Health and poverty linkages for population just above the poverty line-A study done in slums of Jaipur, India

Universal Health Coverage, as a milestone of Sustainable Development Goal − 3 has its own predened limitations for a resource constraint economy. Underdeveloped and developing nations are not in a position to provide critical and crucial health services to all its citizens and those who remain uncovered are likely to face nancial hardships. Division of limited resources is never easy andchoosing which services to offer and to whom in order to benet the weaker sections becomes a complex choice. This study examines, that despite the availability of health systems and insurance schemes, does a vulnerable sections of the societyremains unprotected against Catastrophic Health Expenditure. Is catastrophic health expenditure leading to impoverishment in urban poor of Jaipur city? Primary data was collected from 426 households of urban slums of Jaipur City. It was found that of all the households, 8.1 percent households incurred Catastrophic Health Expenditure. The mean excess of expenditure over the dened threshold (i.e. 40 percent of non-subsistence household expenditure) was 33 percent for households which incurred Catastrophic Health Expenditure. There was a signicant association between increased health expenditure and curtailment in expenditure on food and clothing by households, p < 0.0001 and p < 0.05 respectively. There was a signicant rise in impoverishment in urban slums because of out of pocket expenditures on health. There was an absolute 1 percent rise (2.8 percent to 3.8 percent) in poverty on the basis of National Poverty Line and 2.6 percent (37.1 percent to 39.7 percent) when International Poverty Line estimates were taken. Increase in normalized mean positive poverty gap from 29.8 percent to 45.3 percent, indicates the deepening of poverty among existing poor. The result indicates massive discrepancy in estimates of poverty 2.8 percent on National poverty standards and 37.1 percent on International poverty standards. Poverty ratio, as low as 2.8 percent among urban slum (the acknowledged poorer section) based on National Poverty Line indicates need of developing a sensitive poverty standards. Urban slum dwellers of Jaipur are forced to spend more on day-to-day household items because of higher cost of living of the city. This led to an underestimation of the number of poor on National poverty line basis. Lack of considerations of regional variables and factors while designing health schemes is

limitations for a resource constraint economy. Underdeveloped and developing nations are not in a position to provide critical and crucial health services to all its citizens and those who remain uncovered are likely to face nancial hardships. Division of limited resources is never easy andchoosing which services to offer and to whom in order to bene t the weaker sections becomes a complex choice. This study examines, that despite the availability of health systems and insurance schemes, does a vulnerable sections of the societyremains unprotected against Catastrophic Health Expenditure. Is catastrophic health expenditure leading to impoverishment in urban poor of Jaipur city?
Primary data was collected from 426 households of urban slums of Jaipur City. It was found that of all the households, 8.1 percent households incurred Catastrophic Health Expenditure. The mean excess of expenditure over the de ned threshold (i.e. 40 percent of non-subsistence household expenditure) was 33 percent for households which incurred Catastrophic Health Expenditure. There was a signi cant association between increased health expenditure and curtailment in expenditure on food and clothing by households, p < 0.0001 and p < 0.05 respectively.
There was a signi cant rise in impoverishment in urban slums because of out of pocket expenditures on health. There was an absolute 1 percent rise (2.8 percent to 3.8 percent) in poverty on the basis of National Poverty Line and 2.6 percent (37.1 percent to 39.7 percent) when International Poverty Line estimates were taken. Increase in normalized mean positive poverty gap from 29.8 percent to 45.3 percent, indicates the deepening of poverty among existing poor.
The result indicates massive discrepancy in estimates of poverty 2.8 percent on National poverty standards and 37.1 percent on International poverty standards. Poverty ratio, as low as 2.8 percent among urban slum (the acknowledged poorer section) based on National Poverty Line indicates need of developing a sensitive poverty standards. Urban slum dwellers of Jaipur are forced to spend more on dayto-day household items because of higher cost of living of the city. This led to an underestimation of the number of poor on National poverty line basis. Lack of considerations of regional variables and factors while designing health schemes is evident. This raises an argument in favor of recognizing local factors while designing the social insurance schemes.
Evidence based selection of healthcare delivery system -assurance, insurance or mixed is required. The approach must enable the Government to control quality and cost of the healthcare at the same time. In the present scenario, assurance (healthcare services by Public Healthcare Facilities) approach may not only improve the accessibility but also will control the cost of healthcare for the entire population. In place of putting two parallel systems insurance or assurance, the Government should focus to invest funds and efforts in one system. To strengthen the assurance of public health care 'Right based approach to Health' may be adopted.This will result in long term protection of its citizens.

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Declarations
For this study ethical approval was granted by the ethical committee of IIHMR University.
Competing interests: The authors declare no competing interests. It part of authors' phd work.