|Year : 2015 | Volume
| Issue : 3 | Page : 264-268
Household out-of-pocket medical and dental expenses among residents of Modinagar city: A crossectional questionnaire study
Khushboo Singh, Basavaraj Patti, Ashish Singla, Ritu Gupta, Hansa Kundu, Swati Jain
Department of Public Health Dentistry, DJ College of Dental Sciences and Research, Modinagar, Uttar Pradesh, India
|Date of Web Publication||14-Sep-2015|
Department of Public Health Dentistry, DJ College of Dental Sciences and Research, Modinagar, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Out-of-pocket (OOP) payments are the principal source of health care finance in most Asian countries, and India is no exception. Availability and accessibility of the health care are important for the overall health status of any community. Aim: To assess the proportion of monthly family income spent on medical and dental expenses. Materials and Methods: A door to door survey was conducted in Govinpuri ward of Modinagar using dual stage random sampling. A 14-item open-ended questionnaire was used, which was filled by the investigator by interviewing the head of the family. Data were entered into Microsoft excel and analyzed using SPSS version 19 (SPSS Inc., Chicago, IL, USA). Results: A total of 101 families were included in the study. The major amount of the monthly family income was spent on medical treatment as compared to dental treatment. The average OOP expenditure on the dental and medical treatment was 2135.94 ± 656.8 international normalized ratio (INR) and 8771.28 ± 1056.43 INR (P = 0.038), respectively. Medical insurance formed a substantial proportion of the monthly family expenditure as compared to dental insurance (P = 0.023). The total medical expenses were 13.21%, and dental expenses were 8.84% of family income. Conclusion: The present study revealed that the family expenditure on medical and dental treatments differs significantly among the peri-urban population of Modinagar. The average three-month expenditure on the dental treatment was found to be rather depressing when compared to that on medical discourse. There was also a pronounced difference in the dental and medical insurance utilization among the study population.
Keywords: Dental care, health care, health expenditures, health insurance, out-of-pocket
|How to cite this article:|
Singh K, Patti B, Singla A, Gupta R, Kundu H, Jain S. Household out-of-pocket medical and dental expenses among residents of Modinagar city: A crossectional questionnaire study. J Indian Assoc Public Health Dent 2015;13:264-8
|How to cite this URL:|
Singh K, Patti B, Singla A, Gupta R, Kundu H, Jain S. Household out-of-pocket medical and dental expenses among residents of Modinagar city: A crossectional questionnaire study. J Indian Assoc Public Health Dent [serial online] 2015 [cited 2020 Mar 30];13:264-8. Available from: http://www.jiaphd.org/text.asp?2015/13/3/264/165254
| Introductio|| |
Health care finance in developing and low-income nations is still predominantly based on out-of-pocket (OOP) where social security measures an illness not only reduces welfare directly, it also increases the risk of poverty due to high treatment expenditures.  OOP spending is any direct spending by households, including gratuities and in-kind payments, to health practitioners and suppliers of pharmaceuticals, therapeutic appliances, other goods and services whose primary purpose is to bestow to the restoration or enhancement of the wellness condition of individuals or population groups.  It is basically a part of private health expenditure. ,
OOP payment mode is the primary source of health-care financing in many countries like Maldives, Bhutan, Sri Lanka. , Indian health care scenario reveals that out of the total family income, 74% of the income incurs for outpatient treatment, and only 26% is for inpatient treatment followed by purchasing drugs which accounted for 72% of the total private OOP expenditure. Around 30% in rural India actually do not break for any treatment for pure financial reasons. Likewise, in urban areas, it was found that 20% of ailments remained untreated for financial reasons in 2004, increased by 10% in 1995. 
Analysis of per person public spending on health has shown varied results. While on one hand the government of India spends just 19 purchasing power parity dollars on every person for health; the figure stood at 207 in Thailand, 122 in China, 88 in Sri Lanka, 751 in Maldives, and 60 in Bhutan.  The per person government spending on health in India was about 22% of that in Sri Lanka, 16% of that in China, and <10% of that in Thailand implying, public spending on health (0.94% of the gross domestic product (GDP) in our country is among the lowest in the world. Also, the government is facing pressures to increase the budgetary allocations to the social sector. 
Thus, there is a need for some understanding of the behavior of public expenditures on health.  The analysis of health care expenditures, in general, has been a subject of research and discussion in recent times globally. , Inequality in health services access and utilization are influenced by OOP health expenditures in many low- and middle-income countries (LMIC). LMIC support 84% of the global population, comprise 90% of the worldwide disease burden and yet, account for only 12% of global resources spent on health.  Public expenditures on health, as a share of their GDP, are significantly less in LMIC's. ,
In a developing country like India, health planning is an integral part of national socioeconomic planning. The proportion of households that incur catastrophic health expenditure in a country is widely used as an indicator of the extent to which the health system protects households needing health care against financial adversity. Providing such protection is a major destination of health systems and is the purpose of the universal health coverage. ,,,
Limited literature is available in our country for evaluating the OOP expenditure for dental and medical expenses. Besides, till date, no written report has been directed to evaluate the dental expenditure spent by Indian families. Although people are well aware of medical insurance; the level of knowledge regarding dental insurance is negligible. The lack of information regarding dental insurance further creates a need to measure the present OOP expenditure scenario. Hence, the present study was conducted to assess the proportion of monthly family income spent on medical and dental expenses.
| Materials and methods|| |
A cross-sectional study was conducted in Modinagar area of Uttar Pradesh from March 2014 to April 2014. Modinagar is a city and a municipal board in Ghaziabad district in the Indian state of Uttar Pradesh. As per the 2011 provisional census report of India, the population of Modinagar is 182 811, with a male: female ratio of 1.14:1. The average literacy rate of Modinagar is 87.03%, of which 93.21% males, and 80.07% females were literate. 
The study protocol was approved by the Institutional Review Board. Written informed consent was obtained from the bread earner of the household who were willing to take part in the survey.
Dual stage random sampling method was used. In the first stage; for the study purpose Modinagar was arbitrarily divided into four zones namely North, South, East, and West Zone out of which North Zone was chosen randomly. There are 14 wards under The North zone. Then in the second stage one ward (Govindpuri) was chosen randomly. A pilot study was carried out among 20 study subjects for the OOP expenditure on dental and medical treatment. Validity was checked using Cronbach's alpha (0.70) test in the pilot study with regard to content, wording, scoring method, easiness, and appropriateness of the questionnaire administration.
A door to door survey was conducted, and a questionnaire was distributed to all the 129 families residing in the area with a response rate of 79%. A 14-item open ended self-administered questionnaire was filled by the investigator in this study. The sociodemographic information was also obtained. The questionnaire comprised of two parts wherein the first part consisted of general information on per capita expenditure on dental treatment while the second part consisted of the information on per capita expenditure on medical treatment.
The data were entered in Excel spreadsheet (Microsoft office) and were analyzed using SPSS version 19 (SPSS Inc., Chicago, IL, USA). The difference between OOP expenditure on medical and dental treatment was compared using Chi-square and Student's t-test. The level of significance was set at P = 0.05.
| Results|| |
In this study, a total of 101 families gave consent to participate in the door to door questionnaire based survey. The educational status of the respondents revealed that out of the total 101 interviewed, 26.8% were graduate and above. Just 17.82% of the families were completely illiterate whereas, 6.93% had only completed primary education level. The survey indicates that the bulk of the survey population were partially skilled (31.7%) watched over by managerial (23.9%), and very few were professional (2.9%) [Table 1].
|Table 1: Sociodemographic characteristics of study population (n=101 families)* |
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The socioeconomic status [Figure 1] of most of the families; according to Modified BG Prasad scale was in class II (24.8%) while very few belonged to class V (14.9%).
|Figure 1: Distribution of socioeconomic status on the basis of income using modified prasad classification (2013)|
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The analysis of the expenditure spent on medical and dental treatment [Table 2] revealed that the major amount of the monthly family income was spent on medical treatment as compared to dental treatment (P = 0.038). Likewise, for the insurance coverage, medical insurance formed a substantial proportion of the monthly family expenditure [Table 3] and [Figure 2] as compared to dental insurance (P = 0.023).
|Table 2: Average out-of-pocket expenditure on dental and medical treatment (INR) of the families (information collected from head of family, n=101 families) |
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|Table 3: Proportion of total family income spent on dental and medical treatments, medicines and insurance coverage (information collected from head of the family, n=101 families) |
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| Discussion|| |
The present questionnaire based house to house survey was carried out among 101 families of Modinagar city to assess the average three monthly family expenditure on medical and dental treatment. The bulk of the study participants belonged to a higher or middle socioeconomic group as classified by Modified BG Prasad scale based on the sociodemographic information obtained. 
The OOP monthly expenditure on dental and medical treatments showed an interesting pattern. The average three monthly expenditure on the dental treatment was found to be rather depressing when compared to that on medical discourse. The findings are in accordance with the findings of Manski et al. who reported the three monthly expenditure on dental treatment for an average Indian family to be international normalized ratio 2135 (32US$) which was remarkably low as compared to USA (200-220 US$).  Similar findings were also reported by the data from 2007 survey by the California Health Foundation. , This could be most probably ascribed to the lower dental service utilization among the occupiers of the developing countries due to the accessibility barriers and lack of consciousness among the people. 
The assessment of expenditure on individual components highlighted the fact that the highest mean monthly expenditure was in the medical and dental consultation/treatment followed by the expenditure on the medications. This might be attributed to the fact that in the developing nations the majority of the health services is availed from the public health care facilities like Dispensaries, Government Hospitals and P.H.Cs where the medications are supplied free of monetary value. Also, those seeking medical care from the private practitioners make no separate expenditure for the medications as they are dispensed by the practitioners themselves. However, the findings were in contradiction to many previously conducted surveys in India and abroad on OOP health expenditure which reported the higher share of the medicines as compared to the treatment/consultation. , This might be due to the different medical and sociodemographic characteristics of our study populations. The study also revealed lesser expenditure on the medicines in the dental treatment when compared to that on medical treatment. This could be ascribed to the fact that there is a very little requirement of the medicines for the discourse of the dental ailments and treatment constitutes the major portion.
Also, it was found that an average Indian household spends around 13.21% of the total income on the medical treatment compared to 8.84% for the dental treatment. The percentage expenditure is highest on the treatment/consultation followed by that on medicines and insurance. These findings are in accord with the results of the survey conducted on the OOP expenditure in rural and urban West Bengal (2012), India which reported around 15% of the average monthly expenditure on medical treatment. This further highlights the poor dental care utilization among the masses. Also, the expenditure on the dental insurance was found to be nil, due to lack of dental insurance services in the country.  In this study also no household reported expenditure on dental insurance due to lack of dental insurance facilities.
Although the present study gave the comprehensive view of OOP medical and dental treatment by an average Indian household there are certain inherent limitations in the study. The study was a questionnaire-based cross-sectional house to house survey which could lead to recall and selection bias. Likewise, the cross-sectional nature of the study prevents the establishment of any causal relationship.
| Recommendations|| |
This study highlighted the various determinants, potentially responsible for high OOP health expenditures among the adult and older population in Modinagar. To ensure equitable health care delivery for all, OOP health expenditure should be minimized. The policies to reduce OOP expenditure should extend beyond curative medical attitudes, to include preventive social welfare aspects. The scope of dental insurance schemes coverage should be expanded in the country along with increased awareness among the masses in the same way as of the medical insurance. Further research in the same field is thereby recommended so as to assess the probable barriers behind the health care utilization and to formulate appropriate policies regarding the same.
| Conclusion|| |
This study revealed that the family expenditure on medical and dental treatments differs significantly among the peri-urban population of Modinagar. The use of essential health services are generally avoided by poor people with the increasing demand for OOP health expenditures. The expenditure on medical treatment was more than that on dental treatment which could be due to lack of awareness regarding the importance of oral health.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Available from: http://www.apps.who.int/nha/database/DataExplorerRegime.aspx. [Last accessed on 2014 Jul 30; Last updated on 2014 Jul 30].
Heijink R, Xu K, Saksena P, Evans D. Validity and comparability of out-of-pocket health expenditure from household surveys: A review of the literature and current survey instruments. Geneva: World Health Organization; 2011. Available from: www.who.int/health_financing/documents/dp_e_11_01-oop_errors.pdf. [Last accessed on 2014 Jun 20].
Raban MZ, Dandona R, Dandona L. Variations in catastrophic health expenditure estimates from household surveys in India. Bull World Health Organ 2013;91:726-35.
Available from: http://www.timesofindia.indiatimes.com/india/Indians-pay-78-of-medical-expenses-from-their-own-pocket/articleshow/7270363.cms. [Last accessed on 2014 Sep 01; Last updated on 2011 Jan 13].
Bhat R, Jain N. Analysis of Public Expenditure on Health Using State Level Data. Indian Institute of Management - Report; 2004. p. 1-44.
Bhat R, Jain N. Analysis of public and private health expenditure. Econ Polit Wkly 2006;41:56-7.
Brinda EM, Andrés AR, Enemark U. Correlates of out-of-pocket and catastrophic health expenditures in Tanzania: Results from a national household survey. BMC Int Health Hum Rights 2014;14:5.
You X, Kobayashi Y. Determinants of out-of-pocket health expenditure in China: Analysis using China Health and Nutrition Survey data. Appl Health Econ Health Policy 2011;9:39-49.
Musgrove P, Zeramdini R, Carrin G. Basic patterns in national health expenditure. Bull World Health Organ 2002;80:134-42.
MOHFW. National Health Accounts India 2004-05. New Delhi: National Health Accounts Cell, Ministry of Health and Family Welfare, Government of India; 2009.
Kumar AK, Chen LC, Choudhury M, Ganju S, Mahajan V, Sinha A, et al.
Financing health care for all: Challenges and opportunities. Lancet 2011;377:668-79.
Available from: http://www.cms.gov/Research./NationalHealthExpendData/.proj2012.pdf. [Last accessed on 2014 Jul 30; Last updated on 2014 Feb 25].
Available from: http://www.censusindia.gov.in/. [Published on 2012 Nov 24; Last accessed on 2014 Jun 19; Last updated on 2013 Mar 30].
Dudala RS, Arlappa N. An updated Prasad's socio economic status classification for 2013. Int J Res Dev Health 2013;1:26-9.
Manski RJ, Richard J, Moeller JF, Chen H, Hyde JS, Pepper JV, St Clair PA. A Research Note on Transitions in Out-of-Pocket Spending on Dental Services. Research on aging 2014. Available: http://roa.sagepub.com/content/37/6/646.full.pdf+html. [Last accessed on 2014 Jun 20]..
Saksena P, Xu K, Elovainio R, Perrot J. Health services utilization and out-of-pocket expenditure at public and private facilities in low-income countries. World Health Report 2010. http:// www.who.int/healthsystems/topics/financing/healthreport/20publicprivate.pdf. [Last accessed on 2014 Jun 28].
Raykarmakar P, Mondal T, Sarkar TK, Chakrabarty A. Health care seeking and treatment cost in a rural community of West Bengal, India. Health 2012;3:67-70.
Available from: http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/H/PDF%20Harris7ConsumerActivism.pdf. [Last accessed on 2014 Dec 24; Last updated on 2014 Jan 01].
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]