Of Out-of-pocket Research Articles

Do employer-sponsored health insurance schemes affect the utilisation of medically trained providers and out-of-pocket payments among ready-made garment workers? A case–control study in Bangladesh

ObjectiveWe estimated the effect of an employer-sponsored health insurance (ESHI) scheme on healthcare utilisation of medically trained providers and reduction of out-of-pocket (OOP) expenditure among ready-made garment (RMG) workers.DesignWe used...

Determinants of out-of-pocket and catastrophic health expenditure in rural population: A community-based study in a block of Purba Barddhaman, West Bengal.

In India, health expenditure accounts for <5% of the Gross domestic product and the level of out-of-pocket (OOP) spending is 69.5% of total health expenditures. OOP expenditure (OOPE) has a negative impact on equity and can increase the risk of vulnerable groups slipping into poverty. The study aimed to estimate the OOPE on health and catastrophic health expenditure (CHE) and their sociodemographic determinants in a rural area of Purba Barddhaman. A community-based cross-sectional study was conducted between July 2018 and February 2019 in Bhatar Block of Purba Bardhaman district, West Bengal. Required sample of 235 households, selected randomly were primary study units. One respondent from each household was interviewed with a predesigned, pretested schedule for sociodemographic and health-care expenditure-related variables. Mann-Whitney U test/Kruskal Wallis H test and multivariable logistic regression was applied. The median OOP health expenditure was Rs. 3870 (inter quartile range: 2156-4952). Of 235 families, 38 (16.2%) had CHE over a period of 1 year. The significant correlates for CHE were type of village according to the presence of public health-care facility (adjusted odds ratio [AOR] = 4.748; 95% confidence interval [CI]: 1.886-11.956), presence of health insurance (AOR = 11.124; 95% CI: 3.690-33.535) and gender of the head of the family (AOR = 18.176; 95% CI: 3.353-98.534). Concentration curve suggested a higher concentration of CHE among poor households. CHE is substantially high in the area. The efforts are required to make the services available as close to the households as possible and to increase awareness about health facilities.

The determinants of out-of-pocket health-care expenses for diabetes mellitus patients in India: An examination of a tertiary care government hospital in Delhi.

Objective:To assess the determinants of out-of-pocket (OOP) expenses on diabetes-related treatment incurred in patients attending outpatient clinics in a tertiary care hospital in Delhi, India.Study Design:A cross-sectional analysis of baseline data from a quasi-experimental study was conducted over 8 months in 2016 in a major tertiary care hospital in Delhi.Methods:The study included 375 diabetes patients up to 65 years of age on treatment for at least a year without significant complications. Data were collected through a patient interview schedule.Results:Of the previous six scheduled appointments, at least two missed appointments were seen in 267 (71.2%) patients. The average patient's OOP expenditure on diabetes-related medicines was ₹63.5 a month, a similar amount was spent on traveling to and from health facilities. Sixty-four (17.1%) patients took antidiabetic medication for <85% of the days in the previous 3 months.Conclusion:There exists a high burden of missed clinic appointments among diabetes patients in tertiary care government health settings in India. This appears to be related to the high cost in terms of both time and money involved in attending appointments for the modest benefit of a dispensation of a 15-day drug refill. Health policy measures focused on strengthening medication coverage need to explore the balance of costs and benefits when determining the frequency of clinical appointments in these settings.

The effect of a community-based health insurance on the out-of-pocket payments for utilizing medically trained providers in Bangladesh.

BackgroundWe aimed to estimate the effect of the community-based health insurance (CBHI) scheme on the magnitude of out-of-pocket (OOP) payments for the healthcare of the informal workers and their dependents. The CBHI scheme was piloted through a cooperative of informal workers, which covered seven unions in Chandpur Sadar Upazila, Bangladesh.MethodsA quasi-experimental study was conducted using a case-comparison design. In total 1292 (646 insured and 646 uninsured) households were surveyed. Propensity score matching was done to minimize the observed baseline differences in the characteristics between the insured and uninsured groups. A two-part regression model was applied using both the probability of OOP spending and magnitude of such spending for healthcare in assessing the association with enrolment status in the CBHI scheme while controlling for other covariates.ResultsThe OOP payment was 6.4% (p < 0.001) lower for medically trained provider (MTP) utilization among the insured compared with the uninsured. However, no significant difference was found in the OOP payments for healthcare utilization from all kind of providers, including the non-trained ones.ConclusionsThe CBHI scheme could reduce OOP payments while providing better quality healthcare through the increased use of MTPs, which consequently could push the country towards universal health coverage.

The impact of health reform in Iran on catastrophic health expenditures: Equity and policy implications.

In 2014, the Islamic Republic of Iran launched the Health Transformation Plan (HTP), with the goal of achieving universal health coverage (UHC) through improved financial protection and access to high-quality health services among Iranian households. We aimed to investigate the impact of the HTP on the level and pattern of out-of-pocket (OOP) payments for health care. Using data from two rounds (2013 and 2016) of the Iranian Statistics Centre's Household Expenditure and Income Survey (HEIS), collected before and after implementation of the HTP, we estimate changes in the level and drivers of OOP payments, and the prevalence, intensity, and distribution of catastrophic health expenditures (CHEs) among Iranian households. Our results indicate that per capita OOP payments on health remained stable during the observed period, with the largest proportion of OOP payments spent on medicines. Using thresholds of 10% and 25% of total consumption, there was a slight increase in the prevalence of CHE. The prevalence of CHE increased from 3.76% to 3.82% at threshold of 25% of total consumption. Using 40% capacity to pay threshold, prevalence diminished modestly from 2.5% to 2.37% and the intensity decreased from 13.16% to 12.32%. At all thresholds, CHE were more concentrated among wealthier households. These results suggest that while financial protection of the poor in Iran has improved due to the HTP, more work is needed to achieve UHC in Iran. For the next phase of health reforms, more emphasis should be placed on shifting away from OOP co-payments for health financing to progressive prepayment mechanisms to facilitate better sharing of financial risks across population groups.

The Impact of Out-of-Pocket Health Expenditure on Maternal Health: Empirical Evidence from Central and Latin American Countries

Objective: The aim of this paper is to assess the impact of out-of-pocket (OOP) health expenditure on maternal health outcomes using a panel of twenty Central and Latin American countries between 2000 and 2015.Material and Methods: Six different estimation techniques were used in the analysis in order to check the robustness of the findings. Those estimation techniques were: the ordinary least squares method, the Prais-Winsten correlated panels corrected standard errors regression, the fixed and the random effects models, the generalized least squares method and the bias-corrected least squares dummy variable method.Results: After controlling for female education, gross domestic product and remittances, it was found that a surge in (OOP) health expenditure significantly deteriorates maternal health as it leads to a decrease in skilled birth attendance and an increase in maternal mortality. It was also found that in Central and Latin American countries, educated women tended to be healthier, and maternal health care was mainly financed with the money received from friends and family members living abroad.Conclusion: It is therefore recommended that public health authorities design and implement protective health care financing programs, such as health insurance.

High rates of medication adherence in patients with pulmonary arterial hypertension: An integrated specialty pharmacy approach.

Phosphodiesterase-5 inhibitors (PDE-5I) have demonstrated improvement in disease symptoms and quality of life for patients with pulmonary arterial hypertension (PAH). Despite these benefits, reported adherence to PDE-5I therapy is sub-optimal. Clinical pharmacists at an integrated practice site are in a unique position to mitigate barriers related to PAH therapy including medication adherence and costs. The primary objective of this study was to assess medication adherence to PDE-5I therapy within an integrated care model at an academic institution. The secondary objective was to assess the impact of out-of-pocket (OOP) cost, frequency of dosing, adverse events (AE) and PAH-related hospitalizations on medication adherence. We performed a retrospective cohort analysis of adult patients with PAH who were prescribed PDE-5I therapy by the center’s outpatient pulmonary clinic and who received medication management through the center’s specialty pharmacy. We defined optimal medication adherence as proportion of days covered (PDC) ≥ 80%. Clinical data including AEs and PAH-related hospitalizations were extracted from the electronic medical record, and financial data from pharmacy claims. Of the 131 patients meeting inclusion criteria, 94% achieved optimal adherence of ≥ 80% PDC. In this study population, 47% of patients experienced an AE and 27% had at least one hospitalization. The median monthly OOP cost was $0.62. Patients with PDC<80% were more likely to report an AE compared to patients with PDC≥ 80% (p = 0.002). Hospitalization, OOP cost, and frequency of dosing were not associated with adherence in this cohort. Patients receiving PDE-5I therapy through an integrated model achieved high adherence rates and low OOP costs.

Healthcare expenditures among community-dwelling adults with thyroid cancer in the United States: A propensity score matched analysis

ObjectiveThis study assessed the excess healthcare expenditures and factors associated with it among community-dwelling adults with thyroid cancer compared to non-cancer controls in the United States. MethodA retrospective, cross-sectional, matched case-control study design was used by pooling multiple years of Medical Expenditure Panel Survey (MEPS) data (2002–2012). The eligible study sample comprised of adults (age ≥18 years), who were alive during the calendar year and reported positive healthcare expenditure. The case group consisted of adults with thyroid cancer only while the control group consisted of adults who did not have any form of cancer. Total and subtypes of mean annual healthcare expenditures comprised the main study outcome. We also calculated the total and subtypes of out-of-pocket (OOP) expenditures as well as OOP as a percentage of household income. Ordinary Least Square (OLS) regressions on log-transformed expenditures were conducted to elucidate the influence of different factors on healthcare expenditures among adults with thyroid cancer. ResultsThe yearly average total healthcare expenditures among adults with thyroid cancer was significantly higher compared to propensity score matched controls ($9,585 vs. $5,830, p < 0.001). Similar observations were found in terms of inpatient, and outpatient expenditures. Functional status as well as comorbid conditions were significantly associated with excess expenditures. The yearly average total OOP expenditure for adults with thyroid cancer was significantly higher compared to matched controls ($1,425 vs. $974, p < 0.001), with major differences observed in inpatient OOP ($178 vs. $24, p = 0.003), outpatient OOP ($435vs. $256, p < 0.001), and prescription OOP ($554 vs. $423, p < 0.001) expenditures. There was a significant (p < 0.001) difference between the average OOP as a percentage of household income between adults with thyroid cancer (Mean: 7.54%, S.E: 1.52%) and matched controls (Mean: 5.80%, S.E: 0.47%). ConclusionsOur findings suggest that holistic care approach could be helpful to significantly reduce the economic burden in this population. Viable strategies such as limits on OOP costs are required to minimize this high OOP burden among cancer survivors and their families.

Health expenditure and FDI in Europe

The quality of local institutions and the governmental measures sustaining Foreign Direct Investments (FDI) are some of the traditional determinants of multinational agglomerations. One institution which has so far been under-investigated is the health system. Yet several empirical contributions have shown that health is a constituent part of human capital (Bloom and Canning, 2004; Alsan et al., 2006; Ogundari and Awokuse, 2018). Therefore, the quality of the health system may be considered an important FDI attractor factor alongside infrastructures, education, labor force and R&D expenditure (Ingram and Silverman, 2002; Blomström, 2006).The aim of this contribution is to investigate the role of different national institutional settings in attracting FDI within the 28 Member States of the European Union. More specifically, the research focuses on the relation between health expenditure and FDI, assuming that a proxy for institutional quality is the percentage of public health expenditure on the total health expenditure.We adopt a panel GLS methodology with heteroskedasticity and specific autocorrelation and we use a dataset for the 28 European countries that are part of the EU in the period 2000–2013. By means of three model-specifications, we investigate the relation between the inward stock of FDI and: the percentage of government health expenditure on the total health care expenditure; the percentage of Out-Of-Pocket (OOP) expenditure on the total private health care expenditure; and the health coverage regime. We also explore the relation between FDI and population health, a facet of human infrastructure (Globerman and Shapiro, 2002) expressed by healthy life years (HLYs) and the percentage of population claiming to be in perfect/good health. Control variables relate to government regulatory quality, market dimension, government effort in R&D in higher education; and labor productivity. In all models the relation among the dependent variable and the explicative variables related to health expenditure is always significant and, unsurprisingly, it is positive for the percentage of public health expenditure and negative for the percentage of OOP expenditure. The variables describing population health are always positively related to FDI, though population health, expressed in HLYs, is always statistically significant. In contrast, the variable concerning the self-assessment of population good health is only significant in the model where the dummies representing the health coverage regimes are not considered. These last variables appear to absorb the effect of population good health on FDI.Our results are consistent with the idea that health is a component of human infrastructure and is influenced by public policies and governments (Globerman and Shapiro, 2002). Both human infrastructure (resources-population health) and governance infrastructure (institutions-health systems) are key features of a country and determine its potential in attracting FDI.

Out-of-pocket payments in the context of a free maternal health care policy in Burkina Faso: a national cross-sectional survey

BackgroundIn April 2016, Burkina Faso introduced a free health care policy for women. Instead of reimbursing health facilities, as many sub-Saharan countries do, the government paid them prospectively for covered services to avoid reimbursement delays, which are cited as a reason for the persistence of out-of-pocket (OOP) payments. This study aimed to (i) estimate the direct expenditures of deliveries and covered obstetric care, (ii) determine the OOP payments, and (iii) identify the patient and health facility characteristics associated with OOP payments.MethodsA national cross-sectional study was conducted in September and October 2016 in 395 randomly selected health facilities. A structured questionnaire was administered to women (n = 593) who had delivered or received obstetric care on the day of the survey. The direct health expenditures included fees for consultations, prescriptions, paraclinical examinations, hospitalization and ambulance transport. A two-part model with robust variances was performed to identify the factors associated with OOP payments.ResultsA total of 587 women were included in the analysis. The median direct health expenses were US$5.38 [interquartile range (IQR):4.35–6.65], US$24.72 [IQR:16.57–46.09] and US$136.39 [IQR: 108.36–161.42] for normal delivery, dystocia and cesarean section, respectively. Nearly one-third (29.6%, n = 174) of the women reported having paid for their care. OOP payments ranged from US$0.08 to US$98.67, with a median of US$1.77 [IQR:0.83–7.08]). Overall, 17.5% (n = 103) of the women had purchased drugs at private pharmacies, and 11.4% (n = 67) had purchased cleaning products for a room or equipment. OOP payments were more frequent with age, for emergency obstetric care and among women who work. The women’s health region of origin was also significantly associated with OOP payments. For those who made OOP payments, the amounts paid decreased with age but were higher in urban areas, in hospitals, and among the most educated women. The amounts paid were lower among students and were associated with health region.ConclusionThe policy is effective for financial protection. However, improvements in the management and supply system of health facilities’ pharmacies could further reduce OOP payments in the context of the free health care policy in Burkina Faso.

Discussing patients\u2019 insurance and out-of-pocket expenses during GPs\u2019 consultations

BackgroundGenerally, a significant portion of healthcare spending consists of out-of-pocket (OOP) expenses. Patients indicate that, in practice, there are often some OOP expenses, incurred when they receive medical care, which are unexpected for them and should have been taken into account when deciding on a course of action. Patients are often reliant on their GP and may, therefore, expect their GP to provide them with information about the costs of treatment options, taking into consideration their individual insurance plan. This also applies to the Netherlands, where OOP expenses increased rapidly over the years. In the current study, we observed the degree to which matters around patients’ insurance and OOP expenses are discussed in the Netherlands, using video recordings of consultations between patients and GPs.MethodsVideo recordings were collected from patient-GP consultations in 2015–2016. In 2015, 20 GPs and 392 patients from the eastern part of the Netherlands participated. In 2016, another eight GPs and 102 patients participated, spread throughout the Netherlands. The consultations were coded by three observers using an observation protocol. We achieved an almost perfect inter-rater agreement (Kappa = .82).ResultsIn total, 475 consultations were analysed. In 9.5% of all the consultations, issues concerning patients’ health insurance and OOP expenses were discussed. The reimbursement of the cost of medication was discussed most often and patients’ current insurance and co-payments least often. In some consultations, the GP brought up the subject, while in others, the patient initiated the discussion.ConclusionsWhile GPs may often be in the position to provide patients with information about treatment alternatives, few patients discuss the financial effects of their referral or prescription with their GP. This result complies with existing literature. Policy makers, GPs and insurers should think about how GPs and patients can be facilitated when considering the OOP expenses of treatment. There are several factors why this study, analysing video recordings of routine GP consultations in the Netherlands, is particularly relevant: Dutch GPs play a gatekeeper function; OOP expenses have increased relatively swiftly; and patients have both the right to decide on their treatment, and to choose a provider.

Pengeluaran out of pocket rumah tangga untuk upaya pencegahan kesehatan anak: analisis berbasis two part model dan Tobit

Out-of-pocket household expenditure for child health prevention services: two-part and tobit modelPurposeTo find out socio-economic determinants and the amount of out-of-pocket (OOP) for household expenditure in health prevention for children.MethodsThis study compared two approaches from several alternative assumptions including the two-part model and Tobit, which can be used when variable analysis has a problem selection. The dependent variable was household expenditure for children health prevention services in Indonesia, where the probability of dependent variable was affected by latent variables.ResultsThe two-part model and Tobit estimate that rural areas in NTT province can reduce out-of-pocket preventive health expenditures for children three times lower than the rural provinces of Papua. The higher the education of the head of the household, the greater of the possibility of preventive out-of-pocket child health is. Distribution of poverty rates based on quintiles provides a regressive picture of the poorest households based on expenditure per capita. ConclusionThis study is expected to be a comprehensive policy recommendation to suppress out-of-pocket preventive health expenditures for children. Thus, the distribution of health services is a priority for vulnerable groups (children) and the poor.

PP66 Increasing Burden Of Out-Of-Pocket Healthcare Expense On Patients

IntroductionWe conducted an analysis of the key factors triggering cost-sharing mechanisms to understand the status of out-of-pocket (OOP) healthcare expense in the United States (US), Europe, and emerging markets and better appreciate the implications of OOP healthcare expense on patients’ health management.MethodsA review of literature and databases including The Organisation for Economic Co-operation and Development (OECD) and World Bank was performed to understand different cost-sharing mechanisms, factors triggering OOP expenditure and the country-wise trends of OOP expenditure. Additionally, the impact of OOP expenditure on healthcare budget and on patients in terms of medication adherence, uptake of newer therapies and generic substitution was explored.ResultsThe findings reveal that patients are concerned about rising healthcare OOP costs, and we observed an increase of 134 percent in the number of articles published on OOP from 2005 to 2017. The percentage of household spending that goes OOP as healthcare expense is higher in Brazil, Russia, India, and China (BRIC countries; ~11 percent) compared to France, Germany, Italy, United Kingdom, US, Japan, and Canada (G7 countries; ~2 percent). In addition, OOP expenditure increased with age (1.9 percent of take home income in 55-64 age group versus 1.2 percent in 18-25 age group) and is higher in the low-income population (2.8 percent of take home income versus 1 percent in high-income group). Whereas, increasing OOP expenditure reduces the overall healthcare expenditure due to generic substitution (28 percent reduction) and reduction in excessive consumption of supplementary medicines, it also reduces patient adherence (~20 percent decline in dispensed prescriptions) and may foster a reluctance to adopt newer therapies.ConclusionsThe population groups most impacted by increasing OOP expense are the older population, those in the low-income bracket and in poorer countries. While OOP expense may help in the effective and judicious utilization of healthcare system resources and medicines usage, its implementation requires a cautious and considered approach.

Effects of National Health Insurance on household out-of-pocket expenditure structure

Achieving universal health insurance coverage is a major objective for many countries. Taiwan implemented its National Health Insurance (NHI) program with universal coverage in 1995. This study investigates whether the NHI program affects the level and structures of out-of-pocket (OOP) health expenditures. We used data from the Taiwan Survey of Family Income and Expenditure released by the Directorate-General of Budget, Accounting and Statistics. We identified a case and a control group and then employed coarsened exact matching to match the two groups using several available variables. We then conducted a difference-in-difference analysis and determined that there was a statistically significant negative effect on OOP expenditure that was attributable to NHI (a reduction of 2.11 percentage points in total household expenditure). The largest reductions were found in health care services (−1.63%) and pharmaceuticals (−0.45%). We found a statistically significant positive effect on purchases of private insurance related to health care, which was attributable to NHI (an increase of 0.96 percentage points in household budget share). In addition, we discovered that the NHI program had a greater impact on households of a lower socioeconomic status compared with higher socioeconomic status households. The structure of OOP payments in the post-NHI period remained similar to that of the pre-NHI period in the full sample but varied slightly depending on the educational level of the head of the household.

Distress financing of out‐of‐pocket health expenditure in India

AbstractIn the absence of a universal health insurance mechanism, the increasing burden of out‐of‐pocket (OOP) health expenditure has become a growing concern in India. To cope with the cost of illness, people use either their savings and income, or they have to rely upon distress means of finance such as depletion of household assets, borrowings from banks and moneylenders, and contributions from family and friends. This paper analyses the changes that have taken place in the incidence and covariates of distress financing in India by using data from National Sample Survey Organisation for the years 2004 and 2014. Results indicate that during this period the incidence of distress sources as a means to finance OOP health expenditure has hovered around 50%. Further, the results reveal a significant socioeconomic gradient in the incidence of distress financing. Socioeconomic and health‐related covariates significantly impact the likelihood of distress financing as a means to cope with OOP health expenditure. The results indicate the need for government action to formulate a comprehensive plan through an increase in public spending on health care that will improve the quantity and quality of the public health‐care system and enhance the scope of health insurance in India.

Economic burden, impoverishment, and coping mechanisms associated with out-of-pocket health expenditure in India: A disaggregated analysis at the state level.

The high share of out-of-pocket (OOP) health expenditure imposes an extreme financial burden on households, and they have to incur a substantial amount of expenditure to avail health care services. This study analyses the inter-state differentials in the economic burden of OOP health expenditure, resultant impoverishment impact, and sources of finance used as coping mechanisms. The study is based on health expenditure survey, namely the 71st Round on "Key Indicators of Social Consumption in India: Health," (2014) conducted in India by the National Sample Survey Organisation. The study uses headcount, payment gap, and concentration index to measure the economic burden, impoverishment impact of OOP health expenditure, and the level of inequality. On the basis of results, the states can be divided into four distinct categories: (1) States with low economic burden and low poverty impact of OOP health expenditure, (2) low economic burden and high poverty impact of OOP health expenditure, (3) high economic burden and low poverty impact of OOP health expenditure, and (4) high economic burden and high poverty impact of OOP health expenditure. Inter-state differentials in OOP health expenditure and impoverishment need proper attention of the government especially the policy makers.

Why is the inpatient cost of dying increasing in India?

IntroductionThere is an evidence of increasing inpatient expenditure for decedents. Estimates used to assess the economic burden of out-of-pocket (OOP) healthcare expenditure provide an underestimation for inpatient decedent cases. The aims of this paper are to study the trend and pattern of inpatient decedent expenditure and decipher the reasons behind the increasing cost in India.MethodsUsing three rounds of national level National Sample Survey (NSS) data on morbidity & healthcare conducted during 1995–2015 in India, total and component-wise cost of dying was estimated by the socio-demographic characteristics and types of diseases. Generalised linear model was employed to find the changing effect of inpatient decedents on inpatient expenditure on three-time points.ResultsMore than half among inpatient decedents were elderly. Mean inpatient expenditure for neoplasm, circulatory system-related diseases and external causes of mortality and morbidity increased substantially during these two decades. Mean decedent inpatient expenditure become double, diagnostic and bed charges increased by 243%, 323% respectively during 2004–05 to 2014–15. During 2014–15 average decedents aged 15–59 years spent ₹53599 in last twelve month of their life. Controlling all other potential factors, the inpatient expenditure among decedents increased substantially between 1995–96 and 2014–15.DiscussionOut-of-pocket inpatient health expenditure widened between survivor and decedents in between 1995–2014. Increase in the proportion of elderly, proportion of non-communicable and lifestyle-related diseases, expenses on drugs, diagnostics, bed charges largely private sector expenses were the leading reasons for increasing inpatient decedent expenditure. Age-based risk adjustment and modification of end-of-life care are strongly required, future social insurance based on the health-based value of out-of-pocket expenditure rather than their pure consumption value need to be designed to tackle the burden.

Health care spending and hidden poverty in India

India has a high level of out-of-pocket (OOP) health care spending, and lacks well developed health insurance markets. As a result, official measures of poverty and inequality that treat medical spending symmetrically with consumption goods can be misleading. We argue that OOP medical costs should be treated as necessary expenses for the treatment of illness, not as part of consumption. Adopting this perspective, we construct poverty and inequality measures for India that account for impoverishment induced by OOP medical costs. For 2011/12 we estimate that 4.1% of the population, or 50 million people, are in a state of “hidden poverty” due to medical expenses (based on official poverty lines). Furthermore, while poverty in India fell substantially from 1999/00 to 2011/12, the fraction of the remaining poverty that is due to medical costs has risen substantially. Economic growth appears less “pro-poor” if one accounts for OOP medical costs, especially since 2004/05, and especially in rural areas. Finally, we look beyond poverty rates to show how OOP health costs affect the entire shape of the consumption distribution.

Rural–urban differentials in out-of-pocket health expenditure and resultant impoverishment in India: evidence from NSSO 71st Round

In low- and middle-income countries including India people often face the problem of affordability and access to health care, especially the poor and vulnerable. A high share of out-of-pocket (OOP) expenditure in total health expenditure puts a catastrophic burden on population and pushes them below the poverty line. Therefore, the present paper seeks to examine the level of economic burden and the resultant impoverishment of OOP expenditure among different socio-economic variables, separately for rural and urban areas in India. The current paper uses the cross-sectional data from the National Sample Survey Organisation (NSSO) 71st (Key indicators of social consumption in India: health, 71st round (January–June 2014). Ministry of Statistics and Programme Implementation, Government of India, New Delhi, 2014) round. Results reveal that in urban areas, the incidence of OOP health expenditure is concentrated towards poorer consumption groups, whereas in rural areas, it is pro-rich, especially at higher threshold levels. Rural population spent a higher proportion of consumption expenditure on health care, whereas average per capita health expenditure is higher in urban areas. Results also show that 8.1 and 7.9% population in rural and urban areas, respectively, fell below the poverty line due to OOP health expenditure. The poverty deepening is much higher in rural areas as compared to urban areas. Among different socio-economic variables, Muslims, Other Backward Classes, and casual labour have a higher burden of OOP health expenditure and poverty impact, especially in urban areas. We conclude that the unavoidable and extensive dependence on OOP health expenditure leads to poverty, thus making a strong case for the implementation of universal health coverage.

Incidence and Intensity of the Burden in Paying for Health Care in India: A Rural-Urban Analysis

This paper has analyzed the extent and trend in the incidence and intensity of out-of-pocket (OOP) health expenditure at different threshold level in rural, urban and all India between 1999-00 and 2011-12. Data from nationally representative consumption expenditure surveys (CES) conducted by the National Sample Survey Organization (NSSO) in the year 1999-00, 2004-05 and 2011-12 has been used. Results show that between 1999-00 and 2011-12 the concentration of headcount reported OOP health expenditure at different threshold level has shown a decrease towards poor population which is more pronounced in rural areas and at two bottommost thresholds in urban areas. The concentration of overshoot is constant except some thresholds. The rate at which the concentration of headcount has decreased from top to bottom is far greater than the rate of decrease in the concentration of overshoot. Households in rural areas of the country are more vulnerable to catastrophe due to health care expenditure. The study argues for universal health insurance system to protect households from the significant burden of expenditure on critical health care.