A study on health care utilization and out of pocket expenditure in rural central India: A cross-sectional study

Introduction

Universal access to high-quality healthcare services is available to everyone in the community, including promotive, preventive, curative, rehabilitative, palliative services, and mental impairment in people without any financial difficulties.^1,2 The High-Level Expert Group (HLEG) on Universal Health Coverage proposes the performance of a “National Health Package,” encompassing comprehensive health services that will be provided to every individual free of cost.³ Appropriate planning and implementation of healthcare services requires reliable data on trends in morbidity and mortality, also trends in the utilization of healthcare facilities are considered. The socioeconomic status of the population depends on the healthcare utilization services, the disease severity, and the availability, accessibility, and affordability of healthcare services.⁴ The National Health Accounts (2016) in India households that contribute 64.2% of the Total Health Expenditure (THE) through out-of-pocket payments. Although the burden of out-of-pocket expenditure (OOPE) decreased from the 2004 to 2005 estimate (comprising 71% of the total health expenditure), it remains unsatisfactorily high.⁵

Globally, the primary objective of healthcare systems is to establish suitable funding mechanisms, ensuring individuals can access preventive and curative health services without falling into poverty.⁶

The reason for the health system is to enhance access to healthcare and utilization of resources by making them more affordable and to distribute the cost of healthcare services among every individual in a risk pool to decrease the economic burden of illness. however, the insurance penetration rate remains low in India, attributed to either a lack of knowledge or the functional status of the existing health insurance schemes.⁷

The Sustainable Development Goals (SDGs) were completed in September 2015, expanded, and build upon the Millennium Development Goals (MDGs) by incorporating updated targets. Derived from the principle of “leaving no one behind,” the Sustainable Development Goals (SDGs) consist of 17 goals and 169 targets. There are 17 goals in total, with Goal No. 3 specifically dedicated to health. SDG 3 comprises 13 targets, three initiatives are dedicated to improving maternal and child health, while another three focus on addressing both communicable and non-communicable diseases as well as addiction. Additionally, two initiatives target environmental health, and one aims to achieve Universal Health Coverage (UHC). The remaining four objectives encompass the implementation of tobacco control policies, vaccination and medication strategies, health financing, workforce development, and preparedness for global health risks.⁸

In India, health-related public expenditure is managed by three tiers of the government: the Central Government, the State Government, and the local bodies.⁹ Although government businesses and insurance providers are major healthcare funding agencies, each family and individual covers each of the healthcare expenses that can be incurred through OOP payments, insurance premiums, or government taxes.⁴ In India, Gross Domestic Product (GDP) spends only 5% on health and 80% of this takes the form of OOPE in rural areas. Also, rural households designated 3.31% (ranging from 0.4% to 10.96%) of their household budget for out-of-pocket expenditure, which is high in rural areas.^3,5 In a prior investigation examining estimates on worldwide catastrophic spending and out-of-pocket (OOP) payments, it was found that around 150 million individuals experience a financial burden annually due to healthcare expenses. Additionally, approximately 100 million individuals fall into poverty as an outcome of OOP payments.⁶

Chronic health conditions have increased globally as a result of an unequaled increase in risk factors for non-communicable diseases (NCDs). The interaction and tendency to cluster among these NCDs result in the occurrence of comorbidity (the simultaneous presence of two or more NCDs), without a distinct primary index disease. The circumstances in middle-class and low-income nations are comparable. A systematic review revealed that the incidence of comorbidity in South Asia ranges between 4.5% and 83%. The analysis also indicated that the most frequently reported outcomes were decreased physical functioning and increased healthcare. Moreover, in developing Nations, healthcare is predominantly funded through OOP payments, and households facing a significant limitation on their scheme.¹⁰

Rationale

The previous study indicated that the median total OOPE for incurable diseases was determined to amount to 5000 Indian Rupees. Additionally, it was noted that 41.6% of the participants’ overall earnings were allocated to healthcare expenses related to chronic diseases. This percentage suggests a situation of catastrophic health expenditure. Notably, health insurance coverage remains at a low level, and the utilization of social assistance for treatment is minimal.⁹

This study will be conducted because in-patient and out-patient care are associated with the highest out-of-pocket expenditure and less information about healthcare utilization patterns. Only 20 percent of households in Maharashtra have any kind of health insurance that covers at least one member of the household. This study will also fill the knowledge gap in Maharashtra people who are unaware of healthcare utilization patterns and OOPE in rural areas.

Method

Discussion

Harish et al. (2020) have done a cross-sectional in Kerala. The goal of the study is to find the health insurance coverage and its impact on out-of-pocket (OOP) expenditure in rural areas. Health insurance coverage was determined to be 74%. A quarter of patients lack insurance coverage. While all patients face out-of-pocket (OOP) expenses, insured individuals notably incur lower OOP costs.⁷

Dalal K et al. (2017) This study was conducted a household survey in Cambodia. This analysis explores the household impacts of out-of-pocket (OOP) healthcare payments, focusing on their catastrophic, economic, and fairness aspects. The finding indicated inequality and unfairness in healthcare payments, with a higher prevalence of catastrophic spending among the impoverished.⁶

Vasudevan et al. (2019): A cross-sectional study was conducted in Puducherry. To assess the percentage of households incurring out-of-pocket expenses and the mean expenditure per household on healthcare. The study included 240 households, evenly divided between 120 rural and 120 urban. According to this study, the prevalence of households incurring out-of-pocket healthcare expenses was 68.3% in rural areas, while in urban areas, it was 65.8% (ranging from 57% to 73.7%).⁵

Mathumkunnath Vijayan et al. (2020) performed a cross-sectional study in Thrissur district of Kerala. The goal of the study is to understand the patterns of healthcare utilization patterns and out-of-pocket expenditures that are crucial for healthcare policy-making. 26.6% of the study participants had obtained health insurance. Health insurance coverage is minimal, and the utilization of community assistance for treatment is limited. These factors result in high OOP expenses, reaching the level of catastrophic health expenditures.⁹

Thuong et al. (2020) Household Living Standard Surveys in Vietnam is a Southeast Asian. To investigate the effect of these health insurance initiatives on the utilization of healthcare facilities and out-of-pocket health expenditures (OOP). We establish that Health insurance has raised the expectation of seeking outpatient care, the overall total outpatient visits, total visit count, and the mean number of visits at the district level of healthcare providers. The health insurance scheme increased the healthcare utilization services and concurrently reduced out-of-pocket expenses for the participants.²

In 2022 Karan et al., the National Sample Survey Organization (NSSO) 75th round was organized. This study aims to produce current evidence regarding the economic implications of comorbidity on households, particularly regarding OOPE, and their consequences on experiencing catastrophic out-of-pocket expenditure. The findings of this study indicated that the outpatient OOPE is consistently lower when comorbidity is present, in comparison to situations involving single conditions. This study concludes that, the multimorbidity results in elevated and catastrophic out-of-pocket payments by households.¹⁰

Felix Masiye (2016) a cross-sectional dataset from the Zambian Household Health Expenditure and Utilisation Survey (ZHHEUS). To investigate the factors associated with healthcare choices among individuals who are ill. The conclusion drawn from this study the population’s access to healthcare is strongly influenced by their socio-economic status, type of illness, and region of residence.¹¹