Determinants and distribution of out of pocket ex penditure for health care services in a district of western Maharashtra, India: An Observational Study.

Background: Reliability on out of pocket expenditure (OOPE) for health care services is commonly seen among the Indian population. There are various determinants which affect the OOP health expenditure. Aim: The aim of this study was to identify the impact of socioeconomic, demographic, and educational factors on OOPE and distribution of it among various components of health care services and diseases among the households of Pune district of Maharashtra. Method: An observational study was considered for primary data collection. Total 415 households were surveyed and out of them 353 were considered for analysis. Cross-tabulation and chi-square test was used to nd out the signicant relationship between the different variables. Result: It was found that the area of residence, age, gender, and type of disease, marital status, level of education, socioeconomic status of households have signicant relationship with OOPE. The medicine purchase had greatest impact on OOPE followed by OPD and IPD services. Non-communicable diseases increase the burden on OOPE. Conclusion: Households should be made aware of various modes of healthcare nancing; simultaneously government should improve penetration of existing social health insurance schemes. The policy makers should consider the factors mentioned and increase spending on public health to strengthen the existing facilities to further reduce the OOPE burden related to healthcare services.


Introduction
Out of pocket expenditure (OOPE) is "The expenses that the patient or the family made directly to public or private health care providers at the point of receiving health services, without a third-party (insurer, or State)"(WHO). Whereas catastrophic health expenditure is de ned as out-of-pocket spending for health care that exceeds a certain proportion of a household's income with the consequence that household suffer the burden of disease. (1,2) Catastrophic expenditure is common in low and middle income countries where healthcare is mainly nanced by the people through OOPE and less common in high income countries with established prepayment methods. Many factors, such as the availability of health services, nancial resources, perceived and actual needs for healthcare, and patient satisfaction etc., contribute to healthcare utilization, which is re ected in overall OOPE at the individual and/or household level. (10)(11)(12)(13)(14)(15) Out of the many nancing mechanisms, OOPE is considered to be the most unfair for the poor. (15)   Completely answering the questionnaire given was considered as consent from the households for the participation in the study. Cross-tabulation was used to summarize the determinants and distribution of OOPE. Chi-square test was also used to identify the association between dependent and independent variables.

Background Characteristics of Study Participants
The characteristics of the household's participating in the study are depicted in Table 1.To summarize, 52.12% were male participants and 47.87% were female participants; 54.95% were 25-40 years of age, 24.64% were 40-60 years of age. 25.21% had school level education, 40.23% were graduate;66.01% were married; 41.93% were private employees. More than 75% of the households had income level above 20,000 INR per month. Most of the families were nuclear, only 6.80% had more than 5 dependent members. 87.81% of households were from urban areas, out of which 3.96% were from urban slum area; 12.18 % belong to rural communities.45.04% had one earning member, 43.34% had two earning members whereas only 11.61% had 3 and more earning members in their family.   Graph-1: Distribution of Mode of expenditure (in %)

Discussion
In India, the proportion of households with more than 10% OOPE for healthcare has increased more than two times during 2004-2014 (16). OOP payment is a major portion of total health expenditure in India as public investment in healthcare is the lowest. The goal of National Health Policy 2017 was to achieve signi cant reduction in OOP payments, catastrophic health expenditure and impoverishment due to health expenditure (17). This study was conducted to nd out impact of socioeconomic, demographic and educational factors on OOPE and distribution of OOPE among various components of healthcare services and diseases among the households of Pune districts of Maharashtra State of India. Pune district was selected as it resembles mixed strata of urban, urban slum, and rural population of different demographic as well as socioeconomic characteristics.
Findings of the study were as follows OOPE was higher in urban slum and rural households as well as households headed by males. Also OOPE was higher with 18-25 years of age group and households above 60 years of age. Unmarried, highly educated individuals, households with more earning members, less dependent members, more gross monthly income also opt for higher OOPE. The higher incidence of OOPE in the above groups could be because of lack of access to public funded health facility for appropriate treatment, less awareness about available health nancing options, negative perception towards quality of public healthcare services and comparatively good quality of services provided at private hospitals (1,2,(18)(19)(20)(21)(22). In urban slum and rural areas people ignore small health issues to avoid expenditure (1,2,22)and they seek help when problem becomes severe; also they have limited options available and known to them. In case of emergency, access to services in public hospitals is di cult due to long waiting time and at the same point of time poor quality of care, lack of infrastructure forcing them to opt for private organization that increases OOPE (23)(24)(25). On the other hand OOPE is higher among households managed by males and between 18-25 years age households, which may be due to more economic resources with better physical access which further increases utilization (16). Whereas among households above 60 years of age, OOPE increases as healthcare needs, dependency on medication increases with age, also working capacity of this age group decreases which adds to the economic burden, they also lose their employer insurance cover post retirement and personal insurance premiums become expensive with increasing age. (16,(26)(27)(28)(29) Availability of resources and more preferences to private healthcare facilities (16,20) Our study captured the determinants and distribution of OOPE among households of Pune district.
However, the study has some limitations. Sample size is small; details of expenditure are recorded in terms of percentage. Respondents are not children and details of expenditure were recorded against whole household not against each member of household in this study so in-depth evaluation as per family member was not possible in this study. Additionally, it is of course possible for some people not to have incurred OOP expenditures not because they were not in need of health services, but because they were not able to afford them; assessing this phenomenon was not possible with the current dataset and remains a task for future research.

Conclusion
Considering the limitations, this study suggests that the demographic, socioeconomic and educational factors should be considered while formulating the healthcare policies. Government should increase public healthcare expenditure. There is need to develop policy options for building stronger nancial protection mechanisms in India. Implementation of existing social insurance scheme and increasing the penetration of the same may help to reduce OOPE. Government should improvise existing healthcare facility to cover NCD burden and simultaneously maintain supply of essential and generic medicine at public healthcare facilities to reduce OOPE. Data revealing the identity of the participants -NA