We have presented the utilization of healthcare facilities in India in Table-1. The utilization figures are estimated separately for the rural and the urban region. The utilization rate of the patients aged 60 years or above have been compared with the patients of below 60 years of age. For better comparability, we have presented the utilization rate of the 50–59 years age group (approaching ageing) and others age group separately. It has been observed that compared to 2014 hospitalization has decreased in 2017-18 in all the age groups and regions in India. However, decline in hospitalization is sharper among the aged compared to 50–59 years and others age groups. If we study the proportion of population covered under PFHI, we could see that it has decreased among all the age group; however, coverage is much higher among the population aged 60 years and above compared to people of 50–59 years age group. Coverage of PFHI is the lowest for the others age-category in both the regions in India.
Table-1: Publicly Funded Health Insurance & Utilization of Hospitalization Services in India
Indicator
|
Age
|
Rural
|
Urban
|
Combine
|
2017-18
|
2014
|
2017-18
|
2014
|
2017-18
|
2014
|
IP (Per 1000 Population)
|
60 yrs. & above
|
52.7
|
70.4
|
76.1
|
102.1
|
60.4
|
80.3
|
50–59 yrs.
|
25.3
|
33.8
|
31.9
|
47.0
|
27.3
|
37.9
|
Others
|
8.1
|
11.3
|
9.7
|
13.5
|
8.6
|
12.0
|
Total
|
12.9
|
18.0
|
17.3
|
24.0
|
14.2
|
19.8
|
PFHI (Per 1000 Population)
|
60 yrs. & above
|
10.7
|
12.1
|
11.5
|
14.9
|
10.9
|
13.0
|
50–59 yrs.
|
5.1
|
6.7
|
5.5
|
9.8
|
5.2
|
7.7
|
Others
|
1.5
|
2.0
|
1.6
|
2.1
|
1.5
|
2.0
|
Total
|
2.5
|
3.2
|
2.8
|
3.9
|
2.6
|
3.4
|
PFHI (Per 100 IP Cases)
|
60 yrs. & above
|
20.2
|
17.2
|
15.1
|
14.6
|
18.1
|
16.2
|
50–59 yrs.
|
20.0
|
19.9
|
17.3
|
20.9
|
19.0
|
20.3
|
Others
|
18.7
|
17.5
|
16.5
|
15.7
|
18.0
|
16.9
|
Total
|
19.4
|
17.8
|
16.2
|
16.3
|
18.3
|
17.2
|
Source: Author’s estimation based on NSS 71st & 75th round data.
The analysis also shows that the share of PFHI insured patients has increased in hospitalization among the aged in the rural sector. Specifically, in 2017-18 around 20 per cent elderly with PFHI coverage have utilized hospitalization services compared to 17 per cent in 2014. However, share for the 50–59 years age group in hospitalization with PFHI coverage was almost same during the time periods in the rural region. In the urban region on the other hand, this utilization share has decreased among the 50–59 years age group, and it has increased marginally for the aged. For the others category it has decreased in both the regions.
The Table-2 represents the extent of OOPE made by the patients during their hospitalization in the public and private facilities. The estimates are presented separately for patients with PFHI coverage, covered under other insurance category and without any insurance coverage. It has been observed that compared to 2014 the extent of OOPE has increased for the 50–59 years aged patients with PFHI and other insurance coverage in public health facilities of both the rural and urban sector during 2017-18. For the aged, no substantial changes in the extent of OOPE has been observed in the public sector hospitalization in 2017-18 compared to 2014. The trend is same in both rural and urban regions. For the people with PFHI coverage, the rural and urban sector records increase in OOPE for private sector hospitalization except the others age group of the urban region. Others age group of the urban sector has recorded significantly lower OOPE in 2017-18 compared to 2014. Additionally, it has to be mentioned here that irrespective of the insurance coverage and place of residence (rural or urban), the OOPE has decreased for the others age group during public sector hospitalization.
Table-2: Extent of Out-of-pocket Expenditure during Hospitalization in India (in INR)
Year
|
Facility
|
Age
|
Rural
|
Urban
|
PFHI
|
Others
|
Not Covered
|
PFHI
|
Others
|
Not Covered
|
2017-18
|
Public
|
60 yrs. & above
|
2924
|
3374
|
7848
|
3318
|
1765
|
7397
|
50–59 yrs.
|
4147
|
8153
|
5095
|
5004
|
10862
|
6677
|
Others
|
3227
|
10275
|
6189
|
2130
|
4809
|
6381
|
Total
|
3337
|
7132
|
6416
|
3073
|
4730
|
6756
|
Private
|
60 yrs. & above
|
21043
|
28923
|
40507
|
30091
|
43837
|
56923
|
50–59 yrs.
|
22659
|
13363
|
40056
|
29078
|
32394
|
45624
|
Others
|
24603
|
22800
|
32318
|
20677
|
30046
|
38043
|
Total
|
23202
|
22630
|
36066
|
25491
|
36415
|
46097
|
2014
|
Public
|
60 yrs. & above
|
2699
|
8654
|
5752
|
3350
|
5289
|
14878
|
50–59 yrs.
|
3023
|
1246
|
9821
|
2683
|
4129
|
10852
|
Others
|
4626
|
12431
|
8018
|
3493
|
4977
|
14878
|
Total
|
3646
|
10505
|
7700
|
3250
|
7063
|
7973
|
Private
|
60 yrs. & above
|
16620
|
16154
|
30656
|
21790
|
24843
|
51614
|
50–59 yrs.
|
18617
|
24322
|
28610
|
25997
|
20405
|
32309
|
Others
|
20212
|
20377
|
27435
|
22312
|
21226
|
34097
|
Total
|
18939
|
20139
|
28684
|
22987
|
22301
|
40298
|
Source: Author’s estimation based on NSS 71st & 75th round data.
Note
Amount of 2014 has been converted into 2017-18 prices using consumer price index (CPI).
To identify the socioeconomic factors influencing the extent of OOPE we have run three different models and presented the results in Table-3 (rural) & Table-4 (urban). From Model-I of Table-3 it is found that the extent of OOPE increases by 39 per cent and 34 per cent for the richest and the richer MPCE class respectively when compared to the reference category (the poorest class) in the rural region in 2017-18. In the year 2014, these percentages were 85 for the richest and 54 for the richer. In both the years, female has significantly lower OOPE than male. The extent of OOPE increases by 3 times when a person is hospitalized in the private hospital compared to the public facilities in 2017-18. In 2014, OOPE was 2.6 times higher in the private sector hospitals compared to public facilities. It is also observed that compared to patients with PFHI coverage, uncovered patients pay significantly higher amount as OOPE in both the years. Demographic factors like social group, religion were not significant covariate of extent of OOPE during hospitalization in the rural region in India. Importantly, aged patients (60 years and above) are paying lower amount of OOPE than the non-aged (50–59 years) patients in the region.
Table-3: Socio-economic Factors Determining the OOPE in Rural India
Variables
|
Groups
|
Model-I (Coefficient)
|
Model-II (Odds ratio)
|
Model-III (Coefficient)
|
2017-18
|
2014
|
2017-18
|
2014
|
2017-18
|
2014
|
Age (Ref: 50–59 yrs.)
|
60 yrs. & above
|
-0.013
|
-0.361***
|
0.863
|
0.664***
|
0.017
|
-0.006
|
MPCE (Ref: Poorest)
|
Poorer
|
-0.063
|
0.000
|
0.948
|
1.127
|
-0.040
|
-0.096***
|
Middle
|
0.105
|
0.429**
|
1.209
|
1.796***
|
-0.109***
|
-0.096***
|
Richer
|
0.391**
|
0.535***
|
1.483**
|
1.778***
|
-0.077***
|
-0.091**
|
Richest
|
0.340**
|
0.850***
|
1.159
|
1.929***
|
-0.126***
|
-0.154***
|
Sex (Ref: Male)
|
Female
|
-0.192***
|
-0.145**
|
1.085
|
1.022
|
-0.066***
|
-0.039***
|
Religion (Ref: Hindu)
|
Islam
|
0.435
|
0.466*
|
2.107*
|
2.420**
|
-0.068***
|
-0.031
|
Others
|
0.106
|
-0.080
|
1.095
|
0.739
|
-0.076***
|
-0.023
|
SG (Ref: ST)
|
SC
|
-0.071
|
0.039
|
0.834
|
0.936
|
-0.013
|
-0.027
|
OBC
|
-0.081
|
0.222
|
0.837
|
1.025
|
0.013
|
-0.019
|
Others
|
0.273
|
0.745**
|
1.166
|
1.791
|
0.046**
|
0.033
|
Hospital (Ref: Public)
|
Private
|
3.006***
|
2.568***
|
7.189***
|
6.018***
|
0.302***
|
0.230***
|
Insurance (Ref: PFHI)
|
Others
|
-1.316***
|
0.064
|
0.374***
|
0.919
|
-0.040
|
-0.016
|
No Insurance
|
1.199***
|
1.228***
|
2.898***
|
2.787***
|
0.077***
|
0.094***
|
Constant
|
5.429***
|
5.122***
|
1.988**
|
1.693
|
0.112***
|
0.156***
|
# Observations
|
8706
|
5436
|
8706
|
5436
|
8706
|
5436
|
Source: Author’s estimation based on NSS 71st & 75th round data.
Similar result is also observed in Model-II & Model-III. It has to be mentioned here that in 2017-18, if a person is hospitalized in the private hospital, then the probability of OOPE increases by 7.2 times. For the year 2014 it was 6 times. Results of the urban data is presented in Table-4. It is observed that age, MPCE class has no significant influence on OOPE during hospitalization. However, the share of OOPE in annual household expenditure significantly decreases as we move from poorest to richest class in 2017-18 and almost similar result is also found for the year 2014. As observed in the rural region, the extent of OOPE is significantly lower for female compared to male. Social group and religion have no significant influence on OOPE during hospitalization in the urban region also. Type of hospital is an important factor of OOPE in all the models and both the years. The extent of OOPE increases in the private hospitals and patients with PFHI are required to pay lower amount from their pocket during hospitalization in the region.
Table-4: Socio-economic Factors Determining the OOPE in Urban India
Variables
|
Groups
|
Model-I (Coefficient)
|
Model-II (Odds ratio)
|
Model-III (Coefficient)
|
2017
|
2014
|
2017
|
2014
|
2017
|
2014
|
Age (Ref: 50–59 yrs.)
|
60 yrs. & above
|
0.155
|
-0.213*
|
1.139
|
0.763**
|
0.013
|
-0.025
|
MPCE (Ref: Poorest)
|
Poorer
|
0.066
|
-0.050
|
1.050
|
0.902
|
-0.063**
|
-0.079**
|
Middle
|
0.163
|
0.358**
|
1.036
|
1.309*
|
-0.070***
|
-0.124***
|
Richer
|
0.152
|
0.466**
|
0.962
|
1.146
|
-0.080***
|
-0.114***
|
Richest
|
0.168
|
0.475**
|
0.768
|
0.760
|
-0.143***
|
-0.141***
|
Sex (Ref: Male)
|
Female
|
-0.200*
|
-0.229***
|
1.028
|
0.988
|
-0.054***
|
-0.067***
|
Religion (Ref: Hindu)
|
Islam
|
0.127
|
-0.136
|
1.200
|
0.989
|
-0.019
|
-0.061***
|
Others
|
-0.031
|
0.227
|
0.866
|
1.295
|
0.023
|
0.007
|
SG (Ref: ST)
|
SC
|
0.278
|
0.767
|
1.041
|
1.942
|
0.014
|
0.011
|
OBC
|
0.353
|
0.409
|
1.207
|
1.133
|
0.034*
|
0.065**
|
Others
|
0.630
|
0.947*
|
1.323
|
2.118
|
0.055**
|
0.086***
|
Hospital (Ref: Public)
|
Private
|
3.188***
|
2.753***
|
6.105***
|
5.255***
|
0.253***
|
0.249***
|
Insurance (Ref: PFHI)
|
Others
|
-1.245***
|
0.000
|
0.383***
|
0.821
|
0.015
|
-0.067**
|
No Insurance
|
1.395***
|
2.302***
|
2.978***
|
5.891***
|
0.102***
|
0.131***
|
Constant
|
4.860***
|
3.979***
|
1.508
|
0.881
|
0.022
|
0.060
|
# Observations
|
8236
|
5609
|
8236
|
5609
|
8236
|
5609
|
Source: Author’s estimation based on NSS 71st & 75th round data.
Given the results, it would be important to study the effectiveness of PFHI to reduce the extent of OOPE among the elderly in India. We have applied the propensity score matching to estimate the difference in OOP expenditure among the elderly with and without PFHI. The results are presented in Table-5. It is observed that compared to the elderly without PFHI facility, the OOPE for the elderly with PFHI was substantially lower in 2017-18. This result is uniformly observed in both the regions and both public and private healthcare facilities. In 2014, except the public facilities of the rural region, the extent of OOP expenditure was lower among the elderly with PFHI. It has to be noted here that the differences in OOPE in 2017-18 were comparatively higher than 2014. However, there is almost no difference in OOPE in the private facilities of the urban region between the two time points.
Table-5: Differences in OOPE during Hospitalization among the Elderly Patients with and without PFHI in India
Facility
|
Sector
|
Estimation
|
2017-18
|
2014
|
Treated
|
Controls
|
Difference
|
S.E.
|
T-stat
|
Treated
|
Controls
|
Difference
|
S.E.
|
T-stat
|
Public
|
Rural
|
Unmatched
|
5915.59
|
7900.84
|
-1985.25
|
1788.50
|
-1.11
|
3481.44
|
7959.46
|
-4478.02
|
947.63
|
-4.73
|
ATT
|
5915.59
|
5087.09
|
828.51
|
4202.31
|
0.20
|
3481.44
|
7007.37
|
-3525.93
|
2422.33
|
-3.46
|
ATU
|
7908.63
|
5716.63
|
-2192.00
|
|
|
7863.75
|
14132.38
|
6268.63
|
|
|
ATE
|
|
|
-1691.07
|
|
|
|
|
4388.95
|
|
|
Urban
|
Unmatched
|
3624.26
|
10671.91
|
-7047.65
|
2341.97
|
-4.01
|
3912.12
|
9569.86
|
-5657.74
|
1947.72
|
-2.90
|
ATT
|
3624.26
|
8005.01
|
-4380.75
|
6657.97
|
-3.66
|
3912.12
|
7137.45
|
-3225.32
|
3127.49
|
-2.03
|
ATU
|
10702.22
|
2530.93
|
-8171.28
|
|
|
9569.86
|
7153.76
|
-2416.11
|
|
|
ATE
|
|
|
-7540.58
|
|
|
|
|
-2547.03
|
|
|
Private
|
Rural
|
Unmatched
|
17479.34
|
31350.95
|
-13871.61
|
3632.45
|
-3.82
|
24465.75
|
42683.34
|
-18217.59
|
4078.00
|
-4.47
|
ATT
|
17479.34
|
44605.20
|
-27125.86
|
23002.96
|
-3.18
|
24465.75
|
24660.86
|
-195.11
|
5876.61
|
-2.03
|
ATU
|
31460.10
|
22486.98
|
-8973.12
|
|
|
42683.34
|
29498.55
|
-13184.79
|
|
|
ATE
|
|
|
-11827.26
|
|
|
|
|
-10495.62
|
|
|
Urban
|
Unmatched
|
23404.76
|
47080.46
|
-23675.70
|
5016.30
|
-4.72
|
34251.68
|
57830.34
|
-23578.66
|
4965.68
|
-4.75
|
ATT
|
23404.76
|
103927.74
|
-80522.98
|
22107.90
|
-3.64
|
34251.68
|
40176.41
|
-5924.74
|
13486.36
|
-3.44
|
ATU
|
47080.46
|
24000.72
|
-23079.75
|
|
|
57872.52
|
22673.27
|
-35199.25
|
|
|
ATE
|
|
|
-31374.41
|
|
|
|
|
-31582.99
|
|
|
Source: Author’s estimation based on NSS 71st & 75th round data.
Note
ATT – Average treatment effect on the treated; ATE – Average treatment effect; ATU – Average treatment effect on the untreated.