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Social and demographic determinants
of health insurance status in
India: Evidence from a nationally
representative cross‑sectional survey
Website:
www.jehp.net Kiranmayi Vootukuri1, Venkateswara Kumar K. S1, Suresh Naik V2
DOI:
10.4103/jehp.jehp_1006_23
Abstract:
BACKGROUND: Out‑of‑pocket medical expenses are a crucial metric for assessing how well the
healthcare system is working toward obtaining universal health coverage in any country. In India,
out‑of‑pocket expenses for health are relatively high compared to other developed countries due to
a lack of alternative finance arrangements. The disparity in out‑of‑pocket medical expenses largely
depends upon the public health expenditure, government policies, and level of health insurance
coverage.
MATERIALS AND METHODS: The study used a logit regression model to examine the association
of the status of health insurance with socio and demographic variables using National Sample Survey
2018 data. The objective of the study is to analyze the impact of demographic variables on the status
of health insurance in India.
RESULTS: This research found that education and occupation have a significant impact on the
status of health insurance, among other demographic factors.
CONCLUSION: These findings underscore the importance of targeted policies and interventions
aimed at improving access to health insurance among specific demographic groups. Addressing
disparities in health insurance coverage based on educational and occupational factors is essential
for achieving equitable healthcare access and improved health outcomes in the country. Increasing
1
Department of
awareness of health insurance reduces out‑of‑pocket medical expenses and subsequently brings
Business Management,
down economic poverty.
Koneru Lakshmaiah
Education Foundation, Keywords:
Vaddeswaram, Guntur, Catastrophic health expenditure, demographic factors, health insurance, out of pocket expenditure
Andhra Pradesh,
India, 2Department of
Economics, Institute Introduction pollution, sedimentary living, and bad
of Insurance and Risk diet. Such life‑threatening disorders drive

A
Management (IIRM),
ccording to the Indian Constitution, millions of Indians into poverty, as they
Financial District,
the state should prioritize “raising the must spend a sizable percentage of their
Gachibowli, Hyderabad,
Telangana, India
people’s standard of living,” “enhancing the income on medical emergencies. As life
level of nutrition,” and “expanding public expectancy and the prevalence of chronic
Address for health services” among their top priorities diseases have increased, morbidity and
correspondence: as stated in Article 47. India lacks a universal healthcare costs have risen.[2]
Prof. Kiranmayi Vootukuri,
Research Scholar, C/o.
healthcare system; hence, the private health
Dr. K. Venkateswara industry serves as the country’s main The country’s political, economic, social,
Kumar, Department of supplier of medical services.[1] The main and demographic features determine a
Business Management, causes of catastrophic health disasters in country’s proportion of funds allotted
Koneru Lakshmaiah to health care. The percentage of public
Education Foundation,
India include fast‑paced living, excessive
Vaddeswaram, Guntur, health care spending is not the choice of the
This is an open access journal, and articles are
Andhra Pradesh, India. distributed under the terms of the Creative Commons
E‑mail: kiranmayi.koduri@ Attribution‑NonCommercial‑ShareAlike 4.0 License, which How to cite this article: Vootukuri K, Kumar KS,
gmail.com allows others to remix, tweak, and build upon the work Naik VS. Social and demographic determinants of
non‑commercially, as long as appropriate credit is given and health insurance status in India: Evidence from a
Received: 11‑07‑2023 nationally representative cross‑sectional survey.
the new creations are licensed under the identical terms.
Accepted: 26‑09‑2023 J Edu Health Promot 2024;13:150.
Published: 29-04-2024 For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

© 2024 Journal of Education and Health Promotion | Published by Wolters Kluwer - Medknow 1
 Vootukuri, et al.: Social and demographic determinants of health insurance

country; rather it depends on regulations and budgets Indian healthcare system is dominated by private health
allocated within the country.[3] In most cases, developed systems with a significant portion of out‑of‑pocket
countries spend more on health than developing expenditure by individuals towards health. Social
countries as a percentage of GDP. The range of public economic factors such as household income, education,
health spending varies from less than 1% to more than and accessibility of healthcare facilities will be
10% of GDP depending upon the country’s profile.[4] determining the probability of OOP expenses along with
According to the World Bank, overall health spending alternative finance mechanisms like health insurance.[1]
in India in 2020–21 was 2.96 percent of GDP, compared Individuals belonging to the higher economic class have
to the global average of 10.89 percent. The percentages of a higher probability of incurring more out‑of‑pocket
GDP’s total health spending vary little between 2009 and expenses due to the high capacity of payments. Similarly,
2018. The highest was 3.75 in 2013–14, while the lowest out‑of‑pocket expenditure is also greatly influenced by
was 3.2 in 2011. Because India’s health budget is among the level of education.
the lowest in the world, the majority of healthcare costs
are borne by the patient.[5] Even if health insurance is there, many are paying
out‑of‑pocket expenses for drugs, diagnostics, and
The Indian health system is the largest in the world, post‑treatment care, since the out‑patient expenses are
with nearly 1.3 billion prospective beneficiaries. The not covered by the health insurance policy. As a result,
insurance sector has seen new heights in the last decades. insurance may increase the poor’s out‑of‑pocket expenses
However, 75 percent of the Indian population pay for inpatient and inpatient‑related care.[10] Although
medical expenses from their pocket due to the poor state financial protection through public or private health
of the healthcare system in the rural area and lack of insurance lessens the amount people pay directly for
awareness about health insurance plans. In this context, medical care, out‑of‑pocket costs can still be a barrier to
the study has evaluated the socio and demographic healthcare access and usage in some nations. If healthcare
factors determining the status of health Insurance in spending becomes more reliant on out‑of‑pocket
India. The study gives new insight and a way forward for expenditures, the burden is shifted to people who
the insurance industry to enhance insurance penetration consume services more regularly. Out‑of‑pocket (OOP)
and decrease the out‑of‑pocket expenditure. spending is an important indication of financial security
and specifies the private involvement required for health
Out‑of‑pocket medical expenses in India, as a percentage funding. Individuals’ out‑of‑pocket health expenses
of total health expenditure, have decreased from 72 percent means the expenses that are paid directly to hospitals,
in 2004 to 48.2% in 2019 as per the 15th Finance Commission eliminating any prepayments for services such as
as shown in Table 1. Although it is showing decreasing insurance premiums, cost of vaccinations, taxes, or
trend the percentages are relatively high in comparison to contributions.
other industrialized countries. Due to inadequate public
investment in health, a lack of human resources, and poor High out‑of‑pocket health spending has some negative
health infrastructure, the Indian government is unable to implications, including pushing individuals and families
meet the whole spectrum of healthcare needs, increasing into poverty. Majority of people who are forced into
the expense and financial burden of care.[6] extreme poverty because of out‑of‑pocket healthcare
costs live in low‑income and developing countries. In
The study[7] measured the out‑of‑pocket hospitalization countries with limited government expenditure on
costs by disease and their devastating impact on Indian health, the percentage of out‑of‑pocket spending is
households. It answers the question of how OOPE, considerable. As depicted in Figure 1, India is among
Catastrophic Health Expenditure (CHE), and distress the countries with the lowest health expenditure as a
health financing affect hospitalization depending on percentage of GDP, even low‑income countries such
the ailment and kind of healthcare provider (public and as Bhutan (4.4 percent), Sri Lanka (4.1 percent), and
private). In general, a large majority of the public may Nepal (5.2 percent) percent of their GDP to health
spend on outpatient appointments according to their expenditure.[11] In comparison to high‑income countries,
ability to pay; however, inpatient care requires patients Middle East and North African countries spend less on
to use emergency measures if they do not have enough health care.[12] Healthcare spending in the USA accounted
savings/income owing to the severity of the sickness. for 18.8% of GDP, but it was significantly lower in
The government, particularly, must pay close attention Australia and Switzerland (10.6 and 11.8 percent,
to interstate differences in OOP health expenditure respectively). In terms of private health insurance
and the accompanying poverty.[8] Diagnostic tests for coverage, the USA placed first (55 percent). The main
medicine, associated fees, physiotherapy, personal cause for the disparity between other nations and the
medical equipment, blood, oxygen, and other items will USA is due to disparities in workforce funding policies,
not be paid under the programs.[9] pharmaceuticals, and medical equipment being sold at
2 Journal of Education and Health Promotion | Volume 13 | April 2024
 Vootukuri, et al.: Social and demographic determinants of health insurance

20.0 18.8
Table 1: Percentage of public health expenditure and
18.0 OOP health expenditure
Health Expenditrue As a
Percentage of GDP (%)

16.0 Years Government Health Out of Pocket

14.0 Expenditure as a % of Expenditure as a % of
11.8 Total Health Expenditure Total Health Expenditure
12.0 10.6
10.0 2014‑2015 29.0 62.6
8.0 2015‑2016 30.6 60.6
6.0 5.2 5.3
4.4 4.1 2016‑2017 32.4 58.7
4.0 3.0
2017‑2018 40.8 48.8
2.0
2018‑2019 40.6 48.2
0.0
2019‑2020 41.4 47.1
Bhutan
Australia

Switzerland

India

Sri Lanka

Nepal

United States
North Africa
Middle East &
Source: National Health Estimates ‑ 2019‑2020, Report Released by NHA,
April 2023

universal access to excellent health care to their whole

Figure 1: Health Expenditure as a Percentage of GDP for the year 2020. Source: population.[14] As a result, China can cut out‑of‑pocket
World Bank 2023 spending from 62.85 percent in 2002 to 34.79 percent in
2020. Therefore, the objective of this study is to estimate
significantly higher prices in the USA and the deliberate the diverse effects of health insurance together with
ordering of costly medical tests. sociodemographic variables. The main objective of this
study is to determine the impact of demographic factors
OOP payments in India averaged about 54.8 percent such as age, gender, location, marital status, level of
of overall healthcare costs from 2000 to 2019. Although educational level, and type of occupation on the status
the OOP has fallen from 71.7 percent in 2000 to 54.8 of health insurance.
percent in 2019, it remains higher than in many
other nations. For most Indian people, savings from The following is the hypothesis of the study:
income remain the foremost choice for dealing with H0: Demographic factors do not influence the status of
out‑of‑pocket expenditures on health. Each year, health insurance.
such high out‑of‑pocket expenditures force 7% of the H1: Demographic factors influence the status of health
population into poverty.[13] insurance.

In nations like India without Universal Health Materials and Methods

Coverage (UHC), alternative financial arrangements
like health insurance should function very well because Study design and setting
they will help to lessen the load on the individual in the Ethical committee approval obtained from 3.1.2023.
event of hospitalization. Even though the idea of health In this study, we have used data from the 75th round
insurance was first introduced in India in 1948, it is still of the National Sample Survey Office (NSSO) health
not able to function well as a tool to offset out‑of‑pocket survey (NSSO, 2018). The NSSO is a public organization
medical expenses. Therefore, understanding the variables under the Ministry of Statistics and Programme
affecting the state of health insurance is essential for implementation by the Government of India since 1950.
developing better policies. With the aid of logistic The NSSO 75th round survey conducted from July 2017
regression, the current study describes the demographic to June 2018 covered the whole of the Indian Union.
characteristics that affect the availability of health
insurance. It demonstrates how the status of health Study participants and sampling
insurance is influenced by demographic parameters The NSSO collects data on various issues such as
such as age, gender, geography, education, and type of employment, migration, consumption expenditure,
occupation. education attainment, and morbidity. The 25th Schedule
of the 75th round of the NSSO, known as the «Household
The Government of India is attempting to improve Social Consumption: Health» collected quantitative
steps to achieve Universal Health Coverage (UHC), information on the health sector, such as morbidity,
and this became more important than ever after WHO the profile of ailments, including their treatment, the
announced the Sustainable Development Goals in 2015. role of government and the private sector in providing
Countries like China made health insurance one of the healthcare, pharmaceutical spending, expenditure on
means of achieving UHC. China achieved great success medical consultation, and investigation hospitalization
in decreasing OOP spending by establishing centralized and expenditure thereon, maternity and childbirth, the
and state‑owned methods, as well as pioneering a condition of the aged, etc., The NSSO collected information
variety of health insurance systems and providing from 1, 13,823 households (64,552 in rural areas and 49,271
Journal of Education and Health Promotion | Volume 13 | April 2024 3
 Vootukuri, et al.: Social and demographic determinants of health insurance

Table 2: Summary statistics of variables

Variables Measurement n Minimum Maximum Mean SD
Insurance status 0=not covered by insurance, 1=covered by insurance 555107 0.00 1.00 0.1700 0.37559
Gender 1=male, 2=female, 3=transgender 555351 1.00 3.00 1.4901 0.50004
Age (in years) Individuals age 555351 0.00 115.00 28.7408 19.69166
Marital status 1=Never Married, 2=Currently Married, 3=Widowed 555351 1.00 4.00 1.6146 0.58688
and 4=Divorced
General Education 1=Not Literate, 555351 1.00 16.00 6.9730 4.41782
2=Literate Without Any Formal Schooling,
3=Formal Schooling Till Primary,
4=Primary To Higher Secondary,
5=Graduation To Post Graduation And Above
Occupation 1=Self Employed (Own Account Worker), 555351 11.00 99.00 71.0097 32.38012
2=Self Employed ‑ Employer,
3=Unpaid Family Worker,
4=Regular Salaried/Wage Employee,
5=Wage Labour In Public Works,
6=Age Labour In Other Types,
7=Seeking And Available For Work,
8=Attended Educational Institution,
9=Attended Domestic Duties Only,
10=Domestic Duties And Also Involved In Collection,
11=Pensioners And Remittance Recipients,
12=Not Able To Work Due To Disability,
13=Others (Beggars’, Prostitution Etc)
Sector 1=Rural, 2‑ Urban 555351 1.00 2.00 1.4129 0.49236
Valid n (list wise) 555107
Source: 75th Round of NSSO Health Survey, 2018

in urban areas), covering 5, 55,115 persons (3, 25,883 in background. In the binary logistic model, one tries to
rural areas and 2, 29,232 in urban areas). estimate a probability function of an observed discrete
random variable—the status of health insurance. It takes
Data collection tool and technique two values 1 and 0, where 1 is for having health insurance
For all the important factors, separate estimates and 0 is for not having health insurance.
were given for the population in each gender, State/
UT, sector (rural/urban) combination, and for many To ensure the dependent variable lies between 0 and 1,
parameters, by age group as well. The NSSO provides we transform the dependent variable into a cumulative
information on the population with health expenditure distribution function.
coverage in rural and urban. NSSO covered about 14
percent of the rural population, and 19th percent of Prob (Yi=1) = f(Zi) = f(α + βXi)), + where CDF (.) is selected
the urban population had health expenditure. It also in advance and assume
collected information on expenses incurred during
the last 365 days for each State/UT. Expenditure in E (µi = 0
case of hospitalization was calculated including bed 1 1 e Zi
P = ( Yi = 1 ) = Pi = -( α + β X i )
= =
charges, doctors› surgeon›s fees, the total amount paid 1+e 1 + e -Zi 1 + e zi
for medicines, diagnostics tests, attendant charges, And
physiotherapy, personal medicine appliance, and blood
1 Pi 1 + e zi
oxygen, etc., with a reference period of the last 365 days. 1 - Pi = ; = = e zi
1 + e Zi 1 - Pi 1 + e -Zi
Analytical framework  P 
The binary logistic regression model is used to study the Logit = ln  i  = Zi =α + β X i
impact of demographic factors on the status of health  1 - Pi 
insurance. The dependent variable is binary, i.e. “1” for
the individual having health insurance and “0” for not Prob of (Yi=1) tends to 0 as α + βXi tends to minus infinity
having health insurance. The result of logistic regression and Prob (Yi=1) tends to 1 as α + βXi tends to infinity.
was presented as an adjusted odds ratio (AOR). The Thus, probabilities from the logit model will be between
binary choice model is best fitted given the theoretical 0 and 1.
4 Journal of Education and Health Promotion | Volume 13 | April 2024
 Vootukuri, et al.: Social and demographic determinants of health insurance

The theoretical construct as discussed suggests that the hospitalization, 20.7% are covered by health insurance.
explanatory variables are relevant for the model. These No clear pattern of insurance status is observed as far
are demographic variables (age, gender, marital status, as infections‑related diseases are concerned. Further,
education, occupation, etc.). Hence, we construct the the survey data shows that the persons who are
following logit model considering the relevant variables. suffering from non‑communicable diseases are having
more percentage of health insurance than those with
Status of insurance i = β0 + β1 age + β2 gender + β3 marital communicable diseases.
status + β4 location+ β5 education + β6 occupation+ ε
For the model, the status of health insurance was the
dependent variable, whereas sociodemographic (age,
This code includes six variables: five categorical
gender, location, marital status, educational status and
variables (gender, marital status, location, education,
occupation) were the independent variables.
and occupation) and one continuous variable (age).
The one outcome variable is dichotomous, i.e. status of Results:
health insurance (0, with no health insurance and 1, with
health insurance). The analysis is useful in addressing Omnibus Tests of Model Coefficients show that Table 4.
factors determining the status of health insurance. The Sig (p) <.05, hence at least one predictor variable in the
values of each category are arranged vertically for better model is statistically significant. The Sig. (p) is. 000, which
understanding. Categorical variables such as education is less than. 05; this indicates at least one of the predictor
status and occupation have been reclassified for better variables statistically significant for predicting outcome
thoughtful results. variables, i.e. status of health insurance. To discover
which variable is statistically significant in predicting the
As shown in Table 2, data was prepared for analysis
outcome variable, in the table variables in the equation
by being cleaned, coded, and added to SPSS. For
help us to identify the rows where sig. (p) is less than
categorical data, descriptive statistics like frequencies
or equal to. 05.
and proportions were calculated, while continuous
variables were summed up by mean with standard
Discussion
deviation (SD) or median. Then, tables and graphs
were used to present the data. To determine the factors It is observed from Table 5 that the logistic regression
that influence the status of health insurance, variables analysis shows that age is the significant factor
with a P value of less than 0.05 in the bivariate logistic in determining the status of health insurance at
regression analysis were added to the multivariate the (significant level ≤5%). As the age increases, the
logistic regression model. The outcome›s statistically probability of buying health insurance is high. Marital
relevant factors were identified using a P value of less status is not an important factor in determining the
than 0.05 and an AOR with a 95% confidence interval.
status of health insurance (never married, currently
married, and widowed) on the status of health insurance
Results
at the (significant level of ≤5%). In the case of marital
Descriptive statistics of sample has been computed for status, the chance of taking health insurance is less
better understanding of data. Logistic regression analysis than never married, currently married, and widowed.
has been performed to find out impact of demographic Therefore, marital status does not influence the buying
variables on status of health insurance. of health insurance. In the case of education level, there
is no positive relation between the education level and
Table 3 represents the health insurance status and gives determining health status (significant level ≤5%).
an accurate picture concerning various demographic However, occupational categories have a significant
variables. It is reported that out of the total samples effect on the status of health insurance. Among the
of 5, 55, 107, 17% of the people are covered under occupation level, the labor class is showing significant
insurance and the rest of 83% are not covered. The and positive. It depicts that the probability of having
middle and older age groups are having more insurance health insurance in the case of labor is high due to
coverage than the young population. However, there is government schemes. In the case of the self‑employed,
no significant difference observed among gender and the probability of buying health insurance is less in the
sectors, i.e., rural and urban. It is observed that those self‑employed. According to the model, the regular
who have more educational backgrounds, i.e. graduation wage/salary and retirees/pensioners is showing a
and above graduation, are having more percentage high chance of buying health insurance. This means
of insurance. Interestingly, for those who are having that if the government takes care of occupation, then
marital status as separated or divorced, the percentage automatically the insurance penetration increases.
of insurance is more. Among people who underwent According to the analysis, there is no significant effect
Journal of Education and Health Promotion | Volume 13 | April 2024 5
 Vootukuri, et al.: Social and demographic determinants of health insurance

Table 3: Status of Insurance (in %)

Demographic Details Sample Not Covered by
Characteristics Size Covered (%) Insurance (%)
Age (in years) 0‑4 64732 88.5% 11.5%
5‑14 90913 85.0% 15.0%
15‑29 152908 83.6% 16.4%
30‑44 116005 81.5% 18.5%
45‑59 87787 79.7% 20.3%
60‑69 35275 79.3% 20.7%
70 Above 7487 78.8% 21.2%
Gender Male 283197 83.1% 16.9%
Female 271873 82.9% 17.1%
Transgender 37 83.8% 16.2%
Sector (Location) Rural 325876 84.1% 15.9%
Urban 229231 81.4% 18.6%
Education status Not Literate 147273 85.3% 14.7%
Literate Without Any Formal Schooling 2669 90.6% 9.4%
Formal Schooling Till Primary 3558 85.9% 14.1%
Primary To Higher Secondary 346975 83.1% 16.9%
Graduation To Post Graduation And Above 54632 75.6% 24.4%
Marital status Never Married 242415 85.3% 14.7%
Currently Married 285786 81.4% 18.6%
Widowed 25426 80.1% 19.9%
Divorced/Separated 1480 74.1% 25.9%
Occupation Self Employed (Own Account Worker) 63354 83.5% 16.5%
Self Employed ‑ Employer 4966 80.2% 19.8%
Unpaid Family Worker 28187 79.7% 20.3%
Regular Salaried/Wage Employee 39930 72.9% 27.1%
Wage Labour In Public Works 4030 85.2% 14.8%
Wage Labour In Other Types 44051 80.6% 19.4%
Seeking And Available For Work 8223 83.3% 16.7%
Attended Educational Institution 126644 84.1% 15.9%
Attended Domestic Duties Only 107298 82.8% 17.2%
Domestic Duties And Also Involved In Collection 37421 87.9% 12.1%
Pensioners And Remittance Recipients 11741 74.8% 25.2%
Not Able To Work Due To Disability 3209 84.0% 16.0%
Others (Beggars’, Prostitution Etc) 31825 85.8% 14.2%
Source: 75th Round of NSSO Health Survey, 2018

Table 4: Omnibus tests of model coefficients insurance services, policymakers should implement
Chi‑square Df Sig. regional healthcare planning strategies.
Step 1
Step 4316.282 15 0.000 Recommendation
Block 4316.282 15 0.000
Model 4316.282 15 0.000 Given the significant effect of education level on the
Source: Author Calculation from the 75th Round of NSSO data 2018. Note:
Omnibus Tests of Model Coefficients shows that. Sig (p) <0.05, hence at least
status of health insurance services, there is a need for
one predictor variable in the model is statistically significant comprehensive education and awareness campaigns
about the importance of health insurance and how to
of gender on the status of health insurance services. navigate the healthcare system. Policymakers should
There is a significant effect of age, location, marital invest in promoting health literacy, making information
status, level of education, and type of occupation on easily accessible, and providing guidance to individuals
the status of health insurance services (significant with varying levels of education. Policymakers should
level ≤5%). Given the significant effect of age on the recognize the importance of occupation in determining
status of health insurance services, policymakers should access to health insurance services. They should
design age‑specific initiatives to cater to the varying explore ways to address the specific healthcare needs
needs of different age groups. As location has been of different occupational groups and consider tailored
found to have a significant effect on the status of health health insurance options or employee benefits to cater
6 Journal of Education and Health Promotion | Volume 13 | April 2024
 Vootukuri, et al.: Social and demographic determinants of health insurance

Table 5: Variables in the equation

B S.E. Wald Df Sig. Exp (B) 95% C.I. for Exp (B)
Lower Upper
Age 0.009 0.000 713.577 1 0.000*** 1.009 1.008 1.009
Gender 27.005 2 0.000
Male ‑0.134 0.493 0.074 1 0.785 0.874 0.333 2.298
Female ‑0.089 0.493 0.032 1 0.857 0.915 0.348 2.405
Marital Status 55.496 3 0.000
Never Married ‑0.364 0.061 36.135 1 0.000*** 0.695 0.617 0.782
Currently Married ‑0.402 0.060 45.332 1 0.000*** 0.669 0.595 0.752
Widowed ‑0.422 0.062 46.380 1 0.000*** 0.656 0.581 0.740
Location ‑0.099 0.008 160.225 1 0.000*** 0.906 0.892 0.920
Education Status 1565.281 4 0.000
Illiterate ‑0.527 0.015 1313.309 1 0.000*** 0.591 0.574 0.608
Up to Primary Education ‑0.416 0.015 788.221 1 0.000*** 0.660 0.641 0.679
Up to Higher Education ‑0.388 0.012 1106.836 1 0.000*** 0.678 0.663 0.694
Up to Graduation ‑0.121 0.029 17.593 1 0.000*** 0.886 0.837 0.937
Occupation Status 441.617 4 0.000***
Labour 0.206 0.019 117.049 1 0.000*** 1.228 1.184 1.275
Self‑employed ‑0.048 0.021 5.518 1 0.019** 0.953 0.915 0.992
Regular wage/Salary 0.073 0.018 17.286 1 0.000*** 1.076 1.039 1.114
Retirees/Pensioners 0.236 0.028 69.387 1 0.000*** 1.267 1.198 1.339
Constant ‑0.982 0.497 3.906 1 0.048** 0.374
Chi‑square 0.000
Pseudo R2
Source: Author Calculation from the 75th Round of NSSO data 2018. Note: ***Significant at 1 percent, **Significant at 5 Percent and *Significant at 10 percent.
Variables entered in the model are: Age, Gender, Location, Marital Status, Education, and Occupation

to these diverse needs. Policymakers must ensure that expense of their livelihoods, proactive measures must be
all individuals, regardless of gender, have equal access taken to safeguard citizens from unaffordable catastrophic
to health insurance services. While gender might not medical costs. It is a fact that most participants are not
have a significant effect on health insurance status covered by insurance plans; the patient’s family members
according to the analysis, it is crucial to continuously are burdened by OOP costs. It is important to evaluate
monitor this aspect to prevent any potential disparities the various tiers of the current healthcare financing
from emerging. models. Starting at the primary care level itself, existing
health insurance services should be enhanced to make
Limitations them more available, inexpensive, and acceptable to all
The NSSO 2018 survey relies on self‑reporting from beneficiaries. The results of this study indicate that people
respondents, which can cause biases in the data collected. who have higher levels of formal education are more
Potential measurement mistakes could occur because of likely to have health insurance, as they are well aware of
respondents’ erroneous memory or reporting of their the benefits. The data presents a largely favorable picture
health expenses. The NSSO 2018 data is a snapshot of access to health insurance among those who are in
of a particular time, and the factors that influence full‑time employment than self‑employed. Therefore,
out‑of‑pocket medical expenses may change over time. efforts should be made to inform the general public of the
It is possible that the analysis did not take into account advantages of health insurance programs and to persuade
factors like policy modifications, economic situations, or both employees and employers to enlist in group health
healthcare system improvements that took place after insurance programs to lessen personal financial burdens.
2018. The study’s conclusions based on the NSSO 2018
data may differ depending on the period, area, or sample Financial support and sponsorship
size used. In light of the fact that different environments Nil.
can have distinct out‑of‑pocket health expenditure
determinants, extrapolating the findings to other contexts Conflicts of interest
or populations should be done with care. There are no conflicts of interest.

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8 Journal of Education and Health Promotion | Volume 13 | April 2024