In India, the proportion of households with more than 10% OOPE for healthcare has increased more than two times during 2004–2014(16). OOP payment is a major portion of total health expenditure in India as public investment in healthcare is the lowest. The goal of National Health Policy 2017 was to achieve significant reduction in OOP payments, catastrophic health expenditure and impoverishment due to health expenditure (17). This study was conducted to find out impact of socioeconomic, demographic and educational factors on OOPE and distribution of OOPE among various components of healthcare services and diseases among the households of Pune districts of Maharashtra State of India. Pune district was selected as it resembles mixed strata of urban, urban slum, and rural population of different demographic as well as socioeconomic characteristics.
Findings of the study were as follows OOPE was higher in urban slum and rural households as well as households headed by males. Also OOPE was higher with 18–25 years of age group and households above 60 years of age. Unmarried, highly educated individuals, households with more earning members, less dependent members, more gross monthly income also opt for higher OOPE. The higher incidence of OOPE in the above groups could be because of lack of access to public funded health facility for appropriate treatment, less awareness about available health financing options, negative perception towards quality of public healthcare services and comparatively good quality of services provided at private hospitals(1, 2, 18–22). In urban slum and rural areas people ignore small health issues to avoid expenditure(1, 2, 22)and they seek help when problem becomes severe; also they have limited options available and known to them. In case of emergency, access to services in public hospitals is difficult due to long waiting time and at the same point of time poor quality of care, lack of infrastructure forcing them to opt for private organization that increases OOPE(23–25). On the other hand OOPE is higher among households managed by males and between 18–25 years age households, which may be due to more economic resources with better physical access which further increases utilization(16). Whereas among households above 60 years of age, OOPE increases as healthcare needs, dependency on medication increases with age, also working capacity of this age group decreases which adds to the economic burden, they also lose their employer insurance cover post retirement and personal insurance premiums become expensive with increasing age.(16, 26–29)
Availability of resources and more preferences to private healthcare facilities (16, 20)could be the reason for increased OOPE among the educated households, households with more earning members, households with more monthly income, households with less dependent members. Urbanization, industrialization and increased life expectancy have increased the prevalence of NCDs in India in the coming years.(30) According to National Health Accounts estimates (2014-15), households in India face high financial burden with 62.5% OOP payment of total health expenditure, which is due to high cost of treatment of NCDs.(31) Kastor A et al had suggested that the disease pattern has a direct link with the volume and type of health services needed which subsequently has an impact on the health expenditure.(29) As per this study chronic diseases top the list when it comes to OOPE followed by acute diseases. Collective study conducted by Public health foundation of India and Institute Of Health Metrics And Evaluation in various states had shown that the treatment cost for NCDs is usually high in India(32)which may be due to much of the care for NCDs is provided in the private sector.(20, 30) As per the gross expenditure it was found that highest expenditure was on medicine purchase. According to the report of WHO, around 68% of Indian population has limited or no access to essential medicines. (33)Also availability of free medicine in public health facilities has declined in India from 31.2–8.9% for inpatient care and from 17.8–5.9% for outpatient care (34) and medicine purchase alone constitutes 70% of overall OOP payments.(35) The results of our study are also consistent with these findings.
The findings of this study suggest that various factors affect OOPE so public health expenditure should be increased to improving the competence of healthcare facility. Government should facilitate establishment of charitable trust based health facilities across the rural & urban slum area, increasing corporate social responsibility (CSR) funded mobile clinic or government supported or sponsored mohalla clinic and maintain supply of essential and generic medicine may reduce OOPE.
Our study captured the determinants and distribution of OOPE among households of Pune district. However, the study has some limitations. Sample size is small; details of expenditure are recorded in terms of percentage. Respondents are not children and details of expenditure were recorded against whole household not against each member of household in this study so in-depth evaluation as per family member was not possible in this study. Additionally, it is of course possible for some people not to have incurred OOP expenditures not because they were not in need of health services, but because they were not able to afford them; assessing this phenomenon was not possible with the current dataset and remains a task for future research.