determinants of healthcare utilisation and out-of-pocket payments in the context of free public primary healthcare in zambia

background access to appropriate and affordable healthcare is needed to achieve better health outcomes in africa. however, access to healthcare remains low, especially among the poor. in zambia, poor access exists despite the policy by the government to remove user fees in all primary healthcare facilities in the public sector. the paper has two main objectives: (i) to examine the factors associated with healthcare choices among sick people, and (ii) to assess the determinants of the magnitude of out-of-pocket (oop) payments related to a visit to a health provider.   methods this paper employs a multilevel multinomial logistic regression to model the determinants of an individual’s choice of healthcare options following an illness. further, the study analyses the drivers of the magnitude of oop expenditure related to a visit to a health provider using a two-part generalised linear model. the analysis is based on a nationally representative healthcare utilisation and expenditure survey that was conducted in 2014.   results household per capita consumption expenditure is significantly associated with increased odds of seeking formal care (odds ratio [or] = 1.12, p = .000). living in a household in which the head has a higher level of education is associated with increased odds of seeking formal healthcare (or = 1.54, p = .000) and (or = 1.55, p = .01), for secondary and tertiary education, respectively. rural residence is associated with reduced odds of seeking formal care (or = 0.706, p = .002). the magnitude of oop expenditure during a visit is significantly dependent on household economic wellbeing, distance from a health facility, among other factors. a 10% increase in per capita consumption expenditure was associated with a 0.2% increase in oop health expenditure while every kilometre travelled was associated with a k0.51 increase in oop health expenditure.   conclusion despite the removal of user fees on public primary healthcare in zambia, access to healthcare is highly dependent on an individual’s socio-economic status, illness type and region of residence. these findings also suggest that the benefits of free public healthcare may not reach the poorest proportionately, which raise implications for increasing access in zambia and other countries in sub-saharan africa.