Brinda Ethel Mary, Kowal Paul, Attermann Jørn, Enemark Ulrika
Section for Health Promotion and Health Services Research, Department of Public health, Aarhus University, Aarhus, Denmark.
Department of Health Statistics and Information Systems, World Health Organization, Geneva, Switzerland Research Centre for Gender, Health and Ageing, University of Newcastle, New South Wales, Australia.
J Epidemiol Community Health. 2015 May;69(5):489-94. doi: 10.1136/jech-2014-204960. Epub 2015 Jan 9.
Healthcare financing through out-of-pocket payments and inequities in healthcare utilisation are common in low and middle income countries (LMICs). Given the dearth of pertinent studies on these issues among older people in LMICs, we investigated the determinants of health service use, out-of-pocket and catastrophic health expenditures among older people in one LMIC, India.
We accessed data from a nationally representative, multistage sample of 2414 people aged 65 years and older from the WHO's Study on global AGEing and adult health in India. Sociodemographic characteristics, health profiles, health service utilisation and out-of-pocket health expenditure were assessed using standard instruments. Multivariate zero-inflated negative binomial regression models were used to evaluate the determinants of health service visits. Multivariate Heckman sample selection regression models were used to assess the determinants of out-of-pocket and catastrophic health expenditures.
Out-of-pocket health expenditures were higher among participants with disability and lower income. Diabetes, hypertension, chronic pulmonary disease, heart disease and tuberculosis increased the number of health visits and out-of-pocket health expenditures. The prevalence of catastrophic health expenditure among older people in India was 7% (95% CI 6% to 8%). Older men and individuals with chronic diseases were at higher risk of catastrophic health expenditure, while access to health insurance lowered the risk.
Reducing out-of-pocket health expenditure among older people is an important public health issue, in which social as well as medical determinants should be prioritised. Enhanced public health sector performance and provision of publicly funded insurance may protect against catastrophic health expenses and healthcare inequities in India.
在低收入和中等收入国家（LMICs），通过自付费用进行医疗保健融资以及医疗保健利用方面的不平等现象很常见。鉴于LMICs中老年人在这些问题上的相关研究匮乏，我们调查了印度这一LMIC中老年人医疗服务使用、自付费用和灾难性医疗支出的决定因素。
我们获取了世界卫生组织在印度开展的全球老龄化与成人健康研究中2414名65岁及以上老年人的全国代表性多阶段样本数据。使用标准工具评估社会人口学特征、健康状况、医疗服务利用情况和自付医疗费用。采用多变量零膨胀负二项回归模型评估医疗服务就诊的决定因素。采用多变量赫克曼样本选择回归模型评估自付费用和灾难性医疗支出的决定因素。
残疾和低收入参与者的自付医疗费用较高。糖尿病、高血压、慢性肺病、心脏病和结核病增加了就诊次数和自付医疗费用。印度老年人灾难性医疗支出的患病率为7%（95%CI 6%至8%）。老年男性和患有慢性病的人灾难性医疗支出风险较高，而获得医疗保险则降低了风险。
减少老年人的自付医疗费用是一个重要的公共卫生问题，其中社会和医疗决定因素都应优先考虑。加强公共卫生部门的绩效和提供公共资助的保险可能有助于防范印度的灾难性医疗费用和医疗保健不平等问题。
