الفهرس 
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Abstract
Out-of-plan (or out-of-network) use of health services results when patients within a health system’s designated population receive care from providers outside of that system. The conceptualization and measurement of using out-of-plan care differ among studies. There are two types of out-of-plan care; voluntary choice and involuntary use of an out-of-plan physician, and both were said to be influenced by three domains; patient, encounter, and system-related factors. Involuntary searching for out-of-network care occurs in situations where the patients are unaware of the provider-network status at the time of service use, while voluntary out-of-network utilization of care implies individual preferences play a role in choosing a healthcare provider outside the health insurance coverage plan. The latter differs in that the insured client voluntarily chooses to obtain health services from outside-network providers even though the service was available and would have been covered in-network at lower or no cost. seeking voluntary out-of-network care includes a dimension of client satisfaction with their health plans. The current study investigates the latter type (voluntary out-of-plan use) which was measured in the current study as a physician visit from outside the NHIF physician networks in the previous six month to the interview. Out-of-network utilization can lead to further decline in the quality of health insurance facilities, decreasing public support for the facilities used by government employees, and increases in out-of-pocket payments.
The objective of study:
This study aims to investigate the magnitude, its associated determinants, and out-of-pocket payments incurred for seeking out-of-plan care among a representative sample of NHIF beneficiaries of Al Jazirah State in Sudan.
Materials and methods:
This was a cross-sectional survey conducted at primary healthcare centers of the NHIF (Direct Services Provision Centers-DPCs) in Al Jazirah state in Sudan. The minimum sample size of 768 clients was calculated using Ep-info-7 software. The target population consisted of insured clients, 18 years or older, attending NHIF primary care clinics in Al Jazirah state at the time of data collection. Only patients visiting a general practitioner (GP) were included in the current study. Patients who were referred to a specialist consultation were excluded due to the higher severity of their illness. All eight DPCs of the NHIF in Al Jazirah state were included in the study. Proportional sampling was used to determine the required number of beneficiaries at each of the DPCs, based on average monthly visits. The main outcomes for this study were the prevalence and determinants of seeking out-of-network physician care during the six months previous to the interview. Participants were coded as (out-of-network users = 0) and (NHIF users only = 1).
The data collection methods and tools including:
A pre-coded, structured, and interviewer-administered questionnaire based on reviewing the published literature was used to gather the required information. The interview questionnaire was composed of three sections. The first section comprised the participant’s socio-economic (age, sex, family income expressed in Sudanese pound (SDG), education, marital status, and the number of dependents) and health insurance characteristics (period of enrollment in the NHIF plan, number of visits to NHIF clinics). The second section explored participants’ utilization behaviors (whether they voluntarily utilized out-of-network physician visits during the six months previous to the interview or not), perceived quality of care, and waiting time. The last third section was only for participants who reported using at least one out-of-network service in the six months previous to the interview. It was about details of the last out-of-network physician visit used. Data collection took place from September to October 2021, using the kobo toolbox.
Results:
1- Prevalence, expenses, and main reason for out-of-plan use
Of 768 interviewed NHIF clients (mean age 49 years, 55.1% females), 63.2% had reported using out-of-plan physician visits in previous months to the interview. The mean out-of-pocket payment for the last out-of-plan service was 4787 Sudanese pounds. The most common site for utilizing primary care services outside the NHIF network was private hospitals (65.8%). The main reason for seeking out-of-network care was the urgent and serious case reported by 53% of out-of-network users
2- Determinants of out-of-plan use
The regression model revealed that clients’ gender, marital status, self-reported health, overall rating of the quality of care, rating of general practitioner care, and ease of referral to a specialist were the significant predictors for seeking out-of-plan physician visits.