title: 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).
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.
authors.affiliation: Section for Health Promotion and Health Services Research, Department of Public health, Aarhus University, Aarhus, Denmark.
authors.forename: Ethel Mary
authors.initials: EM
authors.lastname: Brinda
authors.affiliation: 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.
authors.forename: Paul
authors.initials: P
authors.lastname: Kowal
authors.affiliation: Section of Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark.
authors.forename: Jørn
authors.initials: J
authors.lastname: Attermann
authors.affiliation: Section for Health Promotion and Health Services Research, Department of Public health, Aarhus University, Aarhus, Denmark.
authors.forename: Ulrika
authors.initials: U
authors.lastname: Enemark
mesh_terms: D017677:Age Distribution; D000368:Aged; D002388:Catastrophic Illness / Q000191:economics* / Q000453:epidemiology; D003430:Cross-Sectional Studies; D004522:Educational Status; D005260:Female; D005382:Financing, Personal / Q000191:economics / Q000706:statistics & numerical data*; D005102:Health Expenditures; D006296:Health Services / Q000145:classification / Q000191:economics / Q000706:statistics & numerical data*; D054625:Healthcare Disparities / Q000191:economics*; D006801:Humans; D007194:India / Q000453:epidemiology; D007348:Insurance, Health / Q000145:classification / Q000191:economics; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D017678:Sex Distribution; D064890:Social Determinants of Health / Q000191:economics / Q000706:statistics & numerical data*; D014944:World Health Organization
keywords: AGEING; HEALTH SERVICES; PUBLIC HEALTH; SOCIO-ECONOMIC