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Health and Millennium Development Goal 1: Reducing Out-of-pocket Expenditures to Reduce Income Poverty - Evidence from India
Abstract
This study uses the second National Family Health Survey (NFHS-2) of India to estimate the effect of state public health spending on mortality across all age groups, controlling for individual, household, and state-level covariates. We use a state’s gross fiscal deficit as an instrument for its health spending. Our study shows a 10 % increase in public spending on health in India decreases the average probability of death by about 2%, with effects mainly on the young, the elderly, and women. Other major factors affecting mortality are rural residence, household poverty, and access to toilet facilities.
... Here is an attempt to bring out some of the prominent research papers for our discussion. As has been documented, household medical expenses are rising more than ever (Wagstaff & Doorslaer, 2003;Garg, Karan, et al., 2005;Ghosh, 2011). The public expenditure on health is at an all-time low, and the private health sector has grown aggressively during the past few decades (Baru, 2016). ...
... Recent international findings identify the cause of catastrophic spending on healthcare for households to be the high share of total household resources that OOP expenditure represents (Xu et al., 2003;O'Donnell et al., 2005). The literature also shows that a large proportion of households in India make catastrophic payments, and a substantial proportion of those households which incur catastrophic payments belong to the well-off categories (O'Donnell et al., 2005;Garg, Karan, et al., 2005;Roy & Howard, 2007). This may reflect on the capacity of better-off households to respond to medical needs by diverting resources from expendable consumption while poor households are constrained with regards to the extent to which they can divert resources away from food and shelter (O'Donnell et al., 2005;Roy & Howard, 2007). ...
... A cross-country analysis of household consumption expenditure data spanning eleven South Asian countries including India, suggests that using 1 US dollar as the norm for poverty 7 , over 37 million people in India were pulled down below the poverty line due to high OOP payments during 1999/2000(Van Doorslaer et al., 2007. Using Indian official poverty lines, Garg et al. (2005) estimate the number in the same year to have been 32.5 million. Wagstaff et al. (2018) analyze 553 household surveys with quality checks from 133 countries for catastrophic health spending between 1984 and 2015. ...
... In 2006, UNICEF launched several initiatives to promote the maternal and child health and education within islands [43]. All these initiatives have dramatically enhanced the Comoros government's efforts towards achieving the MDGs [71], as shown in Figure 1 and Table 3. Maternal and child mortality has declined to more than half due to the substantial decrease in malaria deaths and the increase in skilled birth attendants in 2012 [72]. Also, various initiatives aimed at strengthening the primary health care initiated by the Government with its partners have considerably improved maternal and child health after the Fomboni Declaration (See Figure 1), resulting in great improvement in achieving MDGs (Table 3). ...
... However, a lot has to be done to reduce poverty and hunger, which remain vital challenges facing the population in Comoros. Most recently, Comoros was ranked as the third hungriest nation in the world [71]. As a response to such difficulties, the Comorian Government developed a National Strategic to reduce poverty and accelerate economic growth to reduce the socioeconomic disparities among the population. ...
... In addition, as shown in Figure 2, the Government health expenditure and External resource for health as % of THE dramatically decline during the political turbulence, attaining its minimal point of 4.98% and 19.51% respectively in 2001. In such a situation, the out-of-pocket health expenditure as % of private health expenditure was 100%, which harms household consumption and ultimately an impoverishing effect on households and a decline in the use of health service [71,75]. ...
Background: There is ongoing scientific evidence pointing out the adverse effects of conflict on population health and development. Union of Comoros has experienced nearly two decades of political instability and military rule. This comprehensive review was carried out to ask whether the health crisis in Comoros is attributable to the consequences of the chronic political instability.
Methods: This study involved a series of semi-structured interviews with key informants complemented by a comprehensive literature search of electronic databases and grey literature. A literature search was performed using all identified keywords associated with health indicators in Comoros to identify potential eligible publications in both English and French from 1975 to July 2020.
Results: The analysis demonstrated that political instability and lack of proper leadership from the Government undermine the establishment of health policies which contributed dramatically to the decline in health performance. Additionally, the resurgence and emergence of old and new diseases such as cholera, chikungunya, malaria, HIV/AIDS as indicators of inadequate health services were most likely during political turmoil. Data also showed an out-migration of the health workforce and an increased overseas medical treatment demand, which indicate less attractive working conditions and weak health systems in the country. Meanwhile, an increasing performance of health status indicators was observed after the comprehensive peace process of the 2000-Fomboni Declaration.
Conclusions: The chronic political instability in Comoros has contributed to the health crisis facing the Union of Comoros. It has hampered the implementation of proper institutions, which might guarantee the socio-economic development and prosperity of the population. Further studies were needed to evaluate the health burden associated with the two decades of political instability and military rule.
... In 2006, UNICEF launched several initiatives to promote the maternal and child health and education within islands [43]. All these initiatives have dramatically enhanced the Comoros government's efforts towards achieving the MDGs [71], as shown in Figure 1 and Table 3. Maternal and child mortality has declined to more than half due to the substantial decrease in malaria deaths and the increase in skilled birth attendants in 2012 [72]. Also, various initiatives aimed at strengthening the primary health care initiated by the Government with its partners have considerably improved maternal and child health after the Fomboni Declaration (See Figure 1), resulting in great improvement in achieving MDGs (Table 3). ...
... However, a lot has to be done to reduce poverty and hunger, which remain vital challenges facing the population in Comoros. Most recently, Comoros was ranked as the third hungriest nation in the world [71]. As a response to such difficulties, the Comorian Government developed a National Strategic to reduce poverty and accelerate economic growth to reduce the socioeconomic disparities among the population. ...
... In addition, as shown in Figure 2, the Government health expenditure and External resource for health as % of THE dramatically decline during the political turbulence, attaining its minimal point of 4.98% and 19.51% respectively in 2001. In such a situation, the out-of-pocket health expenditure as % of private health expenditure was 100%, which harms household consumption and ultimately an impoverishing effect on households and a decline in the use of health service [71,75]. ...
Background: There is ongoing scientific evidence pointing out the adverse effects of conflict on population health and development. Union of Comoros has experienced nearly two decades of political instability and military rule. This comprehensive review was carried out to ask whether the health crisis in Comoros is attributable to the consequences of the chronic political instability.
... Moreover, OOP health expenditure above a certain threshold level can become catastrophic and force a considerable proportion of the population to live below the poverty line (Wagstaff and Doorslaer 2003). Recently, researchers in India have studied the burden and impact of OOP health expenditure (Berman et al. 2010;Garg and Karan 2008;Ghosh 2010;Karan et al. 2014;Kumar et al. 2015b;Ladusingh and Pandey 2013). Garg and Karan (2008) and Ladusingh and Pandey (2013) investigated ruralurban differentials in India and found that the impoverishment impact of OOP payments is much higher in rural areas and poor states than in urban areas and richer states. ...
... Recently, researchers in India have studied the burden and impact of OOP health expenditure (Berman et al. 2010;Garg and Karan 2008;Ghosh 2010;Karan et al. 2014;Kumar et al. 2015b;Ladusingh and Pandey 2013). Garg and Karan (2008) and Ladusingh and Pandey (2013) investigated ruralurban differentials in India and found that the impoverishment impact of OOP payments is much higher in rural areas and poor states than in urban areas and richer states. Ghosh (2010) found that between 1993 and 1994 and 2004-2005 households in India witnessed an increasing trend in OOP health expenditure that resulted in impoverishment. ...
... The incidence of OOP health expenditure in rural areas was highest among the richer consumption groups, with a slight decrease in 2014, whereas in urban areas the incidence of OOP health expenditure continued to remain concentrated in poorer consumption groups. On the other hand, the intensity of OOP health expenditure in both rural and urban areas became more prevalent in the richer consumption groups, mainly because they have better access to health care facilities than the poor (Garg and Karan 2008;NSSO 2014). Results also revealed that people in India favoured private health care facilities over public health care facilities, particularly in urban areas. ...
Aim
This article aimed to study the burden, impact and coping mechanisms associated with out-of-pocket (OOP) health expenditure in rural and urban areas in India.
Methods
National Sample Survey Organisation (NSSO) data on ‘Health and Morbidity’ gathered in 2004 and 2014 were employed to measure the catastrophic burden, impoverishment impact and various coping strategies associated with out-of-pocket health in India.
Results
Results revealed that over the study period, considerable rural-urban differentials existed in the economic burden and impact of out-of-pocket health expenditure. As a coping strategy, borrowing and other distress sources were used in higher proportions by the rural population than their urban counterparts. Overall, our results demonstrated an alarming situation regarding health care financing in India.
Conclusion
Substantial investment in public health is needed, especially in rural areas as it is here that people are facing the real brunt of catastrophic OOP health expenditures in the form of impoverishment with more dependence on distress sources including borrowing and sale of assets as coping mechanisms.
... Studies have identified that too much reliance on OOP health payments at the time of care, in a health care financing context dominated by private expenditures combined with weak public health systems, and almost negligible health insurance are largely responsible for high prevalence of catastrophic health payments in South Asia (Peters et al. 2002;Xu et al. 2003;Wagstaff and van Doorslaer 2003;O' Donnell et al. 2005; van Doorslaer et al. 2005van Doorslaer et al. , 2006van Doorslaer et al. , and 2007. The Equity in Asia-Pacific �ealth Systems (EQ�ITAP) project in particular has generated a very useful body of evidence on catastrophic payments for health care, among others, for India (see O' Donnell et al. 2005; van Doorslaer et al. 2005van Doorslaer et al. , 2006van Doorslaer et al. , and 2007Garg and Karan 2005). �owever, much of this evidence on India has been generated from the National Sample Survey for the year 1999-2000. ...
... The minor differences from the 2000 round could be due to use of uniform recall period in this study compared to use of mixed recall period in previous studies. For nonfood, the average OOP share of nonfood expenditure is 9.7%, which is slightly lower than 10.7% previously recorded by Garg and Karan (2005) and van Doorslaer et al. (2005). Poverty headcount rate increased by 12.7% after health payments, which is slightly higher than the 11.9% recorded earlier by van Doorslaer et al. (2005). ...
... Around 3.5% of the people fell below the poverty line after adjusting for health payments, which represents 4.9% of the population above the poverty line, or close to 40 million people. These estimates are slightly higher than those found by Garg and Karan (2005) earlier, where the percentage of the population falling below the poverty line in 1999-2000 was 3.25% (or 32.5 million people). This is disconcerting, since the economy is growing, yet catastrophic health payments are affecting a larger number of people. ...
This study investigates the incidence, intensity, and correlates of catastrophic
health payments in India. The paper confirms the continuing high incidence of
catastrophic health payments and increase in poverty headcount and poverty gap
due to health payments. Despite India’s remarkable economic growth, catastrophic
health spending remains a major cause of poverty. Using bivariate analysis and
Heckman sample selection and multinomial logistic regression for multivariate
regression analysis, the paper finds that health payments were 4.6% of total
household expenditure and 9.7% of household nonfood expenditure. Poverty
headcount increased from 27.5% to 31.0% due to health payments, which
translates to 39.5 million people falling below the poverty line due to health
payments. It is important for India to develop effective risk pooling arrangements
for health care.
... People in the developing countries generally spend their own money for medical treatment instead of relying on public health care facilities and this trend is continuing [1]. Reliance on personal funding for healthcare places households to the risk of additional burden [2,3]. ...
... About 89% of the third-world's population worldwide annually experience financial distress because they have to pay for health services from their existing resources and very limited income [8]. Therefore, out-of-pocket expenditures for healthcare 1 are currently and continue to be the most significant means of healthcare issue in the developing world unless appropriate plans take place [9]. In a developing country like Bangladesh, out-of-pocket (OOP) expenditures for health care typically account for the largest share of living budget and are about 64.3% of the total health expenditure 2 [10]. ...
... A serious feature of the illness deceits in the critical susceptibility of the poor to an unexpected and unforeseen healthcare related vulnerabilities, increased indebtedness due to income loss, and even employment. The risk that out-of-pocket (OOP) 1 Out-of-pocket (OOP) expenditures for health are made directly by a member of a household as a patient for the purchase of medical goods and service at the point of service. This kind of extra expenditure can cause a spiral of indebtedness and asset exhaustion time over time [5]. 2 Total Health Expenditure (THE) includes health expenditures in an accounting year under expenditures for all healthcare related functions expenditures stance to poor's living standards is progressively recognized as a key concern in the financing of healthcare issues [13][14][15][16]. ...
... The poor population in low-income countries mainly finance health care from out-of-pocket (OOP) payments that severely affect their consumption during periods of major illness, or forces them to forego treatment, which raises the chance of long-term deterioration of health and earning capacity [1,2]. Costs of health care are therefore claimed to be a major cause of poverty in low-income countries [3], and is also a cause of aggravating poverty [4][5][6]. 1 Hence, it seems that OOP payment is a major threat to the success of national poverty reduction initiatives of developing nations. However, OOP outlays would plausibly vary across illness categories (e.g. between non-communicable diseases [NCDs], and communicable diseases [CDs], and accordingly one would expect the impoverishment impact of OOP payments to also depend on the type of illness. ...
... 4 Prepayment headcount poverty (H preÀpayment ) was calculated by comparing per capita household expenditure (including OOP payments for health care) with a poverty line estimated by the authors. 5 Similarly, the postpayment headcount poverty (H postÀpayment ) was measured by comparing per capita household expenditure (excluding direct OOP payments for health care) with the poverty line. 6 Assume z i to be per day per capita expenditure (including OOP payments for health care), y i is per day per capita OOP payments, P L is the poverty line and n is the number of individuals. ...
... 4 Headcount poverty measures the percentage of individuals or households living below the poverty line, while poverty gap measures poverty deepening or intensity of poverty (the amount by which the poor households fall short of the poverty line). 5 We used both food and non-food expenditure as a proxy for household income. For measuring food expenditure, we considered expenditure on the food bundle consumed by the household for the week preceding the survey. ...
Background
Analysing disease-specific impoverishment impact of out-of-pocket (OOP) payments for health care is crucial for priority setting in any informed policy discussion. Lack of evidence, particularly in the Bangladesh context, motivates our paper.
Objective
To examine disease-specific impoverishment impact of OOP payments for health care.
Methods
The paper estimates the poverty impact of OOP payments by comparing the difference between the average level of headcount poverty and poverty gap with and without health care payments. We used primary data drawn from 3,941 households, distributed over 120 villages of seven districts in Bangladesh during August–September 2009.
Findings
We find that OOP outlays annually push 3.4 % households into poverty. The corresponding figures for those who had non-communicable diseases (NCDs), chronic illness, hospitalization and catastrophic illness were 4.61, 4.65, 14.53 and 17.33 %, respectively. Note that NCDs are the principal reason behind the latter two situations (about 88 % and 85 % of cases, respectively). Looking into individual categories of NCDs we found that major contribution to headcount impoverishment arose out of illnesses such as cholecystectomy, mental disorder, kidney disease, cancer and appendectomy. The intensity of impoverishment is the largest among the hospitalized patients, and more individually among cancer patients.
Conclusions
The poverty impact of OOP outlays for health care, in general, is quite high. However, it is especially high for NCDs, particularly for chronic NCDs and those requiring immediate surgical procedures. Hence, these illnesses should be given more priority for policy framing. In addition to suggesting some ex-ante measures (e.g. raising awareness regarding the risk factors causing NCDs), the paper argues for reforms to enhance efficiency in the public health care facilities and increasing the quality of public health care.
... The high OOP payment adversely affected the deprived sections because of the absence of financial risk protection. After adjusting for health expenditure due to OOP payments, an additional 3.5% of the population fell below the poverty line, grounded on estimates for 2005-2006 (42); comparatively, a slight rising trend was observed when 3.25% fell below the poverty line from the estimate made in 1999-2000 (41,43). Numerous observations were documented by a study of 482 poor households in Udaipur, Rajasthan, which showed that a little less than onethird of the households identified a huge health expenditure as one of the reasons for economic pressure (44). ...
... Facing this certainty, the poor often finance rising healthcare costs by cutting down consumption level expenditures for other household members (45). Thus, an ailment of a household member could have noxious consequences toward further destitution of the households (39,41). ...
Background
India has enjoyed enhanced economic growth, but has fared poorly in human development indicators and health outcomes, over the last two decades. Significant health inequities and access to healthcare continue to exist and have widened within communities across states. This study examine the changes and disparities in maternal and child healthcare (MCH) among disadvantaged and advanced social groups in three states of India.Data and Methods
Four rounds of National Family Health Survey data were used to measure infant mortality rate (IMR) and under-five mortality rate (U5MR) according to the social groups for the selected states. This study investigates the socio-economic inequities manifested into caste and class differentials and inequities in availability, utilization, and affordability of maternal and healthcare services. Descriptive statistics and the logistic regression model were used. Individual- and household-level covariates were employed to understand the differentials in healthcare utilization.ResultsThe probability of not receiving full antenatal care (ANC) or full immunization for the children was highest among the Scheduled Caste/Scheduled Tribe (SC/ST) families, followed by economic class, mother's education and residence. Tamil Nadu showed the highest utilization of public health facilities, while Bihar was the poorest in terms of health outcomes and utilization of MCH care services even after the pre-National Health Mission (NHM) period. Bihar and West Bengal also showed private healthcare dependence.Conclusion
This study detected the presence of significant caste/tribe differentials in the utilization of MCH care services in the selected states of India. Limited accessibility and unavailability of complete healthcare were the foremost reasons for the under-utilization of these services, especially for people from disadvantaged social groups. The result also suggested that it is perilous to confirm “Health for All” immediately. It will be the efficiency with which India addresses inequities in providing healthcare services and guarantees quality care of health services.
... The rural household of an India faces the more Catastrophic Health Expenditure than the urban (rural (25.3%) and urban (17.5%)) [9] because of the out of pocket expenditure 87% rural poverty occurs mainly in the poor states of India and in richest states proposition of poverty in a rural is 67% [18]. Always the percentage of the poverty is very high in rural areas (3.5%) than the urban areas (2.5%) [19,20]. The elementary part of a healthcare system is not only to providing and improving the health status of the population, it has to protect the individual household from a financial crises which take place due to the Out of pocket payments [21][22][23][24]. ...
... The elementary part of a healthcare system is not only to providing and improving the health status of the population, it has to protect the individual household from a financial crises which take place due to the Out of pocket payments [21][22][23][24]. People are protected from the catastrophic if country has risk pooling mechanism [20] but most of the middle and low income/ developing countries experience high OOP payments and due to scarcity of risk-sharing mechanisms and at last OOP will end up in poverty [22][23][24][25][26][27][28]. Indicator is calculated as: OOP=(Household OOP Expenditure for health during the past 12 months/Total annual household income x 100 (WHO). ...
... Flores et al. (2008), using the fifty-second round of National Sample Survey Organization (1998), found that the financial coping strategies finance as much as three-quarters of the cost inpatient care in India. To overcome ecological fallacy of understanding proportion of households, which have become poor as a consequence of OOP health expenditure, as in case of Garg and Karan (2005) and Bonu et al. (2007), this article makes an adjustment for financial coping mechanisms, such as availability of loan for health care. Our analysis is on the lines of Flores et al. (2008) and Berman et al. (2010) but with few distinctions. ...
... There is a significant rural-urban differential, higher for rural than for urban households. These are significantly higher from those of Garg and Karan (2009) but are lower than that of Devadasan (2006). This difference is partly accounted by the difference in the reference dates, 1999-2000 in 2004-05 in case of the present study, while Devadasan (2006) study is confined to inpatients' health care. ...
This article examines impoverishment effect of the out-of-pocket (OOP) payment for health care on households in India where only 10 per cent of the population is covered by insurance. At the national level, 10.1 per cent of rural households as against 6.2 per cent of urban households have either become poor or poorer as a consequence of OOP for health care. The proportion of rural impoverished households due to OOP health expenditure in the four most underdeveloped states of Orissa, Bihar, Uttar Pradesh and Madhya Pradesh are 11.4, 9.5, 7.9 and 7.3 per cents, respectively. The corresponding proportion of urban impoverished households for these states are 7.2, 7.5, 5.9 and 5.1 per cents, respectively. It is also found that the OOP payment tends to increase significantly with inequality in income distribution and shortage of physicians at the state level. Health system inadequacy measure by population density per physician has escalating effect on impoverishment.
... Wagstaff and Doorslaer (2003) pioneered the minimum standard approach based on the concept of horizontal equity. Many studies (for instance, Wagstaff and Doorslaer, 2003, Van Damme et al., 2004, Garg and Karan, 2005a, Schneider and Hanson, 2006, Markova, 2006, and Mendola et al., 2007) use this and other approaches such as concentration index to analyse distribution of financial burden due to OOP health expenditure and poverty impact of OOP health expenditure for different countries. Findings of these studies call for policy measures to protect household's consumption expenditure in the event of health shock. ...
... We examine the determinants of incidence and extent of catastrophic OOP health care expenditure. Studies (for instance Wagstaff, 2003, O'Donnell et al., 2005, Garg and Karan, 2005a, Mendola et al., 2007) define catastrophic OOP health expenditure as OOP 9 Bowley's measure of skewness is based on quartiles and thus is a robust estimate of skewness in case of skewed distribution. 10 Assam shows the lowest IQR amongst all six states. ...
In India, the out-of-pocket health expenditure by households accounts for around 70 percent of the total expenditure on health. Large out-of-pocket payments may reduce consumption expenditure on other goods and services and push households into poverty. Recently, health insurance has been considered as one of the possible instruments in reducing impoverishing effects of large out-of-pocket health expenditure. In India, health insurance has limited coverage and the present paper studies whether it has been effective so far. Literature defines out-of-pocket health expenditure as catastrophic if its share in the household budget is more than some arbitrary threshold level. In the present paper, we argue that for households below poverty line any expenditure on health is catastrophic as they are unable to attain the subsistence level of consumption. Thus, we take zero percent as a threshold level to define catastrophic health expenditure and examine the impact of health insurance on probability of incurring catastrophic health expenditure.
... The policy intervention to reduce the burden of catastrophic health expenditure was found to be ineffective for the households belonging to rural areas and BPL. Similarly, Gumber (2001), Garg and Karan (2005) and O' Donnell et al. (2005) examined the factors that influence the incidence of catastrophic health expenditure. Selvaraj and Karan (2009) and Ghosh (2010) have also reported the ineffectiveness of health policies between the 1990s and 2004-2005 as there was an increase in the catastrophic health payment as well as the impoverishment in India rather than a reduction in them. ...
Health is one of the major determinants of the overall well-being of a society. The World Health Organization has emphasised the right to health for all, and the universal health coverage is a paradigm of this emphasis with an agenda of nobody to be left behind in the provision of health services without any financial burden by 2030.This article tries to analyse the extent of catastrophic expenditure being incurred by the people despite being sheltered under a financial protection (Health Insurance) in the state of Maharashtra. The impact caused by out-of-pocket (OOP) health expenditure on the economic status of the people in the state is assessed using the National Sample Survey Office’s 71st round conducted by the Ministry of Health and Family Welfare, Government of India. It was found that over 4.18% of the population endured the burden caused by OOP expenditure by falling below the poverty line post health payments. A higher proportion of rural population is observed to have experienced a fall in the economic status from above poverty line (APL) to below poverty line (BPL) due to high OOP expenditure than that of the urban population in Maharashtra.
... Degraded quality, services and accessibility of the public sector were considered to be the primary cause for the utilization of private health care services. 4 Babu et al. in their study revealed that due to the unavailability of the government health care facilities within the easy reach of workers, private health care centers are preferred as they are easily accessible for them. In some parts of the country such as Delhi situation varies and are Government health care centers are of easy access for most of the workers but due to their migration they are unaware of facilities available nearby and end up reaching private health care centers, as they have better advertisements. ...
Background
Brick kiln industries are usually located at remote locations due to which labors feel difficulties to even fulfill their basic needs. They are bound to buy their requirements from assigned suppliers. In order to receive treatment, labors don't find much of the options to choose. This study tends to examine the treatment seeking behavior and their level of treatment among brick kiln workers.
Method
A structured interview and in-depth interviews were used for data. Data entry was done in SPSS version 23. Data was analyzed using STATA version 15.
Result
Total of 450 respondents, 82.7% suffered from musculoskeletal disorder, and 53.8% suffered from respiratory disease and similar number of molders were suffering from aforementioned diseases. More than 30% of workers suffered from eye disease and skin disease in 36–50 years of age category. In the study, 95% workers were suffering from occupational morbidity. Out of which 92.5% reported utilization of outpatient care, whereas, 7% of non-users stated, primary reason for not using health care services were, low financial support, unawareness of health centers, tight working hours.
Conclusion
The prevalence of occupational morbidity is high whereas, treatment seeking among workers are not satisfying. Treatment seeking among labors is found to be delayed and above all, labors are highly ignorant about symptoms. Due to low income, low education and skills, deprived workers are considered for low grade and poorly paid jobs in the kilns where they are victimized by their employer and ill treatment regarding salary and wages were also observed.
... The higher burden of OOP health expenditure is also attributed to the expensive nature of health services, type of care, chronic conditions and low capacity to pay in addition to the lack of health insurance (Onwujekwe et al., 2012;Quintussi et al., 2015;Xu et al., 2003). Rural-urban differentials are also visible in the intensity of the burden of OOP health expenditure (Garg & Karan, 2005;Jayakrishnan et al., 2016;Ladusingh & Pandey, 2013;Sangar et al., 2018), as its concentration is pro-rich in rural areas whereas, in urban areas, it is comparatively equally distributed (Garg & Karan, 2008). Type of care is another factor which also plays an important role in deciding the quantum of burden. ...
By using nationally representative consumption expenditure surveys (CES) conducted by the National Sample Survey Organisation (NSSO) in 1999–2000, 2004–05 and 2011–12, this paper has analysed the socioeconomic differentials in the burden of paying for healthcare in India. The study found that in all waves of data, the concentration of population reporting OOP health expenditure has shown a shift towards poor population, while the concentration of overshoot expenditure is still constant among the rich which is more pronounced in the rural areas of the country. Furthermore, Muslims and Sikhs among different religions, Scheduled Casts among social categories, self-employed and casual/agricultural labour among household types and rural areas among sectors are more likely to incur OOP health expenditure as compared to their counterparts. This study argues for the universal health insurance coverage to protect households from the significant burden of expenditure on critical healthcare
... 2 Only 1% of the gross domestic product (GDP) is being spent for financing health care by the government. 3 Curative services have always favored the non-poor. It is seen that for every Rs. 1 spent on the poorest 20% population, Rs. 3 is spent on the richest quintile. ...
Background: Health insurance is an important mechanism in the modern world to save the individuals from the huge health shock, even then very high percentage of people even from educated higher income groups are not covered under any health insurance policy. This study was undertaken to know the knowledge, attitude and practice regarding health insurance.Methods: A community based cross sectional study was conducted among 550 household of Uttar Kannada and Udupi districts. Multistage sampling technique was used.Results: Of the 550 study participants, 384 (69.8%) were BPL card holders. 348 (63.27%) were aware and also subscribed for any type of the health insurance, 115 (20.91%) were aware but did not subscribe while 87 (15.82%) were not aware about it. The main source of information were health workers 185 (39.74%), friends and family 178 (38.44%) and media 99 (21.38%). Of the 348 who had health insurance, only 89 (25.57%) utilized them. Reasons for not availing health insurances other than being unaware were complicated process 85 (42.08%) and provides only partial coverage 49 (24.26%). The main reasons for not using the health insurance were non availability of empanelled hospital 84 (74.34%), disease not being under the scope of scheme 60 (23.17%) and 32 (12.36%) were unaware about the process of availing.Conclusions: Health insurances are the best way to help people reduce their financial burden. Hence it is very important to educate the community regarding the best health insurance available so that they can take the maximum benefits from it.
... P Berman et al (2010) reported an impoverishment rate of 1.3% due to OOP expenditure on inpatient treatment after adjusting for fi nancial coping mechanisms. C C Garg and A K Karan (2005) have reported an impoverishment rate of 3.2%, while S Bonu et al (2007) reported an increase in poverty headcount by 3.5%. K Kumar et al (2015) have also reported a 2.9% increase in poverty headcount due to OOP expenditure on in-patient treatment in India. ...
... The health spending as a percentage of household consumption expenditure is computed to understand the relative differences in health spending of elderly and non-elderly households. In literature, when the health care spending exceeds some fixed proportion of total household expenditure (threshold limit of 5-10 % of total household budget), the health spending is termed as catastrophic Doorslaer 2003, Garg andKaran 2005). Researchers also define catastrophic health spending as 40 % of household's capacity to pay, where the minimum consumption expenditure is deducted from total household expenditure (Xu 2005). ...
Using the consumption expenditure data, National Sample Survey, 2009–2010, this paper test the hypothesis that the monthly per capita household health spending of elderly households is significantly higher than non-elderly households in India. The households are classified into three mutually exclusive groups; households with only elderly members (elderly households), households with elderly and non-elderly members and households without any elderly member. The health spending include the institutional (hospitalization) and non-institutional health expenditure of the households, standardized for 30 days. Descriptive statistics and a two part model are used to understand the differentials in health expenditures across households. Results indicate that the monthly per capita health spending increases with economic status, occupation, age and educational attainment of the head of the household. The monthly per capita health spending of elderly households is 3.8 times higher than that of non-elderly households. While the health spending accounts 13 % of total consumption expenditure for elderly households, it was 7 % among households with elderly and non-elderly members, and 5 % among non-elderly households. Controlling for socio-economic and demographic correlates, the per-capita household health spending among elderly households and among household with elderly and non-elderly members was significantly higher than non-elderly households. The health expenditure is catastrophic for poorer households, casual labourer and households with elderly members. Based on the finding we suggest to increased access to health insurance and public spending on geriatric care to reduce the out-of-pocket expenditure on health care in India.
... The most significant fallout of such a health financing system has been the economic impact and possible impoverishment among households least able to cope with such economic shocks. There are numerous studies examining the phenomenon of financial distress due to high OOPHE in India (Krishna 2004;O'Donnell and Doorslaer et al. 2005;Garg and Karan 2005;Bonu et al. 2007;Gupta 2009;Berman et al. 2010). While both OOPHE as well as its share in total household consumption expenditure increases with increasing ability to pay (ATP), comparisons across groups (e.g., gender, class, social code, region, etc.) indicate horizontal inequities including differences in both degrees of progressivity and the redistributive effect (Roy and Howard 2006). ...
... An EHP should focus on regular supply and access to medicines and diagnostic services. In India more than 70 per cent of total out-of-pocket expenditure is on medicine and diagnostics (11) resulting in barriers to access-to health services and ultimately delayed treatment leading to catastrophic health expenditures. There is evidence from states like Tamil Nadu, Kerala and Rajasthan that have established best practices in procurement and supply of medicines in public health facilities. ...
This document develops a framework for an Essential Health Package comprising 34 health categories. It provides detailed care pathways and associated costs and path-dependent conditional probabilities for Anaemia, Cardio Vascular Disease, Diabetes, and Tuberculosis. Using the frameworks developed here designers of health systems can provide detailed pathways and estimate resource requirements for all the elements of the Essential Health Package.
... The most significant fallout of such a health financing system has been the economic impact and possible impoverishment among households least able to cope with such economic shocks. There are numerous studies examining the phenomenon of financial distress due to high OOPHE in India (Krishna 2004;O'Donnell and Doorslaer et al. 2005;Garg and Karan 2005;Bonu et al. 2007;Gupta 2009;Berman et al. 2010). While both OOPHE as well as its share in total household consumption expenditure increases with increasing ability to pay (ATP), comparisons across groups (e.g., gender, class, social code, region, etc.) indicate horizontal inequities including differences in both degrees of progressivity and the redistributive effect (Roy and Howard 2006). ...
... This strongly provides the evidence that low health facilities and status of the population is a major factor for the persistence of poverty and it can be relieved by proper targeting and provisioning of public healthcare. How to reduce the OOP expenditures and decrease the share of household living standards is a fundamental question (6,7). Therefore, it is a significant subject to identify the linkage between health, healthcare provision and poverty in Bangladesh. ...
Out of pocket (OOP) expenditures for healthcare are largely unpredictable and usually have a diminishing impact on the poor households. The large expenditures on healthcare have catastrophic impacts on household welfare and poverty issues. This study examines the degree of the impact that out-of-pocket expenditures for healthcare on household spending patterns and on poverty in Bangladesh. According to this study, approximately 29.2% of the households employ more than 5% of their total living resources for health care facilities. The OOP healthcare expenditure can be sufficiently expensive as 25.5% of the population in Bangladesh is extreme poor. Healthcare expenditures add another 4.2% population (5.8 million people) to the extreme poverty. This strongly provides the evidence that low health facilities and status of the population is a major factor for the persistence of poverty and it can be relieved by proper targeting and provisioning of public healthcare.
... In India, more than 37 million people went below the poverty line in 1999-2000 as per the $1 norm because of OOP payments (van Doorslaer et al., 2005)-in addition to those already below the poverty line and pushed further into acute poverty because of OOP payments. Two other studies (Bonu, Bhushan, & Peters, 2007;Garg & Karan, 2005) estimated that roughly 3.25 to 3.5 percent of the population became poor because of health care payments. A more recent study with NSSO data reports that after adjusting for the sources (borrowings, contributions and sale of assets etc.) of OOP expenditure, 63.22 million individuals or 11.88 million households were impoverished due to healthcare expenditure in 2004 (Berman, Ahuja, & Bhandari, 2010). ...
Health care can be expensive for the un-insured, often constituting a potential poverty trap. Urban India is particularly vulnerable to this possibility given the greater demand for health, absence of a structured health care system, overburdened public institutions, ubiquitous, and unregulated private health care market and the generic paucity of public funds. Using nationally representative household level data for two points of time and a suitable alteration of an existing methodology, this article computes the degree and depth of impoverishment from out of pocket medical expenses, and its variation across states and select socioeconomic characteristics. Roughly 6 percent of the urban population or about 18 million people face impoverishment entirely due to out of pocket medical expenses in India. There are substantial inter-state and inter-group variations in the incidence of this burden. The findings are potentially crucial as India prepares to embark on its journey toward universal health coverage.
... An EHP should focus on regular supply and access to medicines and diagnostic services. In India more than 70 per cent of total out-of-pocket expenditure is on medicine and diagnostics (11) resulting in barriers to access-to health services and ultimately delayed treatment leading to catastrophic health expenditures. There is evidence from states like Tamil Nadu, Kerala and Rajasthan that have established best practices in procurement and supply of medicines in public health facilities. ...
... Among the household characteristics, the result shows that the household size had a positive association with catastrophic payment but the association is very weak across the thresholds. The study also reveals that the people who lived in rural areas are most likely to incur catastrophic expenditure on healthcare than their urban counterpart (Garg et al. 2005). The probability of incurring catastrophic payment in the rural areas has increased from 1.7 to 2.5 from lowest to highest cut-off levels. ...
... The dominant role of household's socioeconomic level in shaping health-seeking behaviour of the disadvantaged groups is reiterated in this thesis, supporting the conviction that improving health is contingent upon reducing poverty (Braveman and Gruskin 2003). Reducing poverty through specific targeting of the disadvantaged groups with a pro-poor health system i.e., a health system accessible irrespective of the ability or willingness to pay and responsive to their needs and priorities, in a country with large out-of-pocket payments for healthcare is possible (Garg and Karan 2005), and is urgently needed in Bangladesh. ...
... It also aggravates poverty in an already constrained household and leads to severe medical consequences because patients might forgo vital treatment because of unaffordability. Because it consumes the largest portion of households' health-related expenditure, out-of-pocket expenditure on medicines will have the highest effect, especially on poor households [6][7][8][9][10]. ...
Background
The Ethiopian health care system is under tremendous reform. One of the issues high on the agenda is health care financing. In an effort to protect citizens from catastrophic effects of the clearly high share of out-of-pocket expenditure, the government is currently working to introduce health insurance.
Objective
This article aims to highlight the components of the Ethiopian health care financing reform and discuss its implications on access to essential medicines.
Methods
A desk review of government policy documents and proclamations was done. Moreover, a review of the scientific literature was done via PubMed and search of other local journals not indexed in PubMed.
Results
Revenue retention by health facilities, systematizing the fee waiver system, standardizing exemption services, outsourcing of nonclinical services, user fee setting and revision, initiation of compulsory health insurance (community-based health insurance and social health insurance), establishment of a private wing in public hospitals, and health facility autonomy were the main components of the health care financing reform in Ethiopia. Although limited, the evidence shows that there is increased health care utilization, access to medicines, and quality of services as a result of the reforms.
Conclusions
Encouraging progress has been made in the implementation of health care financing reforms in Ethiopia. However, there is shortage of evidence on the effect of the health care financing reforms on access to essential medicines in the country. Thus, a clear need exists for well-organized research on the issue.
... The health spending as a percentage of household consumption expenditure is computed to understand the relative differences in health spending of elderly and non-elderly households. In literature, when the health care spending exceeds some fixed proportion of total household expenditure (threshold limit of 5–10 % of total household budget), the health spending is termed as catastrophic ( Doorslaer 2003, Garg and Karan 2005). Researchers also define catastrophic health spending as 40 % of household's capacity to pay, where the minimum consumption expenditure is deducted from total household expenditure (Xu 2005). ...
Using the consumption expenditure data, National Sample Survey, 2009–2010,
this paper test the hypothesis that the monthly per capita household health spending of
elderly households is significantly higher than non-elderly households in India. The
households are classified into three mutually exclusive groups; households with only
elderly members (elderly households), households with elderly and non-elderly members
and households without any elderly member. The health spending include the institutional
(hospitalization) and non-institutional health expenditure of the households, standardized
for 30 days. Descriptive statistics and a two part model are used to understand the differentials
in health expenditures across households. Results indicate that the monthly per
capita health spending increases with economic status, occupation, age and educational
attainment of the head of the household. The monthly per capita health spending of elderly
households is 3.8 times higher than that of non-elderly households. While the health
spending accounts 13 % of total consumption expenditure for elderly households, it was
7 % among households with elderly and non-elderly members, and 5 % among non-elderly
households. Controlling for socio-economic and demographic correlates, the per-capita
household health spending among elderly households and among household with elderly and non-elderly members was significantly higher than non-elderly households. The health
expenditure is catastrophic for poorer households, casual labourer and households with
elderly members. Based on the finding we suggest to increased access to health insurance
and public spending on geriatric care to reduce the out-of-pocket expenditure on health
care in India.
Keywords Out-of-pocket expenditure � Elderly � Non-elderly � Health care � India
... The estimate for 1999-2000 was that 3.25% of the total population, or approximately 32.5 million people, plunged into poverty because of health care payments. This figure does not include those who were already poor and have plunged into deeper poverty and also confirms that high expenditures on drugs are one of the main reasons for high OOP payments (9). Various kinds of indirect costs such as days, wages, or income lost are not taken into account as part of OOP costs. ...
In Bangladesh, illness results in large out-of-pocket health care expenditures for households. Identifying the components associated with health care expenditures should prove meaningful for future policy formulation in Bangladesh. Thus, the objective of the study was to investigate the overall influence of individual health care costs over data space in a probalistic way using Principal Component Analysis for expenditures incurred due to a recent illness. The study is based on secondary data of the Household Income and Expenditure Survey conducted in 2005 by the Bangladesh Bureau of Statistics. This survey is a nationally representative survey in Bangladesh and its sample includes 8,126 individuals who have incurred health care expenditures in the 30 days prior to the survey. Principal Component Analysis was used to analyze the influence of the factors of health care expenditures in Bangladesh. According to results, 58% of the information on the overall data space confirmed that the cost of medicine is greater than any other factor for health care expenditures. Drug-related health expenditures represented a large component and suggest the need for policies promoting the rational use of drugs. If such strategies are considered and implemented in operational stages, the quality of health care should improve and drug expenditures should substantially decrease.
... National health accounts show that 72% of all health expenditure is made by individual households [1] which is one of the highest proportions in the world [2]. Estimates from con- sumer expenditure surveys show that an Indian house- hold spends an average of 5% of its total expenditure on health care [3]. ...
... However, the high degree of health inequity existing in Bangladesh (Gwatkin et al. 2000) demands the restructuring and reorientation of the existing health system to improve its ability to reach the poor and the disadvantaged. Reducing poverty through specific targeting of disadvantaged groups with a pro-poor health system is possible in a country with large out-of-pocket payments for health care (Garg and Karan 2005), and is urgently needed in Bangladesh. ...
In Bangladesh, there is a lack of knowledge about the large body of informal sector practitioners, who are the major providers of health care to the poor, especially in rural areas, knowledge which is essential for designing a need-based, pro-poor health system. This paper addresses this gap by presenting descriptive data on their professional background including knowledge and practices on common illnesses and conditions from a nationwide, population-based health-care provider survey undertaken in 2007. The traditional healers (43%), traditional birth attendants (TBAs, 22%), and unqualified allopathic providers (village doctors and drug sellers, 16%) emerged as major providers in the health care scenario of Bangladesh. Community health workers (CHWs) comprised about 7% of the providers. The TBAs/traditional healers had <5 years of schooling on average compared with 10 years for the others. The TBAs/traditional healers were professionally more experienced (average 18 years) than the unqualified allopaths (average 12 years) and CHWs (average 8 years). Their main routes of entry into the profession were apprenticeship and inheritance (traditional healers, TBAs, drug sellers), and short training (village doctors) of few weeks to a few months from semi-formal, unregulated private institutions. Their professional knowledge base was not at a level necessary for providing basic curative services with minimum acceptable quality of care. The CHWs trained by the NGOs (46%) were relatively better in the rational use of drugs (e.g. use of antibiotics) than the unqualified allopathic providers. It is essential that the public sector, instead of ignoring, recognize the importance of the informal providers for the health care of the poor. Consequently, their capacity should be developed through training, supportive supervision and regulatory measures so as to accommodate them in the mainstream health system until constraints on the supply of qualified and motivated health care providers into the system can be alleviated.
... Limited access to formal health insurance (less than 10%) results in 75% of health spending being financed through out-of-pocket payments. The EQUITAP studies on India report similar estimates of OOP share, a high incidence of catastrophic payments and pronounced poverty impact of such payments on households [23,30]. ...
The lack of formal health insurance and inadequate social safety nets cause families in most low-income countries to finance health spending through out-of-pocket (OOP) payments, leaving poor families unable to insure their consumption during periods of major illnesses.
To examine how well the Indian healthcare system protects households of differing living standards against the financial consequences of unanticipated health shocks.
The data are drawn from the 52nd round of National Sample Survey, a nationally representative socioeconomic and health survey conducted in 1995-1996. The sample comprises 24,379 (3.84%) households where a member was hospitalized during the 1-year reference period.
We estimate, using ordinary least squares, the relationship between household consumption (proxy for ability to pay) and OOP payments for hospitalization. We also estimate the relationship between consumption and OOP share in consumption.
Our results indicate that both utilization (payments) and the consequent financial burden (payment share) increases with increasing ability to pay (ATP). While this relationship is retained across the different subgroups (e.g., gender, social code, region, etc.), comparisons across groups indicate horizontal inequities including differences in both degrees of progressivity and the redistributive effect.
The finding that OOP payments do not decline with ATP could be an indication of: (1) the lack of insurance which implies that the better-off must pay from OOP to secure quality health care and (2) the absence of risk-pooling or prepayments mechanisms which poses financial impediments to the consumption of health care by the poor.
... National health accounts show that 72% of all health expenditure is made by individual households [1] which is one of the highest proportions in the world [2] . Estimates from consumer expenditure surveys show that an Indian household spends an average of 5% of its total expenditure on health care [3]. Contrary to most other consumption expenses, medical expenditure is largely unpredictable both in timing and quantity. ...
More than 72% of health expenditure in India is financed by individual households at the time of illness through out-of-pocket payments. This is a highly regressive way of financing health care and sometimes leads to impoverishment. Health insurance is recommended as a measure to protect households from such catastrophic health expenditure (CHE). We studied two Indian community health insurance (CHI) schemes, ACCORD and SEWA, to determine whether insured households are protected from CHE.
ACCORD provides health insurance cover for the indigenous population, living in Gudalur, Tamil Nadu. SEWA provides insurance cover for self employed women in the state of Gujarat. Both cover hospitalisation expenses, but only upto a maximum limit of US$23 and US$45, respectively. We reviewed the insurance claims registers in both schemes and identified patients who were hospitalised during the period 01/04/2003 to 31/03/2004. Details of their diagnoses, places and costs of treatment and self-reported annual incomes were obtained. There is no single definition of CHE and none of these have been validated. For this research, we used the following definition; "annual hospital expenditure greater than 10% of annual income," to identify those who experienced CHE.
There were a total of 683 and 3152 hospital admissions at ACCORD and SEWA, respectively. In the absence of the CHI scheme, all of the patients at ACCORD and SEWA would have had to pay OOP for their hospitalisation. With the CHI scheme, 67% and 34% of patients did not have to make any out-of-pocket (OOP) payment for their hospital expenses at ACCORD and SEWA, respectively. Both CHI schemes halved the number of households that would have experienced CHE by covering hospital costs. However, despite this, 4% and 23% of households with admissions still experienced CHE at ACCORD and SEWA, respectively. This was related to the following conditions: low annual income, benefit packages with low maximum limits, exclusion of some conditions from the benefit package, and use of the private sector for admissions.
CHI appears to be effective at halving the incidence of CHE among hospitalised patients. This protection could be further enhanced by improving the design of the CHI schemes, especially by increasing the upper limits of benefit packages, minimising exclusions and controlling costs.
Caste in Sri Lanka
An examination of the role of Buddhism and democracy,
two supposedly egalitarian institutions, in encouraging
the perpetuation of caste-based differentiation among
the Sinhalese
Focus on healthcare patterns and their determinants among the urban poor is crucial in order to move towards universal health coverage. However, published literature on these aspects in India is scarce. This study was undertaken to estimate out-of-pocket healthcare expenditures and resultant catastrophic health expenditure rates among the urban poor. It has been found that CHE rates are significantly higher among males, illiterates, older age groups, those hospitalised at private facilities and those reporting non-communicable diseases as the reason for hospitalisation.
Migration has emerged as an important issue in contemporary global politics and in the discourse around human development. This book highlights the role of migration in socioeconomic development and its interdependence with urbanization, employment, labour and industry. This volume identifies the challenges which migration and the subsequent dynamism in population and spatial parameters pose to land-use patterns, ecology, social politics and international relations. Through a study of migration patterns and trends in different parts of India, this collection analyzes the relationship of migration with social and occupational mobility, poverty and wealth indices, inequality, distribution of resources and demographic change. It also explores policy measures and frameworks which can bring migration into the fold of national development strategies. Timely and comprehensive, the book underscores the importance of migration and urbanization, sustainability and inclusivity to economic growth and development. It will be an essential read for scholars and researchers of migration studies, political studies, sociology, urban studies, development studies and political sociology.
Introduction
In this paper, we present district level out‐of‐pocket (OOP) expenditures with respect to outpatient consultation within last 15 days and hospitalization in last 1 year for Haryana state.
Methods
The data from a large cross‐sectional household survey covering all 21 districts of Haryana comprising of randomly selected 79 742 households were analyzed. Of the total sample, 56 056 households consisting of 314 639 individuals in 21 districts of Haryana state were surveyed to gather information on OOP expenditure incurred on outpatient consultation within last 15 days. Similarly, 59 901 households and 324 977 respondents were interviewed to elicit OOP expenditures for any hospitalization during the 1 year preceding the survey. Mean OOP expenditure per OP consultation, per hospitalization as well as per capita were computed. Mean OOP expenditure was also estimated by the type of provider, gender, and district.
Results
The mean OOP expenditure for OP consultation and hospitalization in Haryana was Indian National Rupees (INR) 1005 (US Dollar [USD] 16.1; 95% CI: INR 934‐1076) and INR 22 489 (USD 360.0; 95% CI: INR 21 375‐23 608), respectively. Mean per capita OOP expenditure for OP consultation, which was INR 85 (USD 1.3) in Haryana, varied from INR 595 (USD 9.5) in district Panipat to INR 29 (USD 0.5) in district Kaithal.
Conclusion
This is the first study to comprehensively present district level estimates for OOP expenditure for health care. These estimates are useful for policy planning, and preparation for district and state health accounts.
Health status of the population is one of the significant indicators of social and economic well-being. Government of India has tried to ensure the highest possible health status of India’s population and access to quality health care through a number of policy documents. Improved overall health status and socioeconomic pressures have resulted in changes in the demographic profile. The type of health-care service requirement has changed due to the rise of lifestyle-related diseases and communicable diseases. It is also crucially relevant that maternal and infant mortality continue to remain unacceptably high in several parts of the country. States like Kerala have performed well and “Kerala Model Health System” is often viewed as a rare combination of higher order human development and not so noticeable pattern of consistent exponential economic growth. However, the well-known “Kerala Model Health System” has been facing a crisis due to the demographic transition in Kerala and it is reflected in its patterns of morbidity and hospitalization. Bihar, on the other hand, has low longevity and performs poor in terms of medical and educational facilities, and it has the lowest rates of reported morbidity. At this context, this article tries to assess the socioeconomic determinants of morbidity and hospitalization in the states of Kerala and Bihar.
This article explores the issue of demand for health care and medicines in India where household share of total health expenditure is one of the highest among high- and low-income countries. Previous work found that important determinants include health status, socio-demographics, income and demand for care was inelastic. Compared with previous studies, this article uses large household data sets including data on medicine expenditure to explore health-seeking behaviour. Count models find that determinants include health status, socio-demographic information, health insurance, household expenditure and government regulation. Elasticities range from −0.13 to 0.03 and are generally consistent with literature findings. For inpatient care, conditional on having at least one hospitalization, the expected number of hospitalizations increases with being male and household expenditure. Medicine expenditure accounts for a large share of household health expenditure. Low-income individuals could experience problems and raises important policy implications on the demand and supply side to improve access to health care and medicines for patients in India.
Examining panel data for more than 13,000 rural Indian households over the 12-year period 1993-94 to 2004-05 confirms on a large scale what grassroots studies have identified before: two parallel and opposite flows regularly reconfigure the national stock of poverty. Some formerly poor people have escaped poverty; concurrently, some formerly non-poor people have fallen into the pool of poverty. These inward and outward flows are asymmetric in terms of reasons. One set of reasons is associated with the flow into poverty, but a different set of reasons has helped raise households out of poverty. Both sets of reasons vary considerably across and within states. Not a single factor matters consistently across all states of India. Any standardised national policy is thus largely irrelevant. Diverse threats operate and different opportunities exist that must be identified and tackled at the sub-national level.This paper was presented at the Chronic Poverty Research Centre International Conference on ‘Ten Years of “War against Poverty”: What have we learned since 2000 and what we should do 2010-2020?’ Manchester, UK, 8-10 September 2010.
This paper provides an analysis of the utilisation of formal health care and out-ofpocket
(OOP) payments in rural areas of Bangladesh. The broader focus of the
investigation is to gauge how far Bangladesh has to traverse to achieve universal
health coverage (UHC). We used the data from the baseline survey (conducted in
diversifi ed geographical locations on about 4,000 households) of a longitudinal
research project (entitled Microinsurance, Poverty and Vulnerability) of the Institute
of Microfi nance (InM). The study fi nds that over 12-month period, only 40 per
cent of the 6,352 sick individuals utilised formal health care. The poor and the
children are the most deprived section in the utilisation. Out-of-pocket expenses
per affected household during 12 months preceding the survey was BDT 4,686,
which accounted for about 6 per cent of the total household expenditure. Drug, the
single largest component of the OOP category, accounts for about 60 per cent of
the direct OOP expenditure. The incidence of catastrophic expenditure was 15 per
cent at the 10-per cent threshold level. In about 33 and 41 per cent of the cases,
households needed to borrow or deplete assets for coping with inpatient care and
catastrophic illnesses, respectively. Poor effective access to formal healthcare and
high OOP expenditure indicate that Bangladesh has major challenges to overcome
in achieving the universal health coverage. Membership in Grameen Kalyan micro
health insurance scheme, essentially a discounted basic care package, has
a signifi cant association with the likelihood of using formal health care, though
access to microcredit appear not to relieve households of the need to search for
additional funds to cope with catastrophic events. An obvious suggestion is to
introduce a risk-sharing mechanism (e.g., micro health insurance) to pool funds
for the provision of health care in rural areas. Awareness building on the value of
professional medical advice and measures targeted at effective regulation of the
prices of essential drugs and restricting the sales of over-the-counter drugs are
also put forward as elements of a sound public health policy framework.
Key words: Health care seeking behaviour, out-of-pocket payments, catastrophic
illness, Bangladesh.
JEL Classifi cation: G22, J44, I12, H51, H52, H53, and H75.
Urban residents in India face important health problems due to unhygienic conditions, excessive crowding and lack of proper sanitation. The private sector has started occupying the centre stage of the health system and households are burdened with increasing levels of health expenditure. This paper aims to study out-of-pocket expenditure (OOPE) and the extent of catastrophic payments for health care among households in a highly urbanised state, Tamil Nadu. The study used data on morbidity and health care for the year 2004 collected by the National Sample Survey Organization, India. Care was sought for 84 per cent of illness episodes in urban areas, and the majority used private sector providers (67 per cent for inpatients and 78 per cent for outpatients). Mean OOPE for inpatients and outpatients was higher for households with higher income. The average cost burden per visit was higher among those who sought care from private providers for inpatient services (29 per cent of household consumption expenditure) and outpatient services (20% of household consumption expenditure) compared with the burden associated with public health service use (3-4 per cent of consumption expenditure). About 60 per cent of households which used private health services faced catastrophic payments at the 10 per cent threshold level. To avoid catastrophic expenditure, greater use of the public sector which is providing services at an affordable cost is needed. Improving access to public health services, better gate-keeping systems, stronger controls on drug prices and increasing the quality of services are required to reduce the incidence of catastrophic expenditure both on inpatients and outpatients. Greater use of risk pooling mechanisms would encourage the poor to seek health care and also to protect households from all socio-economic groups from catastrophic expenditure. Copyright © 2009 John Wiley & Sons, Ltd.
Examining panel data for more than 13,000 rural Indian households over the 12-year period 1993–94 to 2004–05 shows that two parallel and opposite flows regularly reconfigure the national stock of poverty. Some formerly poor people have escaped poverty; concurrently, some formerly non-poor people have fallen into poverty. These simultaneous inward and outward flows are asymmetric in terms of reasons. One set of reasons is associated with the flow into poverty, but a different set of reasons is associated with the flow out of poverty. Both sets of reasons vary considerably across and within states. No factor matters consistently across all states of India. Standardized national policies do not represent the best use of available resources. Diverse threats and different opportunities must be identified and tackled at the sub-national level.
The purpose of this study was to generate data regarding the drug utilization pattern in pediatric population of our tertiary care hospital so that we could generate an essential medicine list (EML).
Drug therapy accounts for a major portion of expenditure toward health care. Reduction in health care cost for an individual can be achieved by lowering the cost of drug treatment.
This was an observational study conducted in the Advanced Pediatric Centre of our hospital, during which prescriptions and case records were reviewed.
During the study a total of 891 prescriptions were reviewed. Antibiotics and nutritional supplements were the major drugs prescribed. A large percentage of drugs were prescribed as trade names. Eighty three per cent of the drugs were prescribed from the National List Of Essential Medicine 2003 (India). Antibiotics accounted for the major bulk of cost of drugs, most of which were purchased by the patients.
Restricted use of newer antibiotics, branded drugs and prescribing from the EML could be considered as targets for reduction of cost of therapy.
This is the second part of the special section, edited by Professors Margaret Whitehead and Göran Dahlgren, on the equity impacts of different health care systems, which includes studies conducted within the framework of the Affordability Ladder Program.
In the early 1990s, India embarked upon a course of health sector reform, the impact of which on an already unequal society is now becoming more apparent. This study sought to deepen understanding of equity effects by exploring gender and class dynamics vis-à-vis basic access to health care for self-reported long-term ailments. The authors drew on the results of a cross-sectional household survey in a poor agrarian region of south India to test whether gender bias in treatment-seeking is class-neutral and whether class bias is gender-neutral. They found evidence of “pure gender bias” in non-treatment operating against both non-poor and poor women, and evidence of “rationing bias” in discontinued treatment operating against poor women overall, but with some differences between the poor and poorest households. In poor households, men insulated themselves and passed the entire burden of rationing onto women; but among the poorest, men, like women, were forced to curtail treatment. There were economic class differences in continued, discontinued, and no treatment, but class was a gendered phenomenon operating through women, not men.
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