Are there disparities between the rich and the poor in health expenditures for treatment of illness and for preventive purposes? Evidence of barriers to access in Kerala, India

Objective: We examine patterns of expenditures on health services in Kerala, India, evaluate the extent of health expenditure disparities and identify factors associated with these disparities.

Methods: Longitudinal data of annual health care consumption for 531 households (2926 individuals) is used. Expenses are categorized according to type of health need: expenditures for episodes of illness and expenditures for episodes of health maintenance (preventive purposes). For each individual, data on occurrence of events of health services utilization was recorded, as well as any expenditures related to each utilization. Expenditures considered included direct expenditures (doctor and hospital fees, prescriptions, tests, etc.) and non-direct expenditures (transportation, lodging costs, etc). ANOVA, marginal estimates means, multiple comparison tests (with Scheffé adjustments) are used. For episodes of illness, the analyses were controlled for episode severity.

Results: Substantial disparities in health expenditures exist between India's rich and poor, and these are greater for episodes of illness considered "severe". Individuals considered as living below the poverty line (BPL) spend less for treatment of episodes of illness than non-BPL individuals. The poorest are also 7.6 times more likely than the richest to have no health expenditure at all when faced with a severe episode of illness. The gap in health expenditures between the rich and the poor becomes more important when we consider expenditures for health maintenance purposes (preventive care), with the poorest spending only a fraction of what the richest spend (5% when we consider caste groups; 26% when we consider the poverty line indicator) on preventive care. Gender differences in health expenditures also exist.

Conclusion: Results provide consistent evidence of inequality in health expenditures across socio-economic groups. Poorer individuals face severe budget constraints for health care expenditures. While significant disparities are present across social groups for the treatment of episodes of illness, results indicate that the poorest caste group simply cannot afford maintenance/preventive care.