Abstract
ObjectiveWe report inequity in out-of-pocket payments (OOPP) for hospitalisation in India between 1995 and 2014 contrasting older population (60 years or more) with a population under 60 years (younger population). MethodsWe used data from nationwide healthcare surveys conducted in India by the National Sample Survey Organisation in 1995–96, 2004 and 2014 with the sample sizes ranging from 333,104 to 629,888. We used generalised linear and fractional response models to study the determinants of OOPP and their burden (share of OOPP in household consumption expenditure) at a constant price. The relationship between predicted OOPP and its burden with monthly per capita consumption expenditure (MPCE) quintiles and selected socioeconomic characteristics were used to examine vertical and horizontal inequities in OOPP. ResultsThe older population had higher OOPP for hospitalisation at all time points (range: 1.15–1.48 times) and a greater increase between 1995–96 and 2014 than the younger population (2.43 vs 1.88 times). Between 1995–96 and 2014, the increase in predicted mean OOPP for hospitalisation was higher for the poorest than the richest (3.38 vs 1.85 times) older population. The increase in predicted mean OOPP was higher for the poorest (2.32 vs 1.46 times) and poor (2.87 vs 1.05 times) older population between 1995–96 and 2004 than in the latter decade. In 2014, across all MPCE quintiles, the burden of OOPP was higher for the less developed states, females, private hospitals, and non-communicable disease and injuries, more so for the older than the younger population. In 2014, the predicted absolute OOPP for hospitalisation was positively associated with MPCE quintiles; however, the burden of OOPP was negatively associated with MPCE quintiles indicating a regressive system of healthcare financing. ConclusionHigh OOPP for hospitalisation and greater inequity among older population calls for better risk pooling and prepayment mechanisms in India.
Highlights
Achieving equity in the delivery of healthcare, protection from the risk of financial loss and attaining fairness in the distribution of the financing burden are the fundamental goals of healthcare systems
To assess vertical inequities, we examined how predicted out-of-pocket payments (OOPP) for hospitalisation, both absolute and as a share of household consumption expenditure varied across monthly per capita consumption expenditure (MPCE) quintiles
The increase in mean annual OOPP for hospitalisation was higher than the increase in mean annual household consumption expenditure per capita, more so for the poorest older population (4.60 vs 1.25 times)
Summary
Achieving equity in the delivery of healthcare, protection from the risk of financial loss and attaining fairness in the distribution of the financing burden are the fundamental goals of healthcare systems. Equitable financing, based on the premise that the risk each household faces due to the costs of the healthcare is distributed according to the ability to pay rather than to the risk of illness is a key dimension of health system's performance (World Health Organization, 2000). Financial protection is the key element of Universal Health Coverage which aims at ensuring health services for people without the risk of financial catastrophe (World Health Organization, 2010). Catastrophic healthcare expenditures are a major cause of household debt for families on low and middle incomes; the cost of healthcare is a leading cause of poverty in India (David et al, 2001; Van Doorslaer et al, 2006; Garg and Karan, 2009; Shahrawat and Rao, 2012).
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