Socioeconomic inequality in healthcare utilization and expenditure in the older population of India

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. 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.