Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
BMC Public Health
Published in: BMC Public Health 1/2019

Open Access 01-12-2019 | Public Health | Research article

Do poor people in the poorer states pay more for healthcare in India?

Authors: Anjali Dash, Sanjay K. Mohanty

Published in: BMC Public Health | Issue 1/2019

Login to get access

Abstract

Background

Rising health spending is associated with high out-of-pocket expenditure (OOPE), catastrophic health spending (CHS), increasing poverty, and impoverishment. Though studies have examined poverty and impoverishment effect of health spending in India, there is limited research on the regional patterns of health spending by type of health centers. This paper tests the hypothesis that the poor people from the poorer states of India pay significantly more for hospitalization in public health centers than those in the richer states of India.

Methods

Data from the Social Consumption of Health Survey (71st round, 2014), carried out by the National Sample Survey (NSS) is used in the analyses. Descriptive statistics, log-linear regression model and tobit model were used to examine the determinants and variations in health spending.

Results

Inter-state variations in the utilization of public health services and the OOPE on hospitalization are high in India. States with high levels of poverty make higher use of the public health centers and yet incur high OOPE. In 2014, the mean OOPE per episode of hospitalization in public health centers in India was ₹5688 and ₹4264 for the economically poor households. It was lowest in the economically developed state of Tamil Nadu and highest in the economically poorer state of Bihar. The OOPE per episode of hospitalization in public health centers among the poor in the poorer states was at least twice that in Tamil Nadu. Among the poor using public health centers, the share of direct cost account 24% in Tamil Nadu compared to over 80% in Bihar, Odisha and other poorer states. Adjusting for socio-economic correlates, the cost of hospitalization per episode (CHPE) among the poor using public health centers was 51% lower than for the non-poor using private health centers in India.

Conclusion

The poor people in the poorer states in India pay significantly more to avail hospitalization in public health centers than those in the developed states. Provision of free medicines, surgery and free diagnostic tests in public health centers may reduce the high OOPE and medical poverty in India.
Appendix
Available only for authorised users
Literature
1.
WHO. Health systems financing: The path to universal coverage. World Health Organization. 2010.
2.
3.
van Doorslaer E, O’Donnell O, Rannan-Eliya RP, Somanathan A, Adhikari SR, Garg CC, et al. Effect of payments for health care on poverty estimates in 11 countries in Asia: an analysis of household survey data. Lancet. 2006;368(9544):1357–64.PubMedCrossRef
4.
O’Donnell O, van Doorslaer E, Rannan-Eliya RP, Somanathan A, Adhikari SR, Harbianto D, et al. The incidence of public spending on healthcare: comparative evidence from Asia. World Bank Econ Rev. 2007;21(1):93–123.CrossRef
5.
Wagstaff A, Flores G, Hsu J, Smitz MF, Chepynoga K, Buisman LR, et al. Progress on catastrophic health spending in 133 countries: a retrospective observational study. Lancet Glob Heal. 2018;6(2):e169–79.CrossRef
6.
Li Y, Wu Q, Xu L, Legge D, Hao Y, Gao L, et al. Factors affecting catastrophic health expenditure and impoverishment from medical expenses in China: policy implications of universal health insurance. Bull World Health Organ. 2012;90(9):664–71.PubMedPubMedCentralCrossRef
7.
Kumara AS, Samaratunge R. Patterns and determinants of out-of-pocket health care expenditure in Sri Lanka: evidence from household surveys. Health Policy Plan. 2016;31(8):970–83.PubMedCrossRef
8.
Molla AA, Chi C, Mondaca ALN. Predictors of high out-of-pocket healthcare expenditure: an analysis using Bangladesh household income and expenditure survey, 2010. BMC Health Serv Res. 2017;17(1):94.PubMedPubMedCentralCrossRef
9.
Pandey A, Ploubidis GB, Clarke L, Dandona L. Trends in catastrophic health expenditure in India: 1993 to 2014. Bull World Health Organ. 2018;96(1):18–28.PubMedCrossRef
10.
Berki SE. A look at catastrophic medical expenses and the poor. Health Aff. 1986;5(4):138–45.CrossRef
11.
Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJ. Household catastrophic health expenditure: a multicountry analysis. Lancet. 2003;362(9378):111–7.PubMedCrossRef
12.
McIntyre D, Thiede M, Dahlgren G, Whitehead M. What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts? Soc Sci Med. 2006;62(4):858–65.PubMedCrossRef
13.
14.
15.
Xu K, Evans DB, Carrin G, Aguilar-Rivera AM, Musgrove P, Evans T. Protecting households from catastrophic health spending. Health Aff. 2007;26(4):972–83.CrossRef
16.
Xie X, Wu Q, Hao Y, Yin H, Fu W, Ning N, et al. Identifying determinants of socioeconomic inequality in health service utilization among patients with chronic non-communicable diseases in China. PLoS One. 2014;9(6):e100231.PubMedPubMedCentralCrossRef
17.
18.
19.
Arsenijevic J, Pavlova M, Groot W. Measuring the catastrophic and impoverishing effect of household health care spending in Serbia. Soc Sci Med. 2013;78:17–25.PubMedCrossRef
20.
21.
Bhojani U, Thriveni B, Devadasan R, Munegowda C, Devadasan N, Kolsteren P, et al. Out-of-pocket healthcare payments on chronic conditions impoverish urban poor in Bangalore, India. BMC Public Health. 2012;12(1):990.PubMedPubMedCentralCrossRef
22.
Karan A, Selvaraj S, Mahal A. 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. PLoS One. 2014;9(8):e105162.PubMedPubMedCentralCrossRef
23.
24.
Pallegedara A. Impacts of chronic non-communicable diseases on households’ out-of-pocket healthcare expenditures in Sri Lanka. Int J Heal Econ Manag. 2018;18(3):301–19.CrossRef
25.
Garg CC, Karan AK. Reducing out-of-pocket expenditures to reduce poverty: a disaggregated analysis at rural-urban and state level in India. Health Policy Plan. 2009;24(2):116–28.PubMedCrossRef
26.
Ghosh S. Catastrophic payments and impoverishment due to out-of-pocket health spending. Econ Polit Wkly. 2011;46(47):63–70.
27.
Mohanty SK, Kim R, Khan PK, Subramanian SV. Geographic variation in household and catastrophic health spending in India: assessing the relative importance of villages, districts, and states, 2011-2012. Milbank Q. 2018;96(1):167–206.PubMedPubMedCentralCrossRef
28.
Carrin G, Mathauer I, Xu K, Evans DB. Universal coverage of health services: tailoring its implementation. Bull World Health Organ. 2008;86(11):857–63.PubMedPubMedCentralCrossRef
29.
Limwattananon S, Prakongsai P, Tangcharoensathien V, Limwattananon S, Prakongsai P. The equity impact of universal coverage: health care finance, catastrophic health expenditure, utilization and government subsidies in Thailand BT - Consortium for Research on Equity in Health Systems (CREHS) Report. Report of the Consortium for Research on Equitable Health Systems (CREHS). 2011. http://​www.​crehs.​lshtm.​ac.​uk/​thai_​biafia_​19jul.​pdf. Accessed 3 June 2018.
30.
Zhang L, Liu N. Health reform and out-of-pocket payments: lessons from China. Health Policy Plan. 2014;29(2):217–26.PubMedCrossRef
31.
Levesque J-F, Haddad S, Narayana D, Fournier P. Outpatient care utilization in urban Kerala. India Health Policy Plan. 2006;21(4):289–301.PubMedCrossRef
32.
33.
Peters DH. Better health systems for India’s poor : findings, analysis, and options. World Bank; 2002.CrossRef
34.
Mohanty SK, Kastor A. Out-of-pocket expenditure and catastrophic health spending on maternal care in public and private health centres in India: a comparative study of pre and post national health mission period. Health Econ Rev. 2017;7(1):31.PubMedPubMedCentralCrossRef
35.
36.
37.
Hooda SK. Out-of-pocket payments for healthcare in India. J Health Manag. 2017;19(1):1–15.CrossRef
38.
Karan A, Yip W, Mahal A. Extending health insurance to the poor in India: an impact evaluation of rashtriya swasthya Bima yojana on out of pocket spending for healthcare. Soc Sci Med. 2017;181:83–92.PubMedPubMedCentralCrossRef
39.
Berman P, Ahuja R, Bhandari L. The impoverishing effect of healthcare payments in India : new methodology and findings. Econ Politcal Wkly. 2010;45(16):65–71.
40.
Mukherjee S, Haddad S, Narayana D. Social class related inequalities in household health expenditure and economic burden: evidence from Kerala, South India. Int J Equity Health. 2011;10(1):1.PubMedPubMedCentralCrossRef
41.
Singh P, Kumar V. The rising burden of healthcare expenditure in India: a poverty nexus. Soc Indic Res. 2017;133(2):741–62.CrossRef
42.
Bajpai V, Singh N, Sardana H, Kumari S, Vettiyil B, Saraya A. Economic and social impact of out-of-pocket expenditure on households of patients attending public hospitals. Natl Med J India. 2017;30(1):15–20.PubMed
43.
Selvaraj S, Karan AK. Why publicly-financed health insurance schemes are ineffective in providing financial risk protection. Econ Polit Wkly. 2012;47(11):60–8.
44.
Ghosh S. Publicly financed health insurance for the poor. Econ Polit Wkly. 2014;xlIX(43):93–99.
45.
Joe W, Perkins JM, Kumar S, Rajpal S, Subramanian SV. Institutional delivery in India, 2004–14: unravelling the equity-enhancing contributions of the public sector. Health Policy Plan. 2018;33(5):645–53.PubMedCrossRef
46.
Hooda SK. Out-of-pocket payments for healthcare in India: who have affected the most and why? J Health Manag. 2017;19(1):1–15.CrossRef
47.
Chandra R, Singh A, Mukherjee S, Delhi N, Health G, Unit SC. A disaggregated analysis of change in household out-of-pocket expenditure on healthcare in India, 1995–2004. 2013;3(1):257–66.
48.
Gupta I, Chowdhury S, Prinja S, Trivedi M. Out-of-pocket spending on out-patient care in India : assessment and options based on results from a district level survey. PLoS One. 2016;11(11):e0166775.PubMedPubMedCentralCrossRef
49.
Deogaonkar M. Socio-economic inequality and its effect on healthcare delivery in India: inequality and healthcare. J Sociol. 2004;8:1–12.
50.
Subramanian SV, Nandy S, Irving M, Gordon D, Lambert H, Davey SG. The mortality divide in India: the differential contributions of gender, caste, and standard of living across the life course. Am J Public Health. 2006;96(5):818–25.PubMedPubMedCentralCrossRef
51.
Mohanty SK. Multiple deprivations and maternal care in India. Int Perspect Sex Reprod Health. 2012;38(1):6–14.PubMedCrossRef
52.
Ladusingh L, Pandey A. Health expenditure and impoverishment in India. J Health Manag. 2013;15(1):57–74.CrossRef
53.
54.
Ladusingh L, Pandey A. The high cost of dying. Econ Politcal Wkly. 2013;48(11):44–9.
55.
56.
57.
Binnendijk E, Koren R, Dror DM. Hardship financing of healthcare among rural poor in Orissa , India Hardship financing of healthcare among rural poor in Orissa, India. BMC Health Serv Res. 2012;12(1):23.PubMedPubMedCentralCrossRef
58.
Motkuri V, Mishra US. Human resources in healthcare and health outcomes in India; 2018.
59.
Chaudhuri A. Socio-economic inequity in health care utilization & expenditures in richer states in India. Indian J Med Res. 2012;136(3):368–9.PubMedPubMedCentral
60.
Pandey A, Ploubidis GB, Clarke L, Dandona L. Horizontal inequity in outpatient care use and untreated morbidity: evidence from nationwide surveys in India between 1995 and 2014. Health Policy Plan. 2017;32(7):969–79.PubMedPubMedCentralCrossRef
61.
Selvaraj S, Farooqui HH, Karan A. Quantifying the financial burden of households’ out-of-pocket payments on medicines in India: a repeated cross-sectional analysis of national sample survey data, 1994-2014. BMJ Open. 2018;8(5):e018020.PubMedPubMedCentralCrossRef
62.
Mohanty SK, Panda B, Khan PK, Behera P. Out-of-pocket expenditure and correlates of caesarean births in public and private health centres in India. Soc Sci Med. 2019;224:45–57.PubMedCrossRef
63.
Prinja S, Kumar MI, Pinto AD, Jan S, Kumar R. Equity in hospital services utilisation in India. Econ Polit Wkly. 2013;48:52–8.
64.
Mondal S. Health care services in India: a few questions on equity. Health (Irvine Calif). 2013;5(1):53–61.
65.
Sah DC, Kumar Y. Client satisfaction exit interviews: assessing quality of public health institutions through generated feedback. Vikalpa. 2015;40(1):42–61.CrossRef
66.
Das J, Holla A, Mohpal A, Muralidharan K. Quality and accountability in health care delivery: audit-study evidence from primary care in India. Am Econ Rev. 2016;106(12):3765–99.PubMedCrossRef
67.
Ghosh S, Gupta ND. Targeting and effects of rashtriya swasthya bima yojana on access to care and financial protection. Econ Polit Wkly. 2017;LII(4):61–70.
68.
69.
Ranjan A, Dixit P, Mukhopadhyay I, Thiagarajan S. Effectiveness of government strategies for financial protection against costs of hospitalization care in India. BMC Public Health. 2018;18(1):1–12.CrossRef
Metadata
Title
Do poor people in the poorer states pay more for healthcare in India?
Authors
Anjali Dash
Sanjay K. Mohanty
Publication date
01-12-2019
Publisher
BioMed Central
Keyword
Public Health
Published in
BMC Public Health / Issue 1/2019
Electronic ISSN: 1471-2458
DOI
https://doi.org/10.1186/s12889-019-7342-8

Other articles of this Issue 1/2019

BMC Public Health 1/2019 Go to the issue

Research article

Daily stress as link between disadvantage and smoking: an ecological momentary assessment study

Research article

“For us here, we remind ourselves”: strategies and barriers to ART access and adherence among older Ugandans

Research article

Health monitoring during water scarcity in Mayotte, France, 2017

Research article

Combined nicotine patch with gum versus nicotine patch alone in smoking cessation in Hong Kong primary care clinics: a randomised controlled trial

Research article

Association between dietary acid load and the risk of hypertension among adults from South China: result from nutrition and health survey (2015–2017)

Research article

Body mass index and physical fitness among Chinese adolescents from Shandong Province: a cross-sectional study