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High levels of out-of-pocket spending have been shown to be one of the biggest health reasons people fall into poverty when accessing care, or choose to forgo care. Globally it is estimated that 100 million people are pushed into poverty every year due to exorbitant out-of-pocket (OOP) health expenditures (WHO, 2013). Universal health coverage (UHC) requires that all individuals regardless of their socio-economic status are able to afford and access quality health care when they need it.  Reducing or eliminating OOP spending is therefore, critically important to promote access to health services and health workers and to prevent impoverishment for vulnerable populations and hence attain universal health coverage.
In Zambia, despite the removal of user fees on public primary healthcare, prior studies suggest that OOP payments are still significant. This peer reviewed article, analyses the prevalence and determinants of hardship financing arising from OOP payments in healthcare, using data from a nationally- representative household health expenditure survey conducted in 2014.
 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6457564/pdf/pone.0214750.pdf