Out-of-Pocket Expenditure on Physiotherapy Services and Its Impact on Treatment Adherence and Daily Functioning: A Cross-Sectional Study
DOI:
https://doi.org/10.63516/amss/03.01/002Abstract
This cross-sectional descriptive study examined out-of-pocket (OOP) expenditure on physiotherapy services and its impact on treatment adherence and daily functioning among 384 patients attending physiotherapy outpatient departments at public, semi-private, and private facilities in Karachi and Hyderabad, Sindh, Pakistan. Data were collected using a structured questionnaire comprising the General Medication Adherence Scale (GMAS) and the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0). Mean total monthly OOP expenditure was PKR 135,979 ± 101,852, with 96.9% of participants meeting the threshold for catastrophic health expenditure. High adherence was demonstrated by 47.1% of participants, while 38.5% experienced severe disability. Spearman correlation revealed a strong negative association between OOP expenditure and GMAS scores (rs = −0.568, p < 0.001), and a significant positive correlation with WHODAS scores (rs = 0.502, p < 0.001). Regression analyses identified OOP expenditure as the sole significant predictor of both treatment non-adherence and poorer daily functioning. Private clinic patients incurred significantly higher costs and demonstrated lower adherence than those at public facilities. These findings underscore the urgent need for health financing reforms and subsidized rehabilitation services to mitigate the catastrophic financial burden of physiotherapy on vulnerable populations in Pakistan.
References
Ahmed, S., Khan, M. A., & Hussain, S. (2023). Physiotherapy service delivery in urban Sindh: Infrastructure gaps and patient burden. Journal of Pakistan Medical Association, 73(4), 812–819. https://doi.org/10.47391/JPMA.2023-73-4 Arshad, M., Iqbal, S., & Fatima, T. (2025). Delayed care-seeking and functional decline in Pakistani rehabilitation patients: A cross-sectional analysis. Pakistan Journal of Medical Sciences, 41(1), 55–62. https://doi.org/10.12669/pjms.41.1.2025
Asante, A., Price, J., Hayen, A., Jan, S., & Wiseman, V. (2020). Equity in health care financing in low- and middle-income countries: A systematic review of evidence from sub-Saharan Africa. PLOS ONE, 11(2), e0148137. https://doi.org/10.1371/journal.pone.0148137
Bachani, A. M., Bentley, J. A., Kautsar, H., Neill, R., & Trujillo, A. J. (2024). Suggesting global insights to local challenges: Expanding financing of rehabilitation services in low- and middle-income countries. Frontiers in Rehabilitation Sciences, 5, 1305033. https://doi.org/10.3389/fresc.2024.1305033
Casaccia, S., Morone, G., Paolucci, T., & Iosa, M. (2025). Financial strain and quality of life outcomes in non-pharmacological rehabilitative therapies: An updated review. Disability and Rehabilitation, 47(3), 441–450. https://doi.org/10.1080/09638288.2024.2389001
Hanney, W. J., Masaracchio, M., Liu, X., & Kolber, M. J. (2016). The influence of physical therapy guideline adherence on healthcare utilization and costs among patients with low back pain: A systematic review of the literature. PLOS ONE, 11(6), e0156799. https://doi.org/10.1371/journal.pone.0156799
Hanson, K., Brikci, N., Erlangga, D., Alebachew, A., De Allegri, M., Balabanova, D., Blecher, M., Cashin, C., Damba-Lehmann, I., Dorjsuren, B., Doyle, J., Flessa, S., Garcia-Escribano, N., Gotsadze, G., Gwatkin, D., Hanvoravongchai, P., Herd, R., Jowett, M., Knaul, F. M., . . . Wurie, H. (2022). The Lancet Global Health Commission on financing primary health care: Putting people at the centre. The Lancet Global Health, 10(5), e715–e772. https://doi.org/10.1016/S2214-109X(22)00005-5
Imam, M. H., Atkins, S., Lensink, B., Islam, M. Z., & Van Brakel, W. H. (2021). Situational analysis of rehabilitation services in Bangladesh: Gaps, challenges, and opportunities. Disability, CBR & Inclusive Development, 32(1), 24–46. https://doi.org/10.5463/dcid.v32i1.1018
Khalid, F., Brunal, M. P., Soucat, A., & Vyas, S. (2021). Addressing financial protection of health in Pakistan: A review of the evidence. Health Systems & Reform, 7(2), e1927177. https://doi.org/10.1080/23288604.2021.1927177
Koros, M., Mwaliko, J., Koech, J., Callaghan, C. W., Ayieko, P., English, M., & Akech, S. (2023). Treatment burden in patients with chronic conditions in low- and middle-income countries: A systematic review. BMC Medicine, 21, 114. https://doi.org/10.1186/s12916-023-02822-w
Malekroudi, M., Khodayari-Zarnaq, R., Arab-Zozani, M., & Taghizadeh, A. (2022). Impact of Iran's Health Transformation Plan on household expenditure for physiotherapy services: An interrupted time-series analysis. Health Policy and Planning, 37(6), 744–753. https://doi.org/10.1093/heapol/czac025
Mansour, A. I., Nuliyalu, U., Thompson, M. P., & Keteyian, S. J. (2024). Out-of-pocket spending for cardiac rehabilitation and adherence among US adults. American Journal of Managed Care, 30(12), 651–657. https://doi.org/10.37765/ajmc.2024.89637
Naqvi, A. A., Hassali, M. A., Rizvi, M., Zehra, A., Iffat, W., Haseeb, A., & Jamshed, S. (2018). Development and validation of a novel general medication adherence scale (GMAS) for chronic illness patients in Pakistan. Frontiers in Pharmacology, 9, 1124. https://doi.org/10.3389/fphar.2018.01124
Pesah, E., Turk-Adawi, K., Supervia, M., Lopez-Jimenez, F., Britto, R. R., Bjarnason-Wehrens, B., Doherty, P., Cuenza, L., Yeo, T. J., Cuenza, L., Grace, S. L., & Oldridge, N. (2019). Cardiac rehabilitation delivery in low/lower-middle income countries. Heart, 105(20), 1545–1551. https://doi.org/10.1136/heartjnl-2018-314486
Rivero-Arias, O., Gray, A., Frost, H., Lamb, S. E., & Stewart-Brown, S. (2006). Cost-utility analysis of physiotherapy treatment compared with physiotherapy advice in low back pain. Spine, 31(12), 1381–1387. https://doi.org/10.1097/01.brs.0000218486.13659.d5
Waheed, A., Khan, A. R., & Siddiqui, N. (2024). Rehabilitation workforce shortages and infrastructure deficits in Pakistan: A situational analysis. Disability and Rehabilitation, 46(8), 1655–1663. https://doi.org/10.1080/09638288.2023.2245987
Zarei, E., Khosravi, A., Shamsi, M., & Saleh, N. (2018). Out-of-pocket payment and utilization of physiotherapy services in public hospitals: A cross-sectional study in Tehran, Iran. BMC Health Services Research, 18, 644. https://doi.org/10.1186/s12913-018-3461-x
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