Health service use, out-of-pocket payments and catastrophic health expenditure among older people in India: The WHO Study on global AGEing and adult health (SAGE) Ethel Mary Brinda, 1 Paul Kowal, 2,3 Jørn Attermann, 4 Ulrika Enemark 1 1 Section for Health Promotion and Health Services Research, Department of Public health, Aarhus University, Aarhus, Denmark 2 Department of Health Statistics and Information Systems, World Health Organization, Geneva, Switzerland 3 Research Centre for Gender, Health and Ageing, University of Newcastle, New South Wales, Australia 4 Section of Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark Correspondence to Dr Ethel Mary Brinda, Section for Health Promotion and Health Services Research, Department of Public Health, Aarhus University, Building 1260, Bartholins alle 2, 8000 Aarhus C, Denmark; ebam@soci.au.dk Received 16 September 2014 Revised 3 December 2014 Accepted 22 December 2014 To cite: Brinda EM, Kowal P, Attermann J, et al. J Epidemiol Community Health Published Online First: [ please include Day Month Year] doi:10.1136/ jech-2014-204960 ABSTRACT Background 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. Methods 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. Results 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. Conclusions 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. INTRODUCTION The demographic and epidemiological transitions associated with population ageing present many new challenges for low and middle income countries (LMICs). Increased healthcare expenditures, chronic disease burden and absence of social secur- ity systems 1 have adverse consequences for the growing ageing populations and also the economies of LMICs. 2 Establishing health equity 3 in health systems by fair distribution of healthcare resources remains a considerable challenge in LMICs. 4 The influences of affordability and accessibility in deter- mining health service use in LMICs 5 have placed their older populations at additional risk of poor health. 6 Studies have shown that as the need for out-of-pocket health expenditure on health services increases, there is a corresponding decrease in the use of such services in LMICs. 78 Inequities in access to health service, health payments and distribution of healthcare are important public health issues in Asia. 19 Healthcare financing through out-of-pocket payments results in catastrophic health expenditure and impoverishment in many Asian countries, with India prominent among them. 8 10 India has the second largest number of older people aged over 65 years (70 million) 11 after China. However, the gross domestic product (GDP) spent on the health sector in India is only 3.7% compared to 11.9% of GDP spent in high-income countries. India also has a high share of private health expend- iture, at 72% of total health expenditure, of which 86% is comprised of out-of-pocket health expend- iture. 12 Lack of comprehensive insurance schemes, 13 higher levels of out-of-pocket payments in public health sectors 14 and increased choice of healthcare seeking in private health sectors affect healthcare equity in India. 1 15 Earlier LMIC studies reported healthcare evading behaviour among older people with disability and chronic disease. 16 17 Insufficient financial resources and lack of risk pooling mechan- isms to protect against catastrophic health expendi- tures are barriers to accessing essential health services. 7 18 The relationship between disparities in observed demand and access to health service in LMICs are codified by the inverse care law, which states that vulnerable people 19 with greater healthcare needs receive the least healthcare. Theoretical under- standing of the factors involved in healthcare use and expenditure is based on Andersen’s behavioural model, 20 which invokes predisposing factors, enab- ling factors and need for healthcare components, as the major determinants of an individual’s predispos- ition to utilise or spend on healthcare. 21 22 Out-of-pocket payments among older people without financial protection increase the risk of catastrophic health expenditure. 10 The WHO defines health expenditure as catastrophic when it exceeds 40% of the effective income remaining after basic subsistence expenditure. 23 Recognising the population at risk of catastrophic health expenditure is important to provide targeted pre- ventative health interventions and financial protect- ive interventions through prepayment schemes. Brinda EM, et al. J Epidemiol Community Health 2015;0:1–6. doi:10.1136/jech-2014-204960 1 Research report JECH Online First, published on January 9, 2015 as 10.1136/jech-2014-204960 Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.