Hans Rosling Center for Population Health, Institute for Health Metrics and Evaluation, University of Washington, Guthrie Annex 3 (GA3), Seattle, WA 98121, USA.
Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA.
Health Policy Plan. 2022 Aug 3;37(7):872-884. doi: 10.1093/heapol/czac035.
India has high rates of catastrophic health expenditure (CHE): 16% of Indian households incur CHE. To understand why CHE is so high, we conducted an in-depth analysis in the state of Odisha-a state with high rates of public sector facility use, reported eligibility for public insurance of 80%, and the provision of drugs for free in government-run facilities-yet with the second-highest rates of CHE across India (24%). We collected household data in 2019 representative of the state of Odisha and captured extensive information about healthcare seeking, including the facility type, its sector (private or public), how much was spent out-of-pocket, and where drugs were obtained. We employ Shapley decomposition to attribute variation in CHE and other financial hardship metrics to characteristics of healthcare, controlling for health and social determinants. We find that 36.3% (95% uncertainty interval: 32.7-40.1) of explained variation in CHE is attributed to whether a private sector pharmacy was used and the number of drugs obtained. Of all outpatient visits, 13% are with a private sector chemist, a similar rate as public primary providers (15%). Insurance was used in just 6% of hospitalizations and its use explained just 0.2% (0.1-0.4) of CHE overall. Eighty-six percent of users of outpatient care obtained drugs from the private sector. We estimate that eliminating spending on private drugs would reduce CHE by 56% in Odisha. The private sector for pharmaceuticals fulfills an essential health system function in Odisha-supplying drugs to the vast majority of patients. To improve financial risk protection in Odisha, the role currently fulfilled by private sector pharmacies must be considered alongside existing shortcomings in the public sector provision of drugs and the lack of outpatient care and drug coverage in public insurance programs.
印度灾难性卫生支出（CHE）发生率较高：16%的印度家庭发生 CHE。为了了解 CHE 为何如此之高，我们在奥里萨邦进行了深入分析——该邦公共部门医疗机构利用率高，报告称公共保险的参保率为 80%，并且政府运营的医疗机构免费提供药品——但在印度，该邦的 CHE 发生率却是第二高（24%）。我们于 2019 年在奥里萨邦收集了具有代表性的家庭数据，并收集了有关医疗保健的广泛信息，包括医疗机构类型、其所属部门（私营或公立）、自付费用以及药品来源。我们采用 Shapley 分解法，将 CHE 和其他财务困难指标的变化归因于医疗保健的特点，并控制了健康和社会决定因素。我们发现，36.3%（95%置信区间：32.7-40.1）的 CHE 变化归因于是否使用私营部门药房以及获得的药品数量。所有门诊就诊中，有 13%是在私营部门药剂师处就诊，与公立初级医疗机构（15%）的就诊率相似。仅 6%的住院治疗使用了保险，其使用仅解释了 CHE 总体的 0.2%（0.1-0.4）。86%的门诊患者从私营部门获得药品。我们估计，在奥里萨邦，消除对私营部门药品的支出将使 CHE 降低 56%。私营部门在奥里萨邦的药品供应中发挥着至关重要的卫生系统功能，为绝大多数患者提供药品。为了改善奥里萨邦的财务风险保护，必须考虑到私营部门药房目前在公共部门药品供应以及公共保险计划中缺乏门诊保健和药品覆盖方面的现有不足。
