1. Use of outpatient visit services and inpatient hospital admission services
• About 22% of household members visited outpatient services once or more during the last four weeks, with mean outpatient visit number of 0.35 per household member, and annual rate of 4.2 per household, while 6.2% of household members admitted to hospital once or more during the last 12 months, with mean hospital admission of 0.07 per household member (70/1000 population), and average length of stay of 5.86 days.
• The governmental/public health providers were the most frequent type of health service providers for outpatient visit services and inpatient services (53.8%, 68.9%, respectively), while private clinic were the most frequent provider for outpatient visits (29.6%), and the most frequent cause of outpatient visits was diseases of the respiratory system (35.1%), while the most frequent cause of hospital admissions was pregnancy, childbirth and the puerperium (37.9%).
• The most frequent means of transportation used by household members to reach outpatient services was public vehicle (46.9%), while the most frequent means of transportation for inpatient services was Taxi/rented public vehicle for one ride (54.1%), and the mean distance time for outpatient visit was 24.33 minutes per visit, while the mean distance time for hospital admissions was 44.94 minutes per admission.
• Significant determinants that increased use of outpatient service during last four weeks included female sex (odds ratio, 1.326), non-employment (odds ratio, 1.334), presence of no children in household (odds ratio, 1.663), being sick in the last four weeks (odds ratio, 43.075), very poor perceived health status (odds ratio, 2.127), charlson-comorbidity index score 1, >1 (1.765, 2.852), while significant determinants that decreased use of outpatient service included lowest quintile of share of household income (odds ratio, 0.611), poorest quintile by wealth index (odds ratio, 0.695), non-presence of usual source of care (odds ratio, 0.557), and chronic disease (odds ratio, 0.469).
• Significant determinants that increased use of outpatient service by ill individuals included female sex (odds ratio, 1.327), non-employment (odds ratio, 1.307), presence of no children in household (odds ratio, 1.569), very poor and average perceived health status (odds ratio, 1.906, 1.373, respectively), charlson comorbidity index score 1, >1(odds ratio, 1.771, 2.912 respectively), while significant determinants that decreased use of outpatient service by ill individuals included lowest, middle and fourth quintiles of share of household income (odds ratio, 0.598, 0.762, 0.763 respectively), upper middle quintile of wealth index (odds ratio, 0.709), non-presence of usual source of care (odds ratio, 0.559) and chronic disease (odds ratio, 0.471).
• Significant determinants that increased use of inpatient service during the last 12 months were female sex (odds ratio, 2.069) ,children <18 years, age group 18- < 25 years, age group 25- <50 years (odds ratio, 13.268, 5.742, 2.750, respectively), married and divorced/widow (odds ratio, 5.080, 5.288, respectively), non-employment (odds ratio, 2.005), lower middle and middle quintiles of wealth index (odds ratio, 1.561, 1.489, respectively), very poor and poor perceived health status (odds ratio, 1.750, 1.788, respectively), and charlson-comorbidity index score >1 (odds ratio, 3.144), while only one significant determinant that decrease use inpatient service which was non-insurance (odds ratio, 0.425).
2. Out-of-pocket payment of outpatient and inpatient services
• About 99% of individuals who used outpatient services during last four weeks incurred out-of-pocket payment, while 97.2% of individuals who used inpatient services during last 12 months incurred out-of-pocket payment, and greater proportion of household members who used outpatient service paid for doctor consultation cost(90.3%), while greater proportion of household members who were admitted to hospitals paid for transportation cost (83.2%).
• The mean total out-of-pocket payment of outpatient services was 134.61 LE/ individual who paid, and 29.87 LE / household member, while the mean total out-of-pocket payment of inpatient services was 2162.96 LE/ individual who paid, 130.01/ household member, and mean costs of outpatient services were 12.5 LE for transportation, 31.38 LE for doctor consultation and 78.12 LE for medications, while the mean cost of hospital stay was 2144.38 LE.
• Greater proportion of total out-of-pocket payment of outpatient services was for medications and medical supplies cost (46.3%), and higher percentage of total out-of-pocket payment of inpatient services was for cost of hospital stay (84.1%).
• The mean household monthly out-of-pocket payment was 129 LE/ household, while catastrophic household burden occurred in 28.4% of households, with a mean of household burden of out-of-pocket payment for outpatient visits per household of 12.22%.
• The greater proportions of both outpatient users and admitted individuals who incurred out-of-pocket payment coped with out-of-pocket payment by paying directly from their own household money (85.8%, 69.2%, respectively).
• Significant determinants that decreased catastrophic household burden were female sex (odds ratio, 0.752), married (odds ratio, 0.622), poorest and middle quintiles of wealth index (odds ratio, 0.641, 0.772, respectively), while significant determinants that increased catastrophic household burden were primary and preparatory education (odds ratio, 1.219), household size 1-4 (odds ratio, 1.371), lowest, second and middle quintiles of share household income (odds ratio, 3.614, 2.536, 2.727, respectively), being sick in the last four weeks (odds ratio, 1.241), perceiving very poor, poor and average health status (odds ratio, 2.286, 1.315, 1.438, respectively) and using outpatient service once or more during last four weeks (odds ratio, 3.086, 7.198, respectively).
Part C: Unmet need for healthcare and delayed medical care
• Prevalence of unmet need among household members was 11.1%, while prevalence of delayed medical care was 3.1%, and the most frequent cause for wanting to see doctor and seek care in unmet need was ”symptoms, signs and abnormal clinical and laboratory findings not elsewhere classified”, while for delayed care it was ”diseases of the digestive system” (20.0%).
• Greater proportions of individuals with unmet need and delayed medical care perceived the health problem as being associated with a lot of pain (68.5%, 72.6%, respectively), not threatening health at all (60.9%, 53.7%, respectively), causing a lot of complications (54.5%, 60.0%, respectively), and limiting of a lot of activities (56.7%, 66.3%,respectively).
• As regard unmet need of healthcare, the greater proportions of individuals did not feel deterioration of their health at all (46.8%), were strongly worried (46.7%), their families and friends did not worry at all (50.6%), bothered strongly by pain (64.5%), had strongly difficulties with daily activities (48.9%), did not have consequences at all on other aspects of their lives (86.8%), did not lose their income at all (87.9%), were not dependent on their family members (84.9%), and their problems remained strongly uncontrolled (77.2%), while in case of delayed medical care,the greater proportions of individuals felt their health deteriorated strongly (54.4%), were strongly worried (58.2%), their families and friends worried strongly (46.7%), bothered strongly by pain (73.7%), had strongly difficulties with daily activities (53.7%), did not have consequences at all on other aspects of their lives (87.4%), did not lose their income at all (94.4%), were not dependent on their family members at all (78.9%), and their problems remained strongly uncontrolled (46.7%).
• Affordability barriers were the most frequent barriers in case of unmet need and delayed medical care (79.9%, 65.2%, respectively), and acceptability barriers came next in order (50.9%, 60.7%, respectively), while geographic accessibility barriers, and availability and accommodation barriers were reported by small proportions of individuals with unmet need and delayed care (2.2%, 2.6%, 5.8%, 5.2%, respectively).
• Significant determinants that increased unmet need were females (odds ratio, 3.908), age groups 25-<50, and 50-<65 years (odds ratio, 2.420, 1.998, respectively), married or divorced/ widow, (odds ratio, 2.405, 2.471), households with no elderly<65 years (odds ratio, 1.358), household size 1-4 (odds ratio, 1.399), middle quintile of share of household income (odds ratio, 1.401), chronic disease (odds ratio, 2.892), very poor, poor, average, good perceived health (odds ratio, 4.466, 2.249, 2.121, 1.869, respectively), while significant determinants that decreased unmet need were charlson-comorbidity index score 1, >1 (odds ratio, 0.691, 0.692, respectively), using outpatient service once or more (odds ratio, 0.596, 0.607, respectively).
• Significant determinants that increased delayed medical care were females (odds ratio, 11.730), married (odds ratio, 2.693), household size 1-4 (odds ratio, 1.880), average and good perceived health status (odds ratio, 1.621, 2.065 respectively), and use of outpatient service once or more (odds ratio, 1.759, 2.365 respectively).
• Poorest quintile by wealth index was found to have (10.985 odds, 3.387 odds) of affordability barriers as reasons for not seeking healthcare or delaying the care respectively relative to the richest quintile while poorest quintile was found to have 0.158 odds of not seeking the health care due to acceptability barrier relative to the richest quintile.
Based on the study conclusions the following recommendations can be suggested:
7. Achieving universal health coverage of equitable effective health services and providing financial protection from catastrophic burden of out-of-pocket payment by applying these recommendations:
• The mandatory health insurance should be expanded to involve all citizens with integration of family health facilities to achieve family health service for all.
• Quality of healthcare provided in health insurance should be improved.
• Medications provided through Ministry of Health and Population facilities and Health Insurance Organization facilities should be effective and of high quality.
• The poor sector and low income households of community should be identified, and protected financially by inclusion in health insurance and development of exemption schemes for the poor.
• Workers in the informal sector especially males should be health insured and provided with medical consultation services at their workplace.
8. The quality of healthcare delivery in governmental facilities should be improved with special emphasis on services to disadvantaged groups; females in reproductive age, divorced and widow females, chronic disease patients and those with severe morbidities and poor health status.
9. User charges in public facilities should be abolished or maintained at very low level.
10. Governmental health spending should be increased.
11. Measures of access to healthcare should be regularly monitored in governmental and family health facilities and included in the required satisfaction surveys.