Moving to universal coverage? Trends in the burden of out-of-pocket payments for health care across social groups in India, 1999-2000 to 2011-12.

Anup Karan,Ajay Mahal,Sakthivel Selvaraj,Rachel A Nugent

doi:10.1371/journal.pone.0105162

Abstract

In the background of ongoing health sector reforms in India, the paper investigates the magnitude and trends in out-of-pocket and catastrophic payments for key population sub-groups. Data from three rounds of nationally representative consumer expenditure surveys (1999–2000, 2004–05 and 2011–12) were pooled to assess changes over time in a range of out-of-pocket -related outcome indicators for the poorest 20% households, scheduled caste and tribe households and Muslims households relative to their better-off/majority religion counterparts. Our results suggest that the poorest 20% of households experienced a decline in the proportion reporting any OOP for inpatient care relative to the top 20% and Muslim households saw an increase in the proportion reporting any inpatient OOP relative to non-Muslim households during 2000-2012. The change in the proportion of Muslim households or SC/ST households reporting any OOP for outpatient care was similar to that for their respective more advantaged counterparts; but the poorest 20% of households experienced a faster increase in the proportion reporting any OOP for outpatient care than their top 20% counterparts. SC/ST, Muslim and the poorest 20% of households experienced as faster increase in the share of outpatient OOP in total household spending relative to their advantaged counterparts. We conclude that the financial burden of out of pocket spending increased faster among the disadvantaged groups relative to their more advantaged counterparts. Although the poorest 20% saw a relative decline in OOP spending on inpatient care as a share of household spending, this is likely the result of foregoing inpatient care, than of accessing benefits from the recent expansion of cashless publicly financed insurance schemes for inpatient care. Our results highlight the need to explore the reasons underlying the lack of effectiveness of existing public health financing programs and public sector health services in reaching less-advantaged castes and religious minorities.

Highlights

The World Health Report 2000 identified financial protection against the costs of ill health as a fundamental objective of health systems, on the premise that a fair health system ensures households make health care payments according to their ability to pay rather than the risk of illness [1]
Our findings on trends suggest that the relative performance of the three groups of disadvantaged households that we considered in terms of the financial burden from OOP spending varies, depending on the group under consideration
The key to understanding these differences is to interpret, as noted in the methods section, a report of -‘‘any OOP spending’’- as an indicator of utilization of healthcare services, Multiple studies have relied on this interpretation of the indicator variable for OOP spending and evidence from household surveys in India containing information both on healthcare use and OOP shows that the indicator variables for reporting any OOP spending and any utilization are highly correlated, with the correlation coefficient exceeding 0.95, both for inpatient care and outpatient care

Summary

Introduction

The World Health Report 2000 identified financial protection against the costs of ill health as a fundamental objective of health systems, on the premise that a fair health system ensures households make health care payments according to their ability to pay rather than the risk of illness [1]. Equity in access to care and financing is a key policy concern in India, as suggested in multiple policy documents, including most recently, a policy report of an expert group on universal health coverage [4,5,6]. This is unsurprising, given that the Indian health care system is characterized by a significant private sector accounting for nearly 80% of all outpatient visits and more than half of all hospital stays [7,8]. Multiple previous studies have suggested that the heavy dependence of the Indian health system on OOP payments as mean of financing health care has contributed significantly to household impoverishment in the country [9,10,11,12,13,14,15,16]

Methods

Results

Conclusion