Health care utilization and expenditure inequities in India: Benefit incidence analysis

Background: The transition from Millennium Development Goals to Sustainable Development Goals 2030 has yet again emphasized on the unfinished agenda of achieving efficient and equitable health systems and universal health coverage. With trifling public spending on healthcare and insignificant insurance coverage, India has recorded 55 million people descending below the poverty line in one year due to healthcare payments. Not only are these health-related payments impoverishing but also the burden of seeking care is disproportionately skewed towards deprived population groups. Against this backdrop, the present paper examines the inequality in health status, utilization of health care services, and financial risk protection. The study is further complemented by assessing who benefits from public subsidies across different economic quintiles and as per epidemiological transition level (ETL) of states. Methods: This study used data nationwide National Sample Survey 75th round data. We perform the Benefit Incidence Analysis (BIA) using concentration indices, concentration curve, and poor-rich equity ratio to measure horizontal and vertical inequity and analyze the redistribution dimension to understand which population segment benefits more from public subsidies. Results: Findings suggest that high out of pocket (OOP) spending on inpatient care, especially in the private sector resulted in lower utilization of health care services especially among marginalized communities. Seeking care for marginalized sub-groups is dilapidating in two major ways-, on one hand, it exhausts all their income/savings for the treatment. On the other, as a result of incapacitation, families lose their daily income. The present analysis finds a higher unmet need for treatment in the poor, and the reasons commonly reported were pertaining to affordability, availability and accessibility. The results also showed that low ETL states faced a higher percentage of catastrophic expenditure vis-& agrave;-vis other states, thereby; stressing health system reforms beyond the "one-size-fits-all " strategy. Conclusions: It is imperative that both Central and State Governments should work together to strengthen the public healthcare system to ensure accessibility and quality of care. Central Government's Pradhan Mantri Jan Arogya Yojana (PM-JAY) health insurance program is a positive step forward to address the healthcare needs of deprived population subgroups.