The study seeks to find the correlates of healthcare utilization, catastrophic health expenditure, distressed financing and seeking low quality or no medical care at the household level. It further attempts to explore the catastrophe related to medical care by going beyond the conventional method of threshold-specific measure of health catastrophe and attempts to draw from Alkire and Foster’s multidimensional vulnerability to poverty approach . The study finds that having large household size, elderly, children, chronically and acute ill members as well as females in the reproductive age increases the rates of seeking hospitalization care. In addition, SC and Muslim households have significantly higher expected rates of hospitalization as compared to ST and non-SC and non-Muslim households. Also, households with elderly members have higher rates of seeking OP care outside district, while having children increases the rates of OP visits in private centres. Even having chronically ill member(s) increases the rates of all types of OP visits, while having acute ill members significantly increases the rates of seeking OP care, both in general as well as in private facilities. These findings can be justified on the basis that both children and elderly are dependent members and prone to multiple diseases leading to an increased utilization of healthcare services. Even larger households especially those with higher share of dependent members will have to take care of the health of its members, leading to an increased utilization of hospitalisation care in either private facilities or outside district as well as OP visits in private facilities. As chronic care requires prolonged care and multiple checkups, households having chronically and acute ill members have higher expected rates of OP visits in both private facilities and outside districts. It thus seems that households with more dependent members and prominent illness characteristics are more prone to seek healthcare. This can be attributed to the positive impact of public health insurance to encourage households to seek care [25, 26]. However, with reference to the richer income groups and forward caste and religious groups, poor and backward socio-religious households have lower expected rates of seeking healthcare. Also households with insured members have higher expected rates of seeking hospitalisation in private facilities. Thus, although public hospitals provide subsidized care, low quality of care might force socio-economically and religiously backward households to have lower rates of utilization of medical care on one hand, with households having insured members seeking hospitalisation in private facilities, on the other.
The study also finds that having elderly and chronically ill members and hospitalizations and OP visits (both in private facility and outside district) in the household significantly increases the likelihood of incurring catastrophic medical care expenditure for both the thresholds 1 and 2 [26–32]. As elderly members are vulnerable to ailments and chronically ill members require multiple OP visits and hospitalization events, they are more likely to incur OOP medical payments. This may also be due to the fact that for elderly, longer life span can lead to the emergence of non-communicable diseases such as musculoskeletal, neurological and dementia diseases which are costly and increase health expenses in the process . It can be further justified by the lack of healthcare resources for the elderly and poor management of chronic diseases. Also seeking good quality care have resulted in people shifting to private hospitals for both inpatient and OP care which play an instrumental role in triggering OOP health expenses . There also exists evidence that outpatient care expenses have the highest proportion in healthcare costs  and this can be attributed to the fact that social health insurance schemes in developing countries like India do not cover outpatient care . There also exists enough empirical literature that suggests a positive relation between chronic illness and OOP health expenditure in LMICs [10, 34–38]. This is primarily because chronic care for NCDs is costly and place substantial burden on household budgets by increasing OOP payments and impoverishing households [39–41]. Our study also indicates that having health insurance significantly reduces the odds of spending more than 40 per cent of non-food expenditure as medical payments as well as likelihood of incurring distressed financing [42, 43]. The muted impact of health insurance can also be attributed to the locality of our sample as health insurance coverage is low or almost non-existent in rural areas.
The findings of the study further reveal that households belonging to lower economic and social strata are less likely to face CHE but have more likelihood to resort to distress financing or seek low quality care or avoid care as compared to their counterparts. Better-off households are more likely to incur catastrophic health spending have been supported by other studies conducted in Nigeria [44, 45], Mongolia [46, 47], Egypt  and Cambodia . A possible explanation is that they have higher capacity to pay and might replace low quality public healthcare service with private healthcare. On the other, it reflects the inability of less-endowed households to divert resources from other basic needs which hinder them to seek care, thereby relying on low quality or no care [48–50]. Also, the lesser likelihood among the poorer economic groups to not face CHE might be explained by the lack of rigour to seek healthcare if their illness is not perceived to be severe. This pattern is however not true for the richer households who are willing to utilize health services at the early signs of illness.
Further, the decision to seek medical care among the poor households also poses a substantial risk of financial loss due to loss of income and added costs of food and accommodation for the caregivers [39, 51–52]. Studies have found that the poor were more prone to not seeking care as they could not afford to seek treatment and/or were unable to take time off work for seeking outpatient care [51, 53]. Similar results are found in a study conducted in Bangladesh on patients with acute febrile illnesses which shows that the mean time of arrival at the referral hospital is longer for the multidimensionally poor households as compared to their richer counterparts . This association of barriers to care with poverty might start at an early stage from first seeking medical help to household’s decision to escalate care to referral hospitals, are also accompanied with higher frequency of visits to unqualified healthcare professionals such as medicine shop owners, private allopathic/non-allopathic doctors or quacks. This is further supported by the growing dissatisfaction among the poorest households regarding the quality of public healthcare . Other factors which might be attributing to this scenario are absenteeism, under-staffing, poor infrastructure, behaviour of health personnel and irregular supply of essential medicines in rural sectors [55, 56]. The higher tendency among the rural sample population to seek low quality or avoid care even with the presence of chronically and acute ill members can also be on account of culturally ingrained traditions and beliefs as well as inconsistencies in accessing affordable healthcare services. Thus, inability of socio-economically and religiously backward households to pay for good quality or prolonged health care may exaggerate their sickness and limit their ability to work, thereby reducing their net earnings. This can contribute to poor health and decreased earnings, thereby placing them in the vicious circle of poverty.
The comparative analysis of the Wagstaff and van Doorslaer approach and the multidimensional approach also shows that backward socio-religious categories such as ST, SC and Muslims had a higher representation in the latter approach vis-à-vis the former. Similarly, the representation of the poor households is highest in the multidimensional approach, which decreases gradually for the higher income groups. This implies that the poor, ST, SC and Muslim households are deprived in more dimensions/indicators apart from incurring catastrophic expenditures more than 10 per cent of TCE or 40 per cent of CTP. The fact that socially backward castes and religious groups face the brunt of medical care catastrophe more than their better off counterparts is also observed in other studies [57, 58]. Thus, while the catastrophic measurement of healthcare payments only focus on the money metric measures, the multidimensional approach looks at demographic, household and healthcare seeking dimensions and highlights those households who are actually more vulnerable. Hence it provides a more convincing and reliable picture of vulnerability imparted as a result of health shocks as compared to identifying households by Wagstaff and van Doorslaer’s method.
However, the limitations of the current approach must be spelt out. First, all the indicators are given equal weightage which might not be acceptable from a theoretical viewpoint. Second, only headcount measures are considered for the analysis and as such for capturing the extent of households with medical care related catastrophe other measures are required as well. Third, the study is not free from the regular limitations of self-reported illness, costs and healthcare utilization data that have been provided to the interviewers by the respondents. Despite these limitations and caveats, the findings of the study might be useful in providing appropriate policy framework and a more refined version can provide further insightful findings.