Socioeconomic inequality in life expectancy in India.

INTRODUCTION: Concern for health inequalities is an important driver of health policy in India; however, much of the empirical evidence regarding health inequalities in the country is piecemeal focusing only on specific diseases or on access to particular treatments. This study estimates inequalities in health across the whole life course for the entire Indian population. These estimates are used to calculate the socioeconomic disparities in life expectancy at birth in the population. METHODS: Population mortality data from the Indian Sample Registration System were combined with data on mortality rates by wealth quintile from the National Family Health Survey to calculate wealth quintile specific mortality rates. Results were calculated separately for males and females as well as for urban and rural populations. Life tables were constructed for each subpopulation and used to calculate distributions of life expectancy at birth by wealth quintile. Absolute gap and relative gap indices of inequality were used to quantify the health disparity in terms of life expectancy at birth between the richest and poorest fifths of households. RESULTS: Life expectancy at birth was 65.1 years for the poorest fifth of households in India as compared with 72.7 years for the richest fifth of households. This constituted an absolute gap of 7.6 years and a relative gap of 11.7 %. Women had both higher life expectancy at birth and narrower wealth-related disparities in life expectancy than men. Life expectancy at birth was higher across the wealth distribution in urban households as compared with rural households with inequalities in life expectancy widest for men living in urban areas and narrowest for women living in urban areas. CONCLUSION: As India progresses towards Universal Health Coverage, the baseline social distributions of health estimated in this study will allow policy makers to target and monitor the health equity impacts of health policies introduced.

Role of insurance in determining utilization of healthcare and financial risk protection in India.

BACKGROUND: Universal health coverage has become a policy goal in most developing economies. We assess the association of health insurance (HI) schemes in general, and RSBY (National Health Insurance Scheme) in particular, on extent and pattern of healthcare utilization. Secondly, we assess the relationship of HI and RSBY on out-of-pocket (OOP) expenditures and financial risk protection (FRP). METHODS: A cross-sectional study was undertaken to interview 62335 individuals among 12,134 households in 8 districts of three states in India i.e. Gujarat, Haryana and Uttar Pradesh (UP). Data on socio-demographic characteristics, assets, education, occupation, consumption expenditure, illness in last 15 days or hospitalization during last 365 days, treatment sought and its OOP expenditure was collected. We computed catastrophic health expenditures (CHE) as indicator for FRP. Hospitalization rate, choice of care provider and CHE were regressed to assess their association with insurance status and type of insurance scheme, after adjusting for other covariates. RESULTS: Mean OOP expenditures for outpatient care among insured and uninsured were INR 961 (USD 16) and INR 840 (USD 14); and INR 32573 (USD 543) and INR 24788 (USD 413) for an episode of hospitalization respectively. The prevalence of CHE for hospitalization was 28% and 26% among the insured and uninsured population respectively. No significant association was observed in multivariate analysis between hospitalization rate, choice of care provider or CHE with insurance status or RSBY in particular. CONCLUSION: Health insurance in its present form does not seem to provide requisite improvement in access to care or financial risk protection.

Inequity & burden of out-of-pocket health spending: District level evidences from India.

BACKGROUND & OBJECTIVES: Numerous studies have highlighted the regressive and immiserating impact of out-of-pocket (OOP) health spending in India. However, most of these studies have explored this issue at the national or up to the State level, with an associated risk of overlooking intra-State diversities in the health system and health-seeking behaviour and their implication on the financial burden of healthcare. This study was aimed to address this issue by analyzing district level diversities in inequity, financial burden and impoverishing impact of OOP health spending. METHODS: A household survey of 62,335 individuals from 12,134 households, covering eight districts across three States, namely Gujarat, Haryana and Rajasthan was conducted during 2014-2015. Other than general household characteristics, the survey collected information on household OOP [sum total of expenditure on doctor consultation, drugs, diagnostic tests etc. on inpatient depatment (IPD), outpatient depatment (OPD) or chronic ailments] and household monthly consumption expenditure [sum total of monthly expenditure on food, clothing, education, healthcare (OOP) and others]. Gini index of consumption expenditure, concentration index and Kakwani index (KI) of progressivity of OOP, catastrophic burden (at 20% threshold) and poverty impact (using district-level poverty thresholds) were computed, for these eight districts using the survey data. The concentration curve (of OOP expenditure) and Lorenz curve (of consumption expenditure) for the eight districts were also drawn. RESULTS: The distribution of OOP was found to be regressive in all the districts, with significant inter-district variations in equity parameters within a State (KI ranges from -0.062 to -0.353). Chhota Udepur, the only tribal district within the sample was found to have the most regressive distribution (KI of -0.353) of OOP. Furthermore, the economic burden of OOP was more pronounced among the rural sample (CB of 19.2% and IM of 8.9%) compared to the urban sample (CB of 9.4% and IM of 3.7%). INTERPRETATION & CONCLUSIONS: The results indicate that greater decentralized planning taking into account district-level health financing patterns could be an effective way to tackle inequity and financial vulnerability emerging out of OOP expenses on healthcare.

Out-of-Pocket Spending on Out-Patient Care in India: Assessment and Options Based on Results from a District Level Survey.

Out-of-pocket spending at out-patient departments (OPD) by households is relatively less analyzed compared to hospitalization expenses in India. This paper provides new evidence on the levels and drivers of expenditure on out-patient care, as well as choice of providers, using household survey data from 8 districts in 3 states of India. Results indicate that the economically vulnerable spend more on OPD as a proportion of per capita consumption expenditure, out-patient care remains overwhelmingly private and switches of providers-while not very prevalent-is mostly towards private providers. A key result is that choice of public providers tend to lower OPD spending significantly. It indicates that an improvement in the overall quality and accessibility of government facilities still remain an important tool that should be considered in the context of financial protection.

Economic burden of malaria in India: The need for effective spending.

About 95%of India's population resides in malaria-endemic areas and, according to government sources, 80%of malaria reported in the country is confined to populations residing in tribal, hilly, difficult and inaccessible areas. Using a nationally representative sample, this study has estimated the economic burden of malaria in India by applying the cost-of-illness approach, using the information on cost of treatment, days lost and earnings foregone, from the National Sample Survey data. A sensitivity analysis was carried out, by presenting two alternative scenarios of deaths. The results indicate that the total economic burden from malaria in India could be around US$ 1940 million. The major burden comes from lost earnings (75%), while 24%comes from treatment costs. Since mortality is low, this is not a major source of economic burden of malaria. An analysis of the trend and patterns in public expenditure by the National Vector Borne Disease Control Programme shows a declining focus of the central government on vector-borne diseases.Also, allocation of financial resources among states does not reflect the burden of malaria, the major vector-borne disease in the country.

Correlates of out-of-pocket spending on health in Nepal: implications for policy.

BACKGROUND: A key objective of universal health coverage is to address inequities in the financial implications of health care. This paper examines the level and trend in out-of-pocket spending (OOPS) on health, and the consequent burden on Nepalese households. METHODS: Using data from the Nepal Living Standard Survey for 1995-1996 and 2010-2011, the paper looks at the inequity of this burden and its changes over time; across ecological zones or belts, development regions, places of residence, or consumption expenditure quintiles; and according to the gender of the head of the household. RESULTS: The average per capita OOPS on health in Nepal increased sevenfold in nominal terms between 1995-1996 and 2010-2011. The share of OOPS in household consumption expenditure also increased during the same period, primarily as a result of higher health spending by poorer households. Thirteen per cent of all households were found to incur catastrophic health expenses in 2010-2011. This proportion of households incurring such expenditure rose between the two time periods most sharply in the Terai belt, eastern region and poorest quintile. CONCLUSION: The health-financing system in Nepal has become regressive over the years, as the share of the bottom two quintiles in the total number of households facing catastrophic burden increased by 14% between the two periods.