Does spending matters? Re-looking into various covariates associated with Out of Pocket Expenditure (OOPE) and catastrophic spending on accidental injury from NSSO 71st round data

P adhan, Jalandha ; Dwi edi, Rinshu; Pa i, Sanghami a; Rou , Sa i Kuma A icle Does spending ma e s? Re-looking in o a ious co a ia es associa ed wi h Ou o Pocke Expendi u e (OOPE) and ca as ophic spending on acciden al inju y om NSSO 71s ound da a Heal h Economics Re iew P o ided in Coope a ion wi h: Sp inge Na u e Sugges ed Ci a ion: P adhan, Jalandha ; Dwi edi, Rinshu; Pa i, Sanghami a; Rou , Sa i Kuma (2017) : Does spending ma e s? Re-looking in o a ious co a ia es associa ed wi h Ou o Pocke Expendi u e (OOPE) and ca as ophic spending on acciden al inju y om NSSO 71s ound da a, Heal h Economics Re iew, ISSN 2191-1991, Sp inge , Heidelbe g, Vol. 7, Iss. 48, pp. 1-16, h ps://doi.o g/10.1186/s13561-017-0177-z This Ve sion is a ailable a : h ps://hdl.handle.ne /10419/197244 S anda d-Nu zungsbedingungen: Die Dokumen e au EconS o dü en zu eigenen wissenscha lichen Zwecken und zum P i a geb auch gespeiche und kopie we den. Sie dü en die Dokumen e nich ü ö en liche ode komme zielle Zwecke e iel äl igen, ö en lich auss ellen, ö en lich zugänglich machen, e eiben ode ande wei ig nu zen. So e n die Ve asse die Dokumen e un e Open-Con en -Lizenzen (insbesonde e CC-Lizenzen) zu Ve ügung ges ell haben soll en, gel en abweichend on diesen Nu zungsbedingungen die in de do genann en Lizenz gewäh en Nu zungs ech e. Te ms o use: Documen s in EconS o may be sa ed and copied o you pe sonal and schola ly pu poses. You a e no o copy documen s o public o comme cial pu poses, o exhibi he documen s publicly, o make hem publicly a ailable on he in e ne , o o dis ibu e o o he wise use he documen s in public. I he documen s ha e been made a ailable unde an Open Con en Licence (especially C ea i e Commons Licences), you may exe cise u he usage igh s as speci ied in he indica ed licence. h ps://c ea i ecommons.o g/licenses/by/4.0/ RESEARCH Open Access Does spending ma e s? Re-looking in o a ious co a ia es associa ed wi h Ou o Pocke Expendi u e (OOPE) and ca as ophic spending on acciden al inju y om NSSO 71s ound da a Jalandha P adhan 1 , Rinshu Dwi edi 1* , Sanghami a Pa i 2 and Sa i Kuma Rou 3 Abs ac Backg ound: Acciden al Inju y is a auma ic e en which no only in luences physical, psychological, and social wellbeing o he households bu also exe s ex ensi e inancial bu den on hem. Despi e he de as a ing economic bu den o inju ies, in India, he e is limi ed da a a ailable on inju y epidemiology. This pape aims o, i s , examine he socio-economic di e en ials in Ou o Pocke Expendi u e (OOPE) on acciden al inju y; second, o look in o he le el o Ca as ophic Heal h Expendi u e (CHE) a di e en h eshold le els; and las , o explo e he adjus ed e ec o a ious socio-economic co a ia es on he le el o CHE. Me hods: Da a was ex ac ed om he key indica o s o social consump ion in India: Heal h, Na ional Sample Su ey O ganisa ion (NSSO), conduc ed by he Go e nmen o India du ing Janua y–June-2014. Logis ic eg ession analysis was employed o analyse he a ious co a ia es o OOPE and CHE associa ed o acciden al inju y. Findings: Bina y Logis ic analysis has demons a ed a signi ican associa ion be ween socioeconomic s a us o he households and he le el o OOPE and CHE on acciden al inju y ca e. People who used p i a e heal h se ices incu ed 16 imes highe odds o CHE han hose who a ailed public acili ies. The esul shows ha i he pe son is co e ed ia any ype o insu ance, he odd o CHE was lowe by abou 28% han he uninsu ed. Longe du a ion o s ay and dea h due o acciden al inju y was posi i ely associa ed wi h highe le el o OOPE. Economic s a us, na u e o heal hca e acili y a ailed and egional a ilia ion signi ican ly in luence he le el o OOPE and CHE. Conclusion: Despi e nume ous e o s by he Cen al and S a e go e nmen s o educe he inancial bu den o heal hca e, la ge numbe o households a e s ill paying a signi ican amoun om hei own pocke s. The e a e huge di e en ials in cos o he ea men among public and p i a e heal hca e p o ide s o acciden al inju y. I is expec ed ha he indings would p o ide insigh s in o he p e ailing magni ude o acciden al inju ies in India, he p o ile o he popula ion a ec ed, and he le el o OOPE among households. Keywo ds: Acciden al, Socioeconomic, OOPE, Logis ic, Economic bu den * Co espondence: [email p o ec ed] 1 Depa men o Humani ies and Social Sciences, Na ional Ins i u e o Technology, Rou kela, O issa 769 008, India Full lis o au ho in o ma ion is a ailable a he end o he a icle © The Au ho (s). 2017 Open Access This a icle is dis ibu ed unde he e ms o he C ea i e Commons A ibu ion 4.0 In e na ional License (h p://c ea i ecommons.o g/licenses/by/4.0/), which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided you gi e app op ia e c edi o he o iginal au ho (s) and he sou ce, p o ide a link o he C ea i e Commons license, and indica e i changes we e made. P adhan e al. Heal h Economics Re iew (2017) 7:48 DOI 10.1186/s13561-017-0177-z In oduc ion Inju ies 1 a e well acknowledged globally as a majo cause o dea h and disabili y, and oad a ic inju ies (RTI) 2 accoun ed o nea ly mo e han 1 million dea hs in 2015 [1–3]. As pe WHO es ima es, RTI, a e p edic ed o be he i h leading cause o dea h in all age g oups by he yea 2030. Inju ies esul s in o mo e annual dea hs as compa ed o HIV, Mala ia, and Tube culosis combined [4]. Each yea app oxima ely 250 million people wo ldwide a e a ec ed by inju y, and o hese mo e han 300,000 people die [5]. The socioeconomic bu - den o inju y is quie signi ican which a ec s mos ad e sely o he younge and mos p oduc i e demo- g aphic segmen o he popula ion [6]. In pa icula , he bu den is disp opo iona ely in Low and Middle-Income Coun ies (LMICs) whe e mo e han 90% o he mo ali y occu s due o unin en ional inju ies, p ima ily due o Road T a ic Acciden s (RTA) 3 [7, 8]. Indi iduals who sus- ain inju ies in LMICs a e six imes mo e likely o die han hose in High-Income Coun ies (HICs), gi en he limi ed capabili ies o auma ca e in low-income se ings [9]. Wi hin LMICs, India aces one o he highes bu - dens o inju ies. Acco ding o a s udy on he bu den o diseases and inju ies, 28% o yea s o li e los (YLL) in India a e a ibu ed o inju ies [10]. In ac , inju ies a e he i s cause o YLL among all causes o dea h in India. As pe he Wo ld Heal h O ganiza ion (WHO), inju y is he second leading cause o dea h in India, wi h dea hs annually om RTA being among he highes in he wo ld [4, 11]. Du ing he pas ew yea s, wi h he g owing pa e n o indus ializa ion and mo o iza ion, he e has been an inc ease in he numbe o dea hs om inju ies [12–14]. This is p ojec ed o escala e u he since he coun y is unde going apid u baniza ion. E en hough he bu den o diseases in India has been ag- g a a ed by acciden al inju ies, limi ed in o ma ion is a ailable abou he economic consequences associ- a ed wi h i . The di ec cos in ol ed in he acciden- al inju y was ound o be huge, which no only o ces he households in o he po e y ap due o high ea men cos and disabili y, bu also imposes high economic as well as socie al cos oo [15, 16]. Es ima ing he cos o inju ies is iden i ied among he i ep io i yi ems oadd ess heglobalbu den o unin en ional inju ies [17]. Backg ound Indian heal h sys em is cha ac e ized by low public spending, as majo sha e o he heal h expendi u e is bo ne by he households in o m o ou -o -pocke expendi u es (OOPE) 4 [18–20]. In case o acciden al inju y, households ha e o bea hea y cos bo h in e mso di ec aswellasindi ec heal hexpendi u e. The impo e ishmen o households in India due o OOPE and he ca as ophic heal h expendi u e (CHE) 5 on heal h a e well documen ed [16, 21, 22] and hese a e epo ed o be highe o inju ies han o o he ailmen s [17]. The majo i y o India’sci i- zens ecei e heal h ca e h ough a publicly unded sys em go e ned by he Minis y o Heal h. Da a om public heal h acili ies may p o ide some insigh s on inju ies, howe e , many o he inju ies could ha e been epo ed o non-public o p i a e heal h ca e a- cili ies o no been epo ed a all [23]. Fu he , hos- pi al eco ds, albei help ul o unde s and pa e ns and mechanisms o inju y e ospec i ely, ha e been ound o be de icien in se e al se ings [24]. Few p e- ious wo ks on a e ia y hospi al had iden i ied ha undamen al in o ma ion on pa ien demog aphics, ci cums ances unde which acciden s 6 occu ; ea - men cos s and modali ies we e equen ly no e- co ded [25]. Despi e he o e whelming bu den o inju ies, he e is limi ed da a on inju y epidemiology and i s ou - comes in India. Mo ali y s a is ics, hough used as an indica o s o inju y magni ude, may ep esen he ‘ ip o he icebe g’since non- a al inju ies exceed a al in- ju ies by up o 20 imes [26, 27]. As such no na ion- wide da a is a ailable on he p e alence, demog aphic p o ile o he inju ed pe sons, ea men and ou come o he acciden al inju y in he coun y. A ailable s ud- ies a e con ined ei he o he single acili y o hey a e limi ed o some speci ic ca ego y such as RTA, which ails in p o iding comple e pic u e o he inju y p o ile in India [24, 27]. Public heal h in e en ions and policies o educe ha m and p e en acciden s would be e ec i e only when hey a e designed o he igh popula ion, a he igh ime and in he igh se ing [28]. Since cos o inju ies may a y acco ding o age and gende , in luenced by sub le a ia ion o cul u al li es yle and beha io al pa e n, knowledge o auma epidemiology is essen ial o iden i ying he co ela es o OOPE on acciden al inju ies and de elopmen o solu ions om he public heal h iewpoin . Acciden al inju y in ol es highe expenses on seeking heal hca e se ices and o ces households o spend signi ican ly highe amoun om hei own pocke s leading o im- po e ishmen . As pe a ailable in o ma ion in he la es NSSO epo (NSS KI(71/25.0, NSSO, 2014), [17] a e age medical expendi u e pe hospi aliza ion case on acciden al inju y, is he i h highes expenses bo ne by he households a e OOPE on o he majo ailmen s such as cance , ca dio- ascula , geni ou i- na y, and psychia ic and neu ological diseases (Appendix 1). Though inju y is an impo an cause o dea h in India, he e is limi ed knowledge ega ding P adhan e al. Heal h Economics Re iew (2017) 7:48 Page 2 o 16 he economic impac on households. Ea lie , s udies examining he economic impac o inju y on house- holds we e based on ei he hospi al se ings o on he basis o limi ed samples. This is no adequa e o ex- plain he o e all economic impac o inju y on house- holds. Gi en he limi a ions o p e iously epo ed s udies, we unde ook a s udy o de e mine he mag- ni ude o inju ies, hei dis ibu ion and associa ed heal h ca e expendi u e in India. The majo objec i es o his pape a e: i s , o desc ibe he p e alence o acciden al inju y among he sampled popula ion, sec- ond, o examine he socio-economic di e en ials in OOPE on acciden al inju y by aking bo h di ec and indi ec cos s in o accoun ; hi d, o look in o he le el o CHE (5%, 10% and 15%) a a ious h eshold le els due o acciden al inju y; ou h, o measu e he adjus ed e ec o a ious co a ia es on he le el o CHE. I is expec ed ha he indings would p o ide insigh s in o he p e ailing magni ude o acciden al inju ies in India, indica e he epidemiological dis ibu- ion, he p o ile o he popula ion a ec ed and co e- la es and iden i y he p e alence o ca as ophic expendi u e, i any. Such b ead h o in o ma ion could be used o in o m he planning cen al o all ace s o inju y p e en ion. Me hod Da a is used om he key indica o s o social consump ion in India: Heal h,Na ional Sample Su ey O ganiza ion (NSSO), conduc ed by he Go e nmen o India Janua y– June-2014 i.e., he 71s ound. The p esen s udy uses household schedule 25.0 ques ionnai es. The Socio- economic Su ey (SES) ounds con ain in o ma ion on household’ssocial consump ion o heal h on a ious heads such as, he p opo ion o ailing pe sons, spells o ailmen s and hei ea men , a e o hospi aliza ion, he cos o ea men -hospi aliza ion and he cos o ea men –non- hospi alized. The ecall pe iods o ins i u ional expenses a e o 365days[17].He eweha eincludedcos unde wo heads i.e., di ec and indi ec . Di ec cos includes doc o ’s/ su geon’s ee (hospi al s a /o he specialis s, medicines, diagnos ic es s, bed cha ges, o he medical expenses (a - endan cha ges, physio he apy, pe sonal medical appliances, blood, and oxygen). Indi ec cos includes he cos o ans- po o he pa ien , o he non-medical expenses (in INR) incu ed by he households ( ood, anspo o o he s, ex- pendi u e on esco , lodging cha ges i any, e c.). The ou - come a iable o he s udy is OOPE on inju y. The app oach o measu e OOPE o heal hca e paymen s was adop ed om Wags a and Doo slae , in he Wo ld Bank documen . In addi ion o he medical and non-medical ex- pendi u e, in o ma ion was also a ailable on he household’s socio-economic and demog aphic cha ac e is ics. Va iables unde s udy This pape explains he associa ion be ween he HE and socio demog aphic a iables and how his changes ac oss cas e, educa ion and o he SES a i- ables. The independen a iables ( ela ing o o he indi iduals and households) in he s udy a e: age (less han 15, 15–29, 30–59 and 60+); sex (male and emale); le el o educa ion (illi e a e, up o p ima y, up o seconda y, g adua ion and abo e); place o esidence (u ban/ u al); social g oup (Scheduled Cas e (SC), Scheduled T ibe (ST), O he Backwa d Cas e (OBC) and O he s); eligious a ilia ion (Hindu, Muslims and O he s); household size (1–3 membe s, 4–6 and 7+ membe s); economic s a us (Poo es , Poo e , Middle, Riche and Riches ); le el o ca e (public/p i a e); insu ance co e age (co e ed/ no co e ed); sou ce o inancing (income/sa ings, bo owings and o he s); su i al s a us (Dead/Ali e); du a ion o s ay (1–2 days, 3–7 days, 8–14 days and 14+ days); and, egion (no h, no heas , eas , cen- al, wes , sou h). Fi s , desc ip i e analysis was done o assess he socio- economic and demog aphic p o ile o he pe sons wi h acciden al inju y. Second, we calcula ed socio-economic di e en ials in OOPE (wi h 95% CI) on he acciden al inju y. Thi d, CHE was calcula ed a di e en h eshold le els (5%, 10%, and 15%). Las , Bina y logis ic eg es- sion analysis was employed o explo e he ela i e e ec o socio-economic and demog aphic cha ac e is ics on he le el o CHE o inju y in India. Logis ic eg ession can be used o p edic a dependen a iable on he basis o independen s, and o de e mine he pe cen o he a iance in he dependen a iable explained by he independen s; o ank he ela i e impo ance o independen s; o assess in e ac ion e ec s, and o unde s and he impac o co a ia es. Logis ic eg ession applies maximum likelihood es ima ion a e ans o ming he dependen in o a logi a iable ( he na u al log o he odds o he dependen occu ing o no ). So, logis ic eg ession es ima es he p obabili y o ce ain e en , whe he occu ing o no . The mul iple logis ic models can be no ed as: ln p 1−p  ¼αþβ1x1þβ2x2þβ3x3þ…βixiþe Whe e, pis he p obabili y o occu ence o mul imo - bidi y, p(у= 1);β 1 β 2 ,β 3 ,…β i e e o he be a coe i- cien s;x 1 x 2 x 3 ….x i Re e o he independen a iables and e is he e o e m. STATA 12 is used o analyze he da a. We ha e also looked in o he p oblem o endo- genei y, which may no a ise in his case due o ollow- ing easons. As we all know he p oblem o endogenei y occu s due o measu emen e o s and omi ed a iable P adhan e al. Heal h Economics Re iew (2017) 7:48 Page 3 o 16 bias. The measu emen e o s could be due o ecall bias and o he simila issues ela ed o he explana- o y a iables. This p oblem is add essed in a la ge sample he e. Fu he , he measu emen e o s will no a ise he e as wha e e is ue o highe cas e o ins ance, will hold good o he lowe cas e o wha - e e is ue o lowe educa ion will also hold good o highe educa ion.I isbecause heexplana o y a iables a e no sys ema ically di e en . Resul s Socio-demog aphic p o ile o he esponden s wi h acciden al inju y Socio-economic and demog aphic cha ac e is ics o he pe sons wi h acciden al inju y 7 (Table 1) indica es ha abou 48% belonged o he age g oup o 30– 59 yea s, 24% we e in age g oup o 15–29, 16% we e aged 60+ and 12% we e in he age g oup o less han 15 yea s. Abou 56% belong o u al backg ound. Nea ly 73% o he pe sons wi h acciden al inju y we e males. Abou , 24% sampled popula ion we e illi e a e, 26% had s udied up o p ima y, 39% up o seconda y, and 12% had s udied up o g adua ion and abo e. Majo i y o he pe sons belonged o OBC g oup, ollowed by O he s, SCs and STs. Nea ly 80% pe sons belonged o he Hindu communi y, 12% we e Mus- lims and 8% we e o o he eligious g oups. Abou 59% people we e a ailing p i a e acili ies; o he s depended on public ca e. Insu ance co e age o acciden- al inju y was low since only 21% we e co e ed by any ype o insu ance scheme; abou 79% we e no co e ed by any insu ance scheme. Nea ly 96% o he households had no ecei ed any eimbu semen om he insu ance p o- ide s. Su i al s a us indica es ha 96% people who su - e ed om acciden al inju y su i ed while 4% died. Nea ly 39% sampled popula ion s ayed in he hospi al o an a e age o 3–7 days, ollowed by o he ca ego ies. A majo sou ce o inancing o acciden al inju y was om household income and sa ings; nea ly 70% inancing was om own pocke while 23% eso ed o bo owings and 7% managed inancing om o he sou ces. Regional dis i- bu ion o he sampled popula ion, who had aced acciden- al inju ies, was highe in he Sou he n (24%) egion ollowed by Cen al (23%), Eas (17%), No he n egion (16%) and o he s. Howe e he sha e o acciden al inju ies ou o he o al sampled gene al popula ion by selec ed socio-economic and demog aphic co a ia es was no ha highe (1.21% ou o gene al popula ion) (Appendix 2). Socio-economic di e en ials in he le el o OOPE Table 2 shows he socioeconomic di e en ials in OOPE. We ha e i s analyzed he pa e n o OOPE (medical, anspo a ion and non-medical), wi hou aking in o conside a ion he o al amoun o eimbu semen om insu ance. La e , o examining he e ec o eimbu se- men on he o al OOPE, he amoun eimbu sed was deduc ed om he o al expendi u e on acciden al inju y ca e. The sha e o mean OOPE (wi hou conside ing eimbu semen amoun ) was highe o medical expenses (INR 24916) ollowed by non-medical ex- pendi u e (INR 1909) and anspo a ion (INR 906), in he o e all acciden al inju y expendi u e (INR 27731). People in he age g oup o 60+ had spen mo e unde all heads i.e., medical ca e (INR 30567), non-medical (INR 2376) and anspo a ion (INR 1097), in compa ison o o he age g oups. Simila ly, spending on acciden al inju y among males was highe han o emales unde all he heads. Those who we e educa ed ill g adua ion o abo e we e spending he highes on medical, anspo a ion and non-medical heads compa ed o o he s. People esiding in he u ban a eas we e spending highe han hei u al coun e pa s on medical, non-medical, and in e ms o o e all expenses. O he cas e people we e spending highe han hei OBC, SC and ST coun e - pa s unde all he heads. Resul s indica e ha Hindus we e spending mo e han o he s and Muslims in acciden al inju y cases. People belonging o he iches weal h quin ile we e spending maximum unde all he heads, ollowed by o he s. Minimum ex- pendi u e was among people who belong o he poo es economic s a us. Simila ly, expenses we e highe i he ac- ciden al inju y ca e was sough om p i a e acili y and wi h access o some so o insu ance co e age. A e age expendi u e unde all he heads was highe o deceased pe sons in compa ison o hose who had su i ed acci- den al inju y. Wi h he leng hening o s ay du a ion in he hospi al, OOPE inc eased a a signi ican a e. The le el o OOPE was highe among households who me hei heal hca e inancing need h ough bo owings [29]. Re- sul s also indica e egional a ia ions in he mean OOPE - spending was highe in he Wes e n egion, ollowed by Cen al and Sou he n egions. Lowes le el o OOPE was eco ded among he No heas e n s a es. Finally, we p esen ed he socio-economic di e en ials in OOPE excluding he amoun o eimbu semen . Resul s sugges ha he mean OOPE was ma ginally lowe o households who ecei ed eimbu semen (INR 26,132), compa ed o hei coun e pa s (INR 27731). The eimbu sed amoun was highe among elde ly popula ion, males, households educa ed abo e g adu- a ion, esiding in he u ban a eas, and belonging o heo he sascas eg oup.Simila ly,Muslims,house- holds wi h 1–3 membe s, highe economic sec ion, seeking p i a e ca e co e ed ia insu ance schemes and ecei ed eimbu semen , s ayed in he hospi al o mo e han 14 days, ecei ed highe eimbu se- men , which ma ginally educed he bu den o OOPE P adhan e al. Heal h Economics Re iew (2017) 7:48 Page 4 o 16 as compa ed o o he ca ego ies. Howe e , e en a e ecei ing eimbu semen om insu ance companies, he households we e paying a signi ican amoun om hei own pocke s o seeking ca e o acciden al inju y. Le el o ca as ophic heal h expendi u e on acciden al inju y ca e Table 3 shows he CHE a 5%, 10% and 15% le el o acciden al inju y ca e. Resul s indica e ha a 5% le el, CHE was highes among ca ego ies -pe sons in he age g oup o 15–29 yea s, males, a ained educa- ion up o g adua ion o abo e, esiding in he u al a eas, belongs o SC and O he social g oup, o he eligious communi ies, household size up o 1–3 membe s and belongs o he poo es sec ion o he popula ion. Simila ly, hose who had a ailed ca e om p i a e p o ide s, no co e ed by insu ance, su i ed a e he acciden al inju y, inanced om he bo owings, Table 1 Socio-economic and demog aphic cha ac e is ics o pe sons wi h acciden al inju y, India, 2014 Co- a ia es Pe cen Numbe Age less han 15 11.9 482 15–29 24.3 985 30–59 47.7 1934 60+ 16.1 654 Sex Male 73.3 2973 Female 26.7 1082 Educa ion le el a Illi e a e 24.1 941 Up o p ima y 25.9 1011 Up o seconda y 38.6 1509 G adua ion and abo e 11.5 449 Residence Ru al 55.8 2264 U ban 44.2 1791 Cas e Scheduled T ibes 9.5 387 Scheduled Cas es 17.9 724 O he Backwa d Classes (OBC) 39.3 1595 O he s 33.3 1349 Religion Hindu 79.6 3227 Muslim 12.2 493 O he s 8.3 335 Household size 1–3 membe 21.0 853 4–6 membe s 57.6 2335 7 + membe s 21.4 867 Weal h quin ile Poo es 15.0 608 Poo e 20.9 845 Middle 19.4 788 Riche 23.0 935 Riches 21.7 879 Le el o ca e Public 41.2 1670 P i a e 58.8 2385 Insu ance co e age a No co e ed 79.2 3098 Co e ed 20.8 812 Reimbu semen s a us Recei ed 4.3 174 Table 1 Socio-economic and demog aphic cha ac e is ics o pe sons wi h acciden al inju y, India, 2014 (Con inued) Co- a ia es Pe cen Numbe No ecei ed 95.7 3881 Su i al s a us Ali e 96.4 3910 Dead 3.6 145 Du a ion o s ay 1–2 days 24.3 985 3–7 days 39.4 1599 8–14 days 17.0 688 14+ days 19.2 783 Sou ce o inancing Household income and sa ing 69.6 2826 Bo owings 23.0 933 O he sou ces 7.3 296 Regions b No h 15.5 628 No heas 7.7 312 Eas 17.2 697 Cen al 22.4 909 Wes 13.1 531 Sou h 24.1 978 To al 100 4055 Sou ce: Au ho s’es ima es om NSSO su ey, 2014 a Based on 3910 cases b No h: J& K Himachal P adesh, Punjab, Chandiga h, Ha yana, Delhi, Rajas han; No heas : Sikkim, A unachal P adesh,, Nagaland, Manipu , Mizo am, T ipu a, Meghalaya, Assam; Eas : Biha , Wes Bengal, Jha khand, Odisha; Cen al: U a P adesh, Chha isga h, Madhya P adesh; Wes : Guj a , Daman and Diu, Dada and Naga Ha eli, Maha ash a, Goa; Sou h: Andh a P adesh, Ka na aka, Lakshadweep, Ke ala, Tamil Nadu, Pondiche y, Andaman and Nicoba , Telangana P adhan e al. Heal h Economics Re iew (2017) 7:48 Page 5 o 16 Table 2 Socio-economic di e en ials in OOPE (in INR), India, 2014 Co- a ia es Medical T anspo Non-medical To al (Including eimbu semen amoun ) To al (Excluding eimbu semen amoun ) Age less han 15 12,822 589 1234 14,646 14,165 15–29 24,535 937 1908 27,380 25,782 30–59 26,606 914 1938 29,457 27,224 60+ 30,567 1097 2376 34,040 33,309 Sex Male 26,173 988 2094 29,255 27,542 Female 21,337 674 1380 23,391 22,116 Educa ion le el a Illi e a e 18,782 785 1568 21,135 20,849 Up o p ima y 20,182 906 1832 22,920 22,248 Up o seconda y 28,415 878 2084 31,377 29,367 G adua ion and abo e 38,660 930 2000 41,589 34,851 Residence Ru al 21,930 979 1863 24,772 24,127 U ban 30,691 765 1997 33,453 30,008 Cas e Scheduled T ibes 12,589 762 1774 15,126 14,917 Scheduled Cas es 19,978 791 1822 22,591 21,537 O he Backwa d Classes (OBC) 24,130 891 1872 26,894 26,073 O he s 31,507 1030 2042 34,579 31,243 Religion Hindu 26,126 927 2014 29,066 27,597 Muslim 18,250 779 1234 20,263 17,858 O he s 23,429 909 1987 26,325 24,752 Household size 1–3 membe 25,892 846 1903 28,640 25,909 4–6 membe s 23,716 890 1827 26,433 24,887 7 + membe s 27,871 1025 2185 31,081 30,486 Weal h quin ile Poo es 15,579 1116 1524 18,219 18,086 Poo e 18,355 770 1462 20,587 20,446 Middle 18,460 746 1570 20,775 19,110 Riche 25,312 799 2023 28,134 27,113 Riches 47,496 1217 3008 51,720 46,467 Le el o ca e Public 7014 746 1426 9186 8869 P i a e 36,261 1008 2215 39,483 37,071 Insu ance co e age a No co e ed 24,466.00 881.00 1861 27,208 27,049 Co e ed 25,565.00 826.00 1936 28,327 21,722 Reimbu semen s a us Recei ed 66,720 1223 22,167 70,159 24,691 P adhan e al. Heal h Economics Re iew (2017) 7:48 Page 6 o 16 s ayed in he hospi al mo e han 14 days, belongs o he wes e n egions, also incu ed highe CHE a 5%. A he 10% le el, also simila pa e n was ob- se ed ega ding CHE excep o a ew excep ions such as, olde popula ion o 60+ yea s, households who belong o he Hindu eligious communi y and pe sons who died a e he acciden al inju y, who in- cu ed highe CHE. A he 15% le el, simila ends we e eco ded in e ms o CHE as obse ed a 10%, on acciden al inju y excep o one excep ion; he e CHE was mo e concen a ed among pe sons who we e illi e a e. Res o he a iables showed simila esul s. Resul s om he logis ic eg ession analysis Table 4 shows he esul s o he Bina y logis ic eg es- sion analysis on he ela ed co a ia es o he de e mi- nan s o acciden al inju y a 5%, 10% and 15% le els o CHE. Resul s e eal ha odds o CHE a 5% a e abou 33% lowe o emales as compa ed o males. Educa- ional le el shows ha pe sons who a e educa ed up o p ima y ha e signi ican ly lowe odds o CHE. Odds o CHE o people who we e educa ed up o g adu- a ion o abo e we e abou wo imes highe han hose who we e illi e a e. The occu ence o CHE was lowe by 44% o Muslims as compa ed o Hindus. Odds o CHE we e signi ican ly lowe by 79% and 68% o he iches and iche sec ion espec i ely, compa ed o he poo es . People who used p i a e heal h se ices incu ed 16 imes highe odds o CHE han hose who a ailed public acili ies. The esul shows ha i he pe son is co e ed ia any ype o in- su ance, he odd o CHE was lowe by abou 28% han he uninsu ed. Du a ion o s ay is an impo an de e minan o CHE. Resul s indica e ha odds o CHE o acciden al inju y ca e was abou 34 imes highe o hose who s ayed in he hospi al o mo e han 14 days, as compa ed o hose who s ayed o 1–2 days. The analysis shows ha odds o CHE a 10% and 15% a e abou wo imes highe o people who belong o he age g oup o 60+ compa ed o less han 15 yea s age g oup. Simila ly, odds o ca a- s ophic spending we e nea ly wo imes highe o people who had educa ion up o g adua ion o abo e. Table 2 Socio-economic di e en ials in OOPE (in INR), India, 2014 (Con inued) Co- a ia es Medical T anspo Non-medical To al (Including eimbu semen amoun ) To al (Excluding eimbu semen amoun ) No ecei ed 23,392 895 1897 26,184 26,184 Su i al s a us a Dead 29,365 1794 2605 33,764 33,661 Ali e 24,723 868 1878 27,469 25,805 Du a ion o s ay 1–2 days 4858 354 400 5613 5422 3–7 days 18,638 842 1320 20,801 19,143 8–14 days 32,199 1181 2433 35,813 34,170 14+ days 60,380 1595 4833 66,809 63,385 Sou ce o inancing Household income and sa ing 20,163 727 1528 22,419 21,157 Bo owings 35,378 1260 2780 39,400 36,973 O he sou ces 29,573 1231 2225 33,031 31,418 Regions b No h 23,729 1046 1990 26,765 24,196 No heas 8970 683 1329 10,982 10,641 Eas 19,256 1038 1555 21,850 19,776 Cen al 25,560 816 1671 28,048 27,654 Wes 35,611 905 1928 38,443 36,187 Sou h 24,520 836 2231 27,586 26,203 To al 24,916. 906 1909 27,731 26,132 Sou ce: Au ho s’es ima es om NSSO su ey, 2014 a Based on 3910 cases b No h: J& K Himachal P adesh, Punjab, Chandiga h, Ha yana, Delhi, Rajas han; No heas : Sikkim, A unachal P adesh,, Nagaland, Manipu , Mizo am, T ipu a, Meghalaya, Assam; Eas : Biha , Wes Bengal, Jha khand, Odisha; Cen al: U a P adesh, Chha isga h, Madhya P adesh; Wes : Guj a , Daman and Diu, Dada and Naga Ha eli, Maha ash a, Goa; Sou h: Andh a P adesh, Ka na aka, Lakshadweep, Ke ala, Tamil Nadu, Pondiche y, Andaman and Nicoba , Telangana P adhan e al. Heal h Economics Re iew (2017) 7:48 Page 7 o 16 Odds o CHE a 10% and 15% le el was 89% and 87% lowe o he iches sec ion o he popula ion as com- pa ed o he poo es g oup. Simila ly, he odds o CHE was 14 (10% le el) and 12 imes (15% le el) highe in p i- a e ca e in compa ison o hose who ha e a ailed ca e om go e nmen acili ies. Odds o CHE a 10% and 15% we e 55% and 70% lowe o hose who su i ed he acci- den han he deceased. Du a ion o s ay signi ican ly in- luences he le el o CHE. Odds o CHE a 10% we e abou 56 imes and a 15% i was 60 imes highe , o hose who s ayed in he hospi al o mo e han 14 days, in compa ison o hose who s ayed only o 1–2days.The esul s indica e ha odds o CHE we e h ee imes highe (a 10% CHE) and wo imes highe (a 15% CHE) o hose who bo owed o acciden al inju y ca e, han o he coun e pa s. Odds o CHE we e nea ly 61% lowe o he sou he n egion people a 10% CHE and 62% lowe a 15% CHE han o he s. Discussion Acciden al inju y is one o he impo an causes o dea hs in India. The e has been a sha p inc ease in cases o acciden al inju y due o hea y indus ializa ion and a disp opo iona e ise in he numbe o ehicles [30]. As pe ou in o ma ion, his s udy is a pionee ing a emp o explo e a ious socio- economic and demog aphic co a ia es o ca as ophic expendi u e on acciden al inju y in India. This s udy indica es he ca as ophic Table 3 CHE a 5, 10 and 15% le el, India, 2014 Co- a ia es 5% 10% 15% Age less han 15 70.1 48.1 34.6 15–29 75.0 56.9 45.1 30–59 71.9 55.2 44.6 60+ 72.5 58.2 49.0 Sex Male 74.4 56.7 45.7 Female 67.5 51.4 40.6 Educa ion le el a Illi e a e 71.3 56.7 45.9 Up o p ima y 71.6 53.4 41.5 Up o seconda y 73.1 54.8 44.5 G adua ion and abo e 75.8 57.8 44.8 Residence Ru al 75.2 57.8 46.3 U ban 69.2 52.1 41.7 Cas e Scheduled T ibes 69.2 47.2 34.1 Scheduled Cas es 73.1 57.1 46.2 Backwa d Classes 72.7 54.9 44.8 O he s 73.1 57.0 45.4 Religion Hindu 72.8 56.1 45.6 Muslim 69.5 51.5 41.7 O he s 73.7 52.8 34.6 Household size 1–3 membe 77.3 62.3 52.2 4–6 membe s 71.7 53.9 42.5 7 + membe s 69.9 52.0 41.1 Weal h quin ile Poo es 79.1 66.1 54.6 Poo e 74.5 57.2 47.6 Middle 74.7 56.1 43.5 Riche 69.1 52.2 41.9 Riches 67.9 48.4 37.0 Le el o ca e Public 52.2 32.8 23.4 P i a e 86.7 71.0 58.8 Insu ance co e age a No co e ed 73.9 56.3 45.0 Co e ed 68.1 51.3 40.8 Su i al s a us Dead 68.2 55.8 48.2 Ali e 72.7 55.2 44.1 Table 3 CHE a 5, 10 and 15% le el, India, 2014 (Con inued) Co- a ia es 5% 10% 15% Du a ion o s ay 1–2 days 44.0 22.0 13.4 3–7 days 74.5 53.6 39.5 8–14 days 86.7 73.9 64.0 14+ days 91.8 84.0 75.4 Sou ce o inance Household income and sa ing 66.1 47.4 36.2 Bo owings 89.7 75.3 64.5 O he sou ces 79.7 66.8 57.7 Regions No h 69.1 51.4 39.9 No heas 70.1 43.9 29.1 Eas 72.8 55.6 44.6 Cen al 74.0 57.7 47.5 Wes 79.8 64.7 53.3 Sou h 69.9 53.7 43.7 To al 72.5 55.3 44.3 Sou ce: Au ho s’es ima es om NSSO su ey, 2014 a Based on 3910 cases P adhan e al. 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