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      Horizontal inequity in outpatient care use and untreated morbidity: evidence from nationwide surveys in India between 1995 and 2014


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          Equity in healthcare has been a long-term guiding principle of health policy in India. We estimate the change in horizontal inequities in healthcare use over two decades comparing the older population (60 years or more) with the younger population (under 60 years). We used data from the nationwide healthcare surveys conducted in India by the National Sample Survey Organization in 1995–96 and 2014 with sample sizes 633 405 and 335 499, respectively. Bivariate and multivariate logit regression analyses were used to study the socioeconomic differentials in self-reported morbidity (SRM), outpatient care and untreated morbidity. Deviations in the degree to which healthcare was distributed according to need were measured by horizontal inequity index (HI). In each consumption quintile the older population had four times higher SRM and outpatient care rate than the younger population in 2014. In 1995–96, the pro-rich inequity in outpatient care was higher for the older (HI: 0.085; 95% CI: 0.066, 0.103) than the younger population (0.039; 0.034, 0.043), but by 2014 this inequity became similar. Untreated morbidity was concentrated among the poor; more so for the older (−0.320; −0.391, −0.249) than the younger (−0.176; −0.211, −0.141) population in 2014. The use of public facilities increased most in the poorest and poor quintiles; the increase was higher for the older than the younger population in the poorest (1.19 times) and poor (1.71 times) quintiles. The use of public facilities was disproportionately higher for the poor in 2014 than in 1995–96 for the older (−0.189; −0.234, −0.145 vs − 0.065; −0.129, −0.001) and the younger (−0.145; −0.175, −0.115 vs − 0.056; −0.086, −0.026) population. The older population has much higher morbidity and is often more disadvantaged in obtaining treatment. Health policy in India should pay special attention to equity in access to healthcare for the older population.

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          This paper offers a critical appraisal of the various methods employed to date to measure inequalities in health. It suggests that only two of these--the slope index of inequality and the concentration index--are likely to present an accurate picture of socioeconomic inequalities in health. The paper also presents several empirical examples to illustrate of the dangers of using other measures such as the range, the Lorenz curve and the index of dissimilarity.
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                Author and article information

                Health Policy Plan
                Health Policy Plan
                Health Policy and Planning
                Oxford University Press
                September 2017
                17 April 2017
                17 April 2017
                : 32
                : 7
                : 969-979
                [1 ]Public Health Foundation of India, New Delhi, India
                [2 ]Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
                [3 ]Centre for Longitudinal Studies, Department of Social Science, UCL–Institute of Education, University College London, UK
                [4 ]Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
                Author notes
                [* ]Corresponding author. Public Health Foundation of India, Plot 47, Sector 44, Gurgaon – 122 002, National Capital Region, India. E-mail: anamika.pandey@ 123456phfi.org
                © The Author 2017. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

                : 1 February 2017
                Page count
                Pages: 11
                Funded by: Wellcome Trust 10.13039/100004440
                Original Articles

                Social policy & Welfare
                concentration index,healthcare use,horizontal inequity,india,older population,outpatient,untreated morbidity


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