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LSHTM Research OnlinePandey, A; (2017) Socioeconomic inequality in healthcare utilization and expenditure in the olderpopulation of India. PhD (research paper style) thesis, London School of Hygiene & Tropical Medicine.DOI: from: 12/DOI: Guidelines:Please refer to usage guidelines at or alternativelycontact under license:

Socioeconomic inequality in healthcare utilization andexpenditure in the older population of IndiaANAMIKA PANDEYThesis submitted in accordance with the requirements for the degree ofDoctor of PhilosophyUniversity of LondonAugust 2017Department of Population HealthFaculty of Epidemiology and Population HealthLONDON SCHOOL OF HYGIENE & TROPICAL MEDICINEFunding: This work was supported by a Wellcome Trust CapacityStrengthening Strategic Award to the Public Health Foundation of India anda consortium of UK universities.1

STATEMENT OF OWN WORKAll students are required to complete the following declaration when submitting theirthesis. A shortened version of the School’s definition of Plagiarism and Cheating is asfollows (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. Tocopy sentences, phrases or even striking expressions without acknowledgement in amanner which may deceive the reader as to the source is plagiarism. Where such copyingor close paraphrase has occurred the mere mention of the source in a biography will notbe deemed sufficient acknowledgement; in each instance, it must be referred specificallyto its source. Verbatim quotations must be directly acknowledged, either in invertedcommas or by indenting” (University of Kent).Plagiarism may include collusion with another student, or the unacknowledged use of afellow student’s work with or without their knowledge and consent. Similarly, the directcopying by students of their own original writings qualifies as plagiarism if the fact thatthe work has been or is to be presented elsewhere is not clearly stated.Cheating is similar to plagiarism, but more serious. Cheating means submitting anotherstudent's work, knowledge or ideas, while pretending that they are your own, for formalassessment or evaluation. Supervisors should be consulted if there are any doubts aboutwhat is permissible.DECLARATION BY CANDIDATEI have read and understood the School’s definition of plagiarism and cheating given in theResearch Degrees Handbook. I declare that this thesis is my own work, and that I haveacknowledged all results and quotations from the published or unpublished work of otherpeople.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 providingcopy editing and, or, proof reading services. I declare that no changes to the intellectualcontent or substance of this thesis were made as a result of this advice, and, that I havefully acknowledged all such contributions. I have exercised reasonable care to ensure thatthe work is original and does not to the best of my knowledge break any UK law orinfringe any third party’s copyright or other intellectual property right.08/08/2017Signed: . Date: .Full Name: ANAMIKA PANDEY2

AbstractBackgroundEquity in access and financing healthcare is a key determinant of population health. Thisstudy examined the socioeconomic inequality in healthcare utilization and expenditurecontrasting older (60 years or more) with younger (under 60 years) population in Indiaover two decades.MethodsNational Sample Survey data from all states of India on healthcare utilization (NSS-HUS1995–96, NSS-HUS 2004 and NSS-HUS 2014) and consumer expenditure (NSS-CES1993–94, 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 thedeterminants of healthcare utilization and burden of out-of-pocket (OOP) payments.Deviations in the degree to which healthcare was utilized according to need wasmeasured by a horizontal inequity index with 95% confidence interval (HI, 95% CI).FindingsWhen compared with younger population, the older population had higher self-reportedmorbidity 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%) in2014. Amongst the older population, the hospitalization rates were comparatively lowerfor female, poor and rural residents. Untreated morbidity was disproportionately higherfor 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 increasedfor the poor over time, more so for the older than the younger population. Householdswith older persons only had higher median per capita OOP payments (2.47-4.00 timesacross NSS-CES and 3.10-5.09 times across NSS-HUS) and catastrophic healthexpenditure (CHE) (1.01-2.99 times across NSS-CES and 1.10-1.89 times across NSSHUS) than the other households. The odds of CHE were significantly higher inhouseholds with older persons, households headed by females and rural households. Boththe vertical and horizontal inequities in OOP payments for hospitalization by the olderpopulation increased between 1995 and 2014.3

ConclusionThese findings can be used for developing an equitable health policy that can moreeffectively provide healthcare protection to the increasing older population in India.4

AcknowledgementsI am grateful to my UK supervisors Ms Lynda Clarke and Professor George B. Ploubidisfor their invaluable support, guidance and encouragement throughout the period of myPhD. I always had the opportunity to get their feedback on my research work. I thankProfessor Ploubidis for the insightful discussion on different aspects of this researchranging from guidance related to data issues and statistical analysis to critical feedback onresearch papers. I also extend my deep sense of gratitude to Ms Clarke for hersupervision, constructive suggestions and generosity with her time, and also facilitatingall requirements for completing this work. I particularly thank her for extensivelyreviewing 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 givingme the opportunity to work with him for my PhD. His tremendous efforts andguidance throughout the course of last four years has strengthened my researchcapabilities. Working with him has been a stimulating experience for me. He has alwaysprovided direction on how to conduct good research, thanks to his expertise in the field ofpublic health and vast research knowledge. His advice on both research as well as on mycareer path have been priceless.It was a pleasure to have Professor Sanjay Kinra in the Advisory Committee. I thank himfor his insights on my research proposal at the time of my upgrading. I would also like tothank the members of my upgrading committee, Dr Rebecca Sear (LSHTM), Dr SannaRead (LSHTM) and Professor Emily Grundy (LSE) for their constructive feedback on theoutline 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 forfunding my PhD at London School of Hygiene and Tropical Medicine. I am grateful tothe Chairs of the Teaching and Training Committee (Professor Sanjay Zodpey, India andProfessor Pat Doyle, UK) and the Director of this programme, Professor Lalit Dandonafor selecting me for the PHFI-UKC programme. A special mention of thanks to themembers of the PHFI-UK Consortium for extending all support and guidance under thecapacity building programme to carry out my research work. I thank the members of5

India and UK Secretariat (Ms Parul Mutreja, Mr Anurag Gautam, Mr Niall Holohan, MsMaebh NiFhalluin and Ms. Najma Hussain) for extending administrative support underthe 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 administrativesupport.The vibrant academic environment at LSHTM, where I met fellow doctoral scholars, wasgreat source of encouragement in itself. My colleagues and friends in India and UK haveall extended their support in a very special way, and I gained a lot from their personal andscholarly interactions. I acknowledge their support with thanks. I am also grateful to DrG. 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’sdegree in demography from the International Institute for Population Sciences, India. Hehad 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) forconsidering 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 anincredible source of inspiration for me at every step of my personal and academic life. Iam grateful to my in-laws (Mr Brajesh Pathak and Ms Subhadra Pathak) for their loveand moral support. A special thanks to my sister (Ms Anupama Pathak) and brother-inlaw (Dr Sushil Kumar Pathak) for patiently reading my thesis and giving suggestions toimprove upon it. I thank my brothers (Mr Gayatri Vallabh and Mr Braj Vallabh) for theirloving and supportive presence in my life. I owe my deepest gratitude towards myhusband (Mr Amit Raj Pathak) for his unending support and understanding of my goalsand aspirations. His unfailing love and support has always been my strength. His patienceand sacrifice will remain an inspiration throughout my life.6

Table of contentsSTATEMENT OF OWN WORK . 2Abstract . 3Acknowledgements . 5List of tables. 12List of figures . 14Acronyms and Abbreviations . 15Relevant publications and conference presentations . 17Chapter 1: Thesis background . 181.1 Introduction . 181.2 Aims and objectives . 211.3 Thesis structure . 221.4 Role of the candidate . 251.5 Ethical clearance . 251.6 Funding . 25Chapter 2. Literature Review . 262.1 Healthcare utilization . 262.1.1 Morbidity and healthcare use . 262.1.2 Socioeconomic inequality in healthcare use in general population: evidence frominternational studies . 272.1.3 Socioeconomic inequality in healthcare use in the general population: evidence fromIndia . 302.1.4 Socioeconomic inequality in healthcare use in the older population: evidence frominternational studies . 312.1.5 Socioeconomic status and healthcare use in the older population: evidence from India. 342.1.6 Socioeconomic inequality in healthcare use: comparison across age groups . 352.1.7 Health insurance and utilization . 352.2 Healthcare expenditure and its burden . 372.2.1 Out-of-pocket payments and morbidity . 382.2.2 Who pays for healthcare? evidence from international studies. 402.2.3 Who pays for healthcare? evidence from India. 422.2.4 Burden of out-of-pocket payments: evidence from international studies . 432.2.5 Burden of out-of-pocket payments: evidence from India . 462.2.6 Burden of out-of-pocket payments: older vs younger. 477

2.2.7 Health insurance and burden of out-of-pocket payments . 492.3 Overview of findings . 50Chapter 3. Study context . 533.1 Demographic transition and population aging . 533.1.1 Population aging: global trends. 533.1.2 Population aging in India . 543.1.3 Socioeconomic and demographic profile of the older population in India . 573.1.4 Societal implications on aging . 593.1.5 Economic implications of aging . 593.2 Policies for older population in India . 623.3 Coverage of the social assistance programmes. 643.4 Epidemiological transition: global and national trends . 653.5 Summary of context . 67Chapter 4. Methods . 694.1 National Sample Survey Organization. 694.2 National Sample Survey on Social Consumption – Health . 704.3 National Sample Survey on Consumer Expenditure . 714.4 NSSO data used for this study . 714.4.1 Healthcare utilization survey . 724.4.2 Consumer expenditure surveys . 734.4.3 Coverage and sampling design of NSS-HUS and NSS-CES . 744.4.4 Concepts and definitions . 774.5 Advantages and disadvantages of the secondary data analyses. 824.6 The Andersen’s model for healthcare utilization . 83Permissions for authors . 87Chapter 5. Hospitalization trends in India from serial cross-sectional nationwide surveys: 1995 to2014 . 895.1 Abstract. 895.2 Introduction . 915.3 Methods. 915.3.1 Ethics statement . 915.3.2 Data sources and participants . 915.3.3 Measures . 928

5.3.4 Statistical methods . 935.4 Results . 955.4.1 Hospitalization trends and differentials . 955.4.2 Compositional change . 995.4.3 Determinants of hospitalization . 1045.4.4 Decomposition of increase in hospitalization rate . 1045.5 Discussion . 1075.6 Acknowledgement . 111Chapter 6. Horizontal inequity in outpatient care use and untreated morbidity: evidence fromnationwide surveys in India between 1995 and 2014 . 1166.1 Abstract. 1166.2 Introduction . 1186.3 Methods. 1186.3.1 Data . 1186.3.2 Measures . 1196.3.3 Statistical analysis . 1196.4 Results . 1216.4.1 Trends in SRM, outpatient care and untreated morbidity . 1216.4.2 Self-reported morbidity . 1236.4.3 Horizontal inequity in outpatient care and untreated morbidity . 1256.4.4 Determinants of outpatient care and untreated morbidity . 1306.4.5 Barriers to healthcare utilization . 1306.5 Discussion . 1326.6 Ethics statement . 1366.7 Acknowledgement . 136Chapter 7. Trends in catastrophic health expenditures in India from serial nationwide surveys:1993 to 2014 . 1407.1 Abstract. 1407.2 Introduction . 1427.3 Methods. 1437.3.1 Consumer expenditure surveys . 1437.3.2 Healthcare utilization surveys . 1437.3.3 Measurement of CHE . 1447.3.4 OOP payments for healthcare . 1449

7.3.5 Associations with CHE . 1447.4 Results . 1457.5 Discussion . 1527.6 Ethics statement . 1567.7 Acknowledgement . 156Chapter 8. Has the inequity in out-of-pocket payments for hospitalization increased in India?Evidence from the National Sample Surveys, 1995–2014 . 1608.1 Abstract. 1608.2 Introduction . 1628.3 Methods. 1638.3.1 Data . 1638.3.2 Dependent variables . 1638.3.3 Covariates . 1638.3.4 Statistical analysis . 1648.4 Results . 1658.4.1 Sample characteristics . 1658.4.2 Determinants of OOP payments for hospitalization . 1658.4.3 Determinants of financial burden of OOP payments for hospitalization . 1678.4.4 Vertical inequities in OOP payments for hospitalization . 1698.4.5 Horizontal inequities in OOP payments for hospitalization . 1698.5 Discussion . 1748.6 Ethics statement . 1818.7 Acknowledgement . 181Chapter 9. Summary and recommendations . 1839.1 Summary of findings. 1839.2 General strengths and limitations . 1869.2.1 General strengths . 1869.2.2 General limitations . 1879.3 Recommendation for future research . 1889.4 Recommendation for surveys. 1899.5 Policy implications . 1909.6 Conclusion . 194References . 19510

Chapter 10. Appendices . 221Appendix A-1 Ethics approval from the Institutional Ethics Committee of Public HealthFoundation of India . 222Appendix A-2 Ethics approval from the Observational/Interventions Research EthicsCommittee of London School of Hygiene and Tropical Medicine . 223Appendix C-1 Estimated and projected population of India between 1950 and 2100 by UnitedNations . 225Appendix E-1 Percent distribution of missing and deceased samples in NSS 1995–96, NSS2004 and NSS 2014, India . 226Appendix E-2 List of diseases grouped according to Global Burden of Disease (GBD) studycategorization of diseases, 2013 . 227Appendix E-3 Hospitalization rates per 1000 (95% CI) for the older population by diseasegroups in the major states in NSS 1995–96, NSS 2004 and NSS 2014, India. 228Appendix E-4 Hospitalization rates per 1000 (95% CI) in public hospitals among the olderpopulation in the major states in NSS 1995–96, NSS 2004 and NSS 2014, India . 230Appendix F-1 Distribution of need variables by MPCE* quintiles for the population under 60years and 60 years or more in India, NSS 1995–96 and NSS 2014 . 232Appendix F-2 Determinants of outpatient care, untreated morbidity and the use of publicfacilities for outpatient care for the population under 60 years in India, NSS 1995–96 and NSS2014 . 234Appendix G-1 Items used in household consumer expenditure surveys to assess out-of-pocketpayments for outpatient and inpatient care, India . 235Appendix G-2 Items used in household healthcare utilization surveys to assess out-of-pocketpayments for outpatient and inpatient care, India . 237Appendix H-1 Selected socio-economic characteristics by monthly per capita consumptionexpenditure quintiles for hospitalized popul

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 specia