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Pandey, a (2017) Socioeconomic Inequality in Healthcare Utilization and Expenditure in the Older Population of India

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Pandey, a (2017) Socioeconomic Inequality in Healthcare Utilization and Expenditure in the Older Population of India Pandey, A (2017) Socioeconomic inequality in healthcare utilization and expenditure in the older population of India. PhD (research paper style) thesis, London School of Hygiene & Tropical Medicine. DOI: https://doi.org/10.17037/PUBS.04645412 Downloaded from: http://researchonline.lshtm.ac.uk/4645412/ DOI: 10.17037/PUBS.04645412 Usage Guidelines Please refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna- tively contact [email protected]. Available under license: http://creativecommons.org/licenses/by-nc-nd/2.5/ Socioeconomic inequality in healthcare utilization and expenditure in the older population of India ANAMIKA PANDEY Thesis submitted in accordance with the requirements for the degree of Doctor of Philosophy University of London August 2017 Department of Population Health Faculty of Epidemiology and Population Health LONDON SCHOOL OF HYGIENE & TROPICAL MEDICINE Funding: This work was supported by a Wellcome Trust Capacity Strengthening Strategic Award to the Public Health Foundation of India and a consortium of UK universities. 1 STATEMENT OF OWN WORK All students are required to complete the following declaration when submitting their thesis. A shortened version of the School’s definition of Plagiarism and Cheating is as follows (the full definition is given in the Research Degrees Handbook): “Plagiarism is the act of presenting the ideas or discoveries of another as one’s own. To copy sentences, phrases or even striking expressions without acknowledgement in a manner which may deceive the reader as to the source is plagiarism. Where such copying or close paraphrase has occurred the mere mention of the source in a biography will not be deemed sufficient acknowledgement; in each instance, it must be referred specifically to its source. Verbatim quotations must be directly acknowledged, either in inverted commas or by indenting” (University of Kent). Plagiarism may include collusion with another student, or the unacknowledged use of a fellow student’s work with or without their knowledge and consent. Similarly, the direct copying by students of their own original writings qualifies as plagiarism if the fact that the work has been or is to be presented elsewhere is not clearly stated. Cheating is similar to plagiarism, but more serious. Cheating means submitting another student's work, knowledge or ideas, while pretending that they are your own, for formal assessment or evaluation. Supervisors should be consulted if there are any doubts about what is permissible. DECLARATION BY CANDIDATE I have read and understood the School’s definition of plagiarism and cheating given in the Research Degrees Handbook. I declare that this thesis is my own work, and that I have acknowledged all results and quotations from the published or unpublished work of other people. I have read and understood the School’s definition and policy on the use of third parties (either paid or unpaid) who have contributed to the preparation of this thesis by providing copy editing and, or, proof reading services. I declare that no changes to the intellectual content or substance of this thesis were made as a result of this advice, and, that I have fully acknowledged all such contributions. I have exercised reasonable care to ensure that the work is original and does not to the best of my knowledge break any UK law or infringe any third party’s copyright or other intellectual property right. 08/08/2017 Signed: ………………….............................................. Date: ................................. Full Name: ANAMIKA PANDEY 2 Abstract Background Equity in access and financing healthcare is a key determinant of population health. This study examined the socioeconomic inequality in healthcare utilization and expenditure contrasting older (60 years or more) with younger (under 60 years) population in India over two decades. Methods National Sample Survey data from all states of India on healthcare utilization (NSS-HUS 1995–96, NSS-HUS 2004 and NSS-HUS 2014) and consumer expenditure (NSS-CES 1993–94, NSS-CES 1999–2000, NSS-CES 2004–05 and NSS-CES 2011–12) were used. Logistic, generalized linear and fractional response models were used to analyze the determinants of healthcare utilization and burden of out-of-pocket (OOP) payments. Deviations in the degree to which healthcare was utilized according to need was measured by a horizontal inequity index with 95% confidence interval (HI, 95% CI). Findings When compared with younger population, the older population had higher self-reported morbidity rate (4.1 times), outpatient care rate (4.3 times), hospitalization rate (3.6 times), and proportion of hospitalization for non-communicable diseases (80.5% vs 56.7%) in 2014. Amongst the older population, the hospitalization rates were comparatively lower for female, poor and rural residents. Untreated morbidity was disproportionately higher for the poor, more so for the older (HI: -0.320; 95% CI: -0.391, -0.249) than the younger (-0.176; -0.211, -0.141) population in 2014. Outpatient care in public facilities increased for the poor over time, more so for the older than the younger population. Households with older persons only had higher median per capita OOP payments (2.47-4.00 times across NSS-CES and 3.10-5.09 times across NSS-HUS) and catastrophic health expenditure (CHE) (1.01-2.99 times across NSS-CES and 1.10-1.89 times across NSS- HUS) than the other households. The odds of CHE were significantly higher in households with older persons, households headed by females and rural households. Both the vertical and horizontal inequities in OOP payments for hospitalization by the older population increased between 1995 and 2014. 3 Conclusion These findings can be used for developing an equitable health policy that can more effectively provide healthcare protection to the increasing older population in India. 4 Acknowledgements I am grateful to my UK supervisors Ms Lynda Clarke and Professor George B. Ploubidis for their invaluable support, guidance and encouragement throughout the period of my PhD. I always had the opportunity to get their feedback on my research work. I thank Professor Ploubidis for the insightful discussion on different aspects of this research ranging from guidance related to data issues and statistical analysis to critical feedback on research papers. I also extend my deep sense of gratitude to Ms Clarke for her supervision, constructive suggestions and generosity with her time, and also facilitating all requirements for completing this work. I particularly thank her for extensively reviewing my thesis and giving critical comments for improving the intellectual content. A special thanks for scheduling regular meetings for discussions as needed. I am profoundly grateful to my supervisor from India, Professor Lalit Dandona for giving me the opportunity to work with him for my PhD. His tremendous efforts and guidance throughout the course of last four years has strengthened my research capabilities. Working with him has been a stimulating experience for me. He has always provided direction on how to conduct good research, thanks to his expertise in the field of public health and vast research knowledge. His advice on both research as well as on my career path have been priceless. It was a pleasure to have Professor Sanjay Kinra in the Advisory Committee. I thank him for his insights on my research proposal at the time of my upgrading. I would also like to thank the members of my upgrading committee, Dr Rebecca Sear (LSHTM), Dr Sanna Read (LSHTM) and Professor Emily Grundy (LSE) for their constructive feedback on the outline and content of the research proposal that helped me greatly improve upon it. I would like to thank the PHFI-UKC Wellcome Trust Capacity Building Programme for funding my PhD at London School of Hygiene and Tropical Medicine. I am grateful to the Chairs of the Teaching and Training Committee (Professor Sanjay Zodpey, India and Professor Pat Doyle, UK) and the Director of this programme, Professor Lalit Dandona for selecting me for the PHFI-UKC programme. A special mention of thanks to the members of the PHFI-UK Consortium for extending all support and guidance under the capacity building programme to carry out my research work. I thank the members of 5 India and UK Secretariat (Ms Parul Mutreja, Mr Anurag Gautam, Mr Niall Holohan, Ms Maebh NiFhalluin and Ms. Najma Hussain) for extending administrative support under the PHFI-UKC programme. I am also thankful to all the staff members form LSHTM, particularly Ms Jenny Fleming and Ms Lauren Dalton for extending their administrative support. The vibrant academic environment at LSHTM, where I met fellow doctoral scholars, was great source of encouragement in itself. My colleagues and friends in India and UK have all extended their support in a very special way, and I gained a lot from their personal and scholarly interactions. I acknowledge their support with thanks. I am also grateful to Dr G. Anil Kumar (PHFI) for the insightful discussions and help related to data management. I was lucky to have Professor Laishram Ladusingh as my mentor during my Master’s degree in demography from the International Institute for Population Sciences, India. He had tremendous belief in my capabilities as a researcher and motivated me to pursue PhD. I would like to thank Professor Ladusingh and Professor Sulabaha Parasuraman (IIPS) for considering me suitable and recommending my candidature for this PhD programme. I am indebted to my father (Dr S.N. Pandey) and mother (Dr Asha Pandey) for being an incredible source of inspiration for me at every step of my personal and academic life. I am grateful to my in-laws (Mr Brajesh Pathak and Ms Subhadra Pathak) for their love and moral support. A special thanks to my sister (Ms Anupama Pathak) and brother-in- law (Dr Sushil Kumar Pathak) for patiently reading my thesis and giving suggestions to improve upon it.
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