OUT-OF-POCKET AND CATASTROPHIC HEALTH EXPENDITURE: A CROSS-SECTIONAL ASSESSMENT OF A RURAL DISTRICT OF THE STATE OF JHARKHAND IN INDIA

Background: India aims at providing universal health coverage, at least at the primary health care level to make quality health care affordable and accessible. An elaborate system of public health is in place, yet in India, out-of-pocket health expenditure constitutes a major source of health care finance for the households, often leading to catastrophic consequences.

Methods: The study aimed at examining the recent pattern of out-of-pocket health expenditure for in-patient and out-patient care using the primary data collected from 986 households in Koderma district of Jharkhand state in India. A multi-staged sampling method was followed to select households with cases of in-patient care and child birth in the last one year and cases of out-patient care in the last 30 days. Cost components for both in-patient and out-patient care were disaggregated for both public and private health care services to understand the burden of costs for different components. Data was also collected on how the families financed these expenses and whether there were catastrophic headcounts from out of pocket financing. The reach and effectiveness of government health insurance programs to cushion against catastrophic expenses was also examined.

Findings: The study found that 71 percent families faced catastrophic situation (medical expense exceeding 40% of all household’s non-food expenses, as per WHO definition) for inpatient care. This situation was more noticeable in cases where services of private health care (includes private doctors, nursing homes, private clinics, hospitals run by private agencies, trust or charitable organisations, but excludes informal providers like unlicensed informal practitioners) was availed, where the cost was more than double of that in public facilities (includes any health facility run by government). Yet 73 percent of the total out-patient cases and 90 percent of the total in-patient cases were availed from private health facilities. Treatments in private health care facilities exclude cases treated by the informal providers.

It was also seen that the cost of drugs constituted more than half of the total out-of-pocket health expenditure. The penetration of any health insurance including the publicly financed health insurance policy was found to be negligible (35 out of 986 families) and even those households enrolled in any of the health insurance policy and incurring out-of-pocket health expenditure for in-patient care did not get any financial benefit from such policies. The burden of out-of-pocket expenditure on out-patient care was also found to be very high and catastrophic in nature and for which there was no insurance coverage. The high proportion of such out-of-pocket health expenditure is regressive in nature knowing that a very high proportion of the households in rural or semi urban settings are poor.

Conclusions: In this backdrop there is an urgent need for increasing public expenditure on health care and stronger and effective regulatory mechanisms to make quality health care affordable and accessible to all, particularly the poorest and most vulnerable sections.