Multi-Layered Catastrophic Health Spending of Inpatient Women by Broad Group of Diseases in India

Healthcare for Indian women needs prioritizing, as they continue to face social and economic discrimination over their healthcare, often with high out-of-pocket payments. The study examines the amount inpatient women have to pay for treatment of major diseases, re-classified into four groups as infectious, reproductive, non-communicable diseases (NCDs), and disabilities & injuries, across the country to comprehend the extent of catastrophic health spending (CHS) they experienced. The study is based on India’s 75th round of the National Sample Survey (NSS), i.e., Household Social Consumption: Health (2017-2018), consisting of 26,938 inpatient women aged 12 and above from India's urban and rural areas. We examine the prevalence of the four categories of diseases by individual, household, community, and healthcare characteristics. Expenditure estimates were derived from cross-tabulation, followed by binary logistic regression to assess the association between covariates and inpatient expenditures for the diseases. Indian women are more likely to be hospitalized for infectious diseases (43%), but the burden of CHS (overall) is highest for disabilities and injuries (INR 24,414), followed by NCDs (INR 23,053). Duration of hospitalization and possession of health insurance by women indicate maximum variation with medical spending. Almost 97% of women have incurred out-of-pocket expenditure on hospitalization, from which we identify three layers of CHS. A substantial proportion of women (23 to 50%) experienced CHS, i.e., up to 0-10%, 11-30%, and >30%, which varies distinctively by place of residence and across the six regions. Covariates like age, economic status, and healthcare are highly significant and associated with disease-wise CHS thresholds. Women in India face divergent financial hardships for healthcare. Given the heterogeneity of morbidities and socio-economic characteristics, the need for women-sensitive public health services and interventions are evident.

Addressing data and methodological limitations in estimating catastrophic health spending and impoverishment in India, 2004–18

Background Estimates of catastrophic health expenditure (CHE) are counterintuitive to researchers, policy makers, and developmental partners due to data and methodological limitation. While inferences drawn from use of capacity-to-pay (CTP) and budget share (BS) approaches are inconsistent, the non-availability of data on food expenditure in the health survey in India is an added limitation. Methods Using data from the health and consumption surveys of National Sample Surveys over 14 years, we have overcome these limitations and estimated the incidence and intensity of CHE and impoverishment using the CTP approach. Results The incidence of CHE for health services in India was 12.5% in 2004, 13.4% in 2014 and 9.1% by 2018. Among those households incurring CHE, they spent 1.25 times of their capacity to pay in 2004 (intensity of CHE), 1.71 times in 2014 and 1.31 times by 2018. The impoverishment due to health spending was 4.8% in 2004, 5.1% in 2014 and 3.3% in 2018. The state variations in incidence and intensity of CHE and incidence of impoverishment is large. The concentration index (CI) of CHE was − 0.16 in 2004, − 0.18 in 2014 and − 0.22 in 2018 suggesting increasing inequality over time. The concentration curves based on CTP approach suggests that the CHE was concentrated among poor. The odds of incurring CHE were lowest among the richest households [OR 0.22; 95% CI: 0.21, 0.24], households with elderly members [OR 1.20; 95% CI:1.12, 1.18] and households using both inpatient and outpatient services [OR 2.80, 95% CI 2.66, 2.95]. Access to health insurance reduced the chance of CHE and impoverishment among the richest households. The pattern of impoverishment was similar to that of CHE. Conclusion In the last 14 years, the CHE and impoverishment in India has declined while inequality in CHE has increased.

Addressing Data and Methodological Limitations in Estimating Catastrophic Health Spending and Impoverishment in India, 2004-18

Background Estimates of catastrophic health expenditure (CHE) are counterintuitive to researchers, policy makers, and developmental partners due to data and methodological limitation. While inferences drawn from use of capacity-to-pay (CTP) and budget share (BS) approaches are inconsistent, the non-availability of data on food expenditure in the health survey in India is an added limitation. Methods Using data from the health and consumption surveys of National Sample Surveys over 14 years, we have overcome these limitations and estimated the incidence and intensity of CHE and impoverishment using the CTP approach. Results The incidence of CHE for health services in India was 12.5% in 2004, 13.4% in 2014 and 9.1% by 2018. Among those households incurring CHE, they spent 1.25 times of their capacity to pay in 2004 (intensity of CHE), 1.71 times in 2014 and 1.31 times by 2018. The impoverishment due to health spending was 4.8% in 2004, 5.1% in 2014 and 3.3% in 2018. The state variations in incidence and intensity of CHE and incidence of impoverishment is large. The concentration index (CI) of CHE was -0.16 in 2004, -0.18 in 2014 and -0.22 in 2018 suggesting increasing inequality over time. The concentration curves based on CTP approach suggests that the CHE was concentrated among poor. The odds of incurring CHE were lowest among the richest households [OR 0.22; 95% CI: 0.21, 0.24], households with elderly members [OR 1.20; 95% CI:1.12, 1.18] and households using both inpatient and outpatient services [OR 2.80, 95% CI 2.66, 2.95]. Access to health insurance reduced the chance of CHE and impoverishment among the richest households. The pattern of impoverishment was similar to that of CHE. Conclusion In the last 14 years, the CHE and impoverishment in India has declined while inequality in CHE has increased. We recommend the CTP approach when estimating CHE and impoverishment in low and middle-income countries.

Addressing Data and Methodological Limitations in Estimating Catastrophic Health Spending and Impoverishment in India, 2004-18

BackgroundEstimates of catastrophic health expenditure (CHE) are counterintuitive to researchers, policy makers, and developmental partners due to data and methodological limitation. While inferences drawn from use of capacity-to-pay (CTP) and budget share (BS) approaches are inconsistent, the non-availability of data on food expenditure in the health survey in India is an added limitation. MethodsUsing data from the health and consumption surveys of National Sample Surveys over 15 years, we have overcome these limitations and estimated the incidence and intensity of CHE and impoverishment using the CTP approach. ResultsThe incidence of CHE for health services in India has declined from 12.5% in 2004 to 9.1% by 2018 and that of intensity of CHE has increased from 1.25 to 1.31 during the same period. The impoverishment due to health spending was 4.8% in 2004, 5.1% in 2014 and 3.3% in 2018. The state variations in incidence and intensity of CHE and incidence of impoverishment is large. The odds of incurring CHE were lowest among the richest households [OR 0.22; 95% CI: 0.21,0.24], households with elderly members [OR 1.20; 95% CI :1.12,1.18] and households using both inpatient and outpatient services [OR 2.80, 95% CI 2.66, 2.95]. Access to health insurance reduced the chance of CHE and impoverishment among the richest households. The pattern of impoverishment was similar to that of CHE. ConclusionWe recommend the CTP approach when estimating CHE and impoverishment in low and middle-income countries.

Does remittance protect the household from catastrophic health expenditure in India

Purpose The purpose of this paper is to examine the dynamic nature of the catastrophic health expenditure (CHE) on remittances receiving households between 2005 and 2012 in India. Design/methodology/approach The study adopted Xu’s (2005) definition of catastrophic health-care expenditure. And also used binary logistic regression to examine the effects of remittances being received on CHE in households across India. The data were drawn from the two rounds of the India Human Development Survey conducted by the University of Maryland, the USA, and the National Council of Applied Economic Research, New Delhi, India. Findings The results show that the percentage of households received remittances, and that the amount of remittances received has substantially increased during 2005 and 2012, though variation is evident by socioeconomic and demographic characteristics of the household. Apparently, the variation (percentage of households received remittances) is more pronounced for factors such as household size, number of 60+ elderly, sectors and by regions. Household’s catastrophic health spending and remittances being received show a statistically significant association. Households which received remittances during both the time showed the lowest likelihood (AOR:0.82; p-value < 0.10; 95% CI:0.64–1.03) to experience catastrophic health spending. Originality/value The paper identified the research gap to examine the occurrence of catastrophic health spending by remittances receiving status of the household using a novel panel data set.

Financial risk protection of Thailand’s universal health coverage: results from series of national household surveys between 1996 and 2015

Background Thailand, an upper-middle income country, has demonstrated exemplary outcomes of Universal Health Coverage (UHC). The country achieved full population coverage and a high level of financial risk protection since 2002, through implementing three public health insurance schemes. UHC has two explicit goals of improved access to health services and financial protection where use of these services does not create financial hardship. Prior studies in Thailand do not provide evidence of long-term UHC financial risk protection. This study assessed financial risk protection as measured by the incidence of catastrophic health spending and impoverishment in Thai households prior to and after UHC in 2002. Methods We used data from a 15-year series of annual national household socioeconomic surveys (SES) between 1996 and 2015, which were conducted by the National Statistic Office (NSO). The survey covered about 52,000 nationally representative households in each round. Descriptive statistics were used to assess the incidence of catastrophic payment as measured by the share of out-of-pocket payment (OOP) for health by households exceeding 10 and 25% of household total consumption expenditure, and the incidence of impoverishment as determined by the additional number of non-poor households falling below the national and international poverty lines after making health payments. Results Using the 10% threshold, the incidence of catastrophic spending dropped from 6.0% in 1996 to 2% in 2015. This incidence reduced more significantly when the 25% threshold was applied from 1.8 to 0.4% during the same period. The incidence of impoverishment against the national poverty line reduced considerably from 2.2% in 1996 to approximately 0.3% in 2015. When the international poverty line of US$ 3.1 per capita per day was applied, the incidence of impoverishment was 1.4 and 0.4% in 1996 and 2015 respectively; and when US$ 1.9 per day was applied, the incidence was negligibly low. Conclusion The significant decline in the incidence of catastrophic health spending and impoverishment was attributed to the deliberate design of Thailand’s UHC, which provides a comprehensive benefits package and zero co-payment at point of services. The well-founded healthcare delivery system and favourable benefits package concertedly support the achievement of UHC goals of access and financial risk protection.

Financial risk protection of Thailand’s Universal Health Coverage: results from series of national household surveys between 1996 and 2015

Background: Thailand, an upper-middle income country, has demonstrated exemplary outcomes of Universal Health Coverage (UHC). The country achieved full population coverage and a high level of financial risk protection since 2002, through implementing three public health insurance schemes. UHC has two explicit goals of improved access to health services and financial protection where use of these services does not create financial hardship. Prior studies in Thailand do not however provide evidence of long-term UHC financial risk protection. This study assessed financial risk protection as measured by the incidence of catastrophic health spending and impoverishment in Thai households prior to and after UHC in 2002.Methods: We used data from a fifteen-year series of annual national household socioeconomic surveys between 1996 and 2015, which were conducted by the National Statistical Office. The survey covered about 52,000 nationally representative households in each round. Descriptive statistics were used to assess the incidence of catastrophic payment as measured by the share of out-of-pocket payments for health by households exceeding 10% and 25% of household total consumption expenditure, and the incidence of impoverishment as determined by the additional number of non-poor households falling below the national and international poverty lines after making health payments. Results: Using the 10% threshold, the incidence of catastrophic spending dropped from 6.0% in 1996 to 2% in 2015. This incidence reduced more significantly when the 25% threshold was applied from 1.8% to 0.4% during the same period. The incidence of impoverishment against the national poverty line reduced considerably from 2.2% in 1996 to approximately 0.3% in 2015. When the international poverty line of US$ 3.1 per capita per day was applied, the incidence of impoverishment was 1.4% and 0.4% in 1996 and 2015 respectively; and when US$ 1.9 per day was applied, the incidence was negligibly low. Conclusion: The significant decline in the incidence of catastrophic health spending and impoverishment was attributed to the deliberate design of Thailand’s UHC, which provides a comprehensive benefits package and zero co-payment at point of services. The well-founded healthcare delivery system and favourable benefit package concertedly support the achievement of UHC goals of access and financial risk protection.