Household healthcare expenditure: A cross-sectional analysis of urban and rural Puducherry, South India

ABSTRACT

Background:

The global healthcare financing landscape highlights the heavy out-of-pocket expenditure (OOPE) burden on households, particularly in low- and middle-income countries like India. Despite efforts towards Universal Health Coverage (UHC), challenges persist. This study in Puducherry aims to estimate the prevalence and amount of OOPE and catastrophic health expenditure (CHE), with a focus on comparing the findings with a 2016 study conducted in the same study setting.

Methods:

A cross-sectional study in rural and urban areas collected data from 378 households using a pilot-tested National Sample Survey Office (NSSO) questionnaire. Utilizing a systematic random sampling method, 189 households from each setting were selected. Data analysis was done using SPSS version 23, with OOPE and CHE prevalence presented as percentages with a 95% confidence interval (CI).

Results:

Overall, 46.6% (n = 378) of all households and 91.6% (n = 192) of households that utilized healthcare services in the past 6 months experienced OOPE. 36.5% of households incurred direct medical expenses, with higher prevalence in urban areas. Non-medical expenditures were reported by 41.5% of households, more prominently in rural settings. Moreover, 13.2% of households experienced CHE, with a higher proportion in rural areas. The study highlights a notable decrease in OOPE from 2016 to 2023, with higher expenditure risks associated with chronic diseases.

Conclusion:

The study unveils healthcare spending patterns in urban and rural Puducherry, emphasizing the significant burden of out-of-pocket expenses and CHEs. It underscores the urgency for interventions to enhance healthcare affordability, particularly in rural areas, where disparities are more pronounced, necessitating targeted efforts to alleviate economic strains and improve access to healthcare.

Introduction

Out-of-pocket expenditure (OOPE) on health remains a significant global concern, affecting individuals and households. Despite efforts to improve healthcare financing, as of 2020, about 20–30% of health financing still depends on OOPE, imposing substantial financial burdens, especially in lower- and middle-income countries. This leads to catastrophic health expenditures (CHEs) and pushes households into poverty.[1,2] In response, initiatives like Universal Health Coverage (UHC) aim to reduce OOPE and enhance financial protection.[3] Achieving Sustainable Development Goal (SDG) 3.8 on UHC is crucial for reducing OOPE, promoting health, alleviating poverty, and fostering economic growth. Understanding OOPE is essential for assessing financial protection and aligning with the broader SDG agenda.[4]

India has one of the highest proportions of household OOPE on health in the world, estimated at 50.59% in the year 2020.[5] Updated data shows that OOPE accounted for 39.2% of total health expenditure (THE) in India, as per NHA 2024, while the Economic Survey 2022-2023 reported OOPE to be 48.2% of THE.[6,7] Despite economic growth, government health spending remains comparatively low, heavily relying on private OOPE.[8] Efforts to increase public health spending and reduce OOPE are underway, including initiatives like the Pradhan Mantri Jan Arogya Yojana (PM-JAY) aimed at providing affordable healthcare to marginalized populations.

In the union territory of Puducherry, studies have shown high proportions of households facing out-of-pocket health expenses, with a significant percentage experiencing catastrophic expenditures, ranging from more than 65%.[9,10] One study found that 81% of households faced OOP expenses, with 66% of them encountering catastrophic expenses.[9] Another survey conducted in 2016 estimated the proportion of households with OOPE to be 68.3% in rural areas and 65.8% in urban areas.[10] However, the previous studies were conducted before the initiation of PM-JAY and the onset of the coronavirus disease (COVID-19) pandemic. Therefore, it is necessary to assess the current status of households’ OOPE to understand the potential impacts of these healthcare policies and the crisis of COVID-19. This study aims to investigate the shifts in OOPE and CHE trends in Puducherry by comparing current data to a study conducted eight years ago.

Methods

Study design and setting

A cross-sectional descriptive study was conducted in the rural and urban service areas of a teaching tertiary care hospital in Puducherry. Puducherry has a robust healthcare infrastructure for providing healthcare, facilitated by 39 primary health centers (PHCs), 4 community health centers, 5 district hospitals, 3 sub-district hospitals, and 2 government medical colleges, providing accessible and free medical care within an average distance of 1.18 km to its population of nearly 16 lakhs. Ethics committee approval date- 25/04/2023.

Study population and study period

The study focused on JIPMER Urban Health Center (UHC) and Rural Health Center (RHC), serving approximately 10,000 population each. These centers primarily cater to lower socio-economic status and working-class demographics, including fishing colonies and slum areas. Government facilities and JIPMER health centers have played a key role in enrolling individuals for the PM-JAY during 2018, thereby improving healthcare access for marginalized communities. The study included households residing in the specified region for at least 6 months. No exclusion criteria were specified. The study was conducted from March 2023 to March 2024.

Sample size and sampling

The sample size was based on a 67% prevalence of OOPE among households in Puducherry,[10] with 5% precision and a 95% confidence level. Accounting for a 10% non-response rate, the final sample size was 378 households, evenly distributed between the RHC and UHC areas, with 189 households each. Systematic random sampling was employed, with a sampling interval of 11 households, and additional attempts were made to include households initially found locked or inaccessible in Supplementary Material 1 [Tables 1 and 2].

Study procedure

Data collection started after receiving approvals and obtaining informed consent, and proceeded using a validated questionnaire, derived from the National Sample Survey Office (NSSO) 75^th round survey (2017-2018)[11] and National Family Health Survey (NFHS)-5 survey (2019-2020),[12] with recall periods of 1 month for outpatient care and 6 months for inpatient care.[10] The questionnaire consisted of seven sections covering various aspects: household demographics and monthly expenditures, individual member details including health status and insurance, family medical history, recent hospitalization events with expenditure specifics, recent illnesses and treatments, outpatient treatment details and expenses, and questions assessing household wealth. Pilot testing was conducted with approximately 10 households to validate the questionnaire.

Operational definitions for OOPE and CHE were established based on National Health Account (NHA) definitions. OOPE refers to direct payments made by households for healthcare services and products.[13] This includes direct medical costs, such as outpatient department (OPD) expenses, inpatient costs, doctor fees, diagnostics, and medicines, and direct non-medical costs, such as travel expenses, accommodation costs, and food expenses related to seeking healthcare services. CHE occurs when out-of-pocket payments exceed 10% of total household expenditure.[14] This household expenditure includes various essential expenses such as food, rent, education, monthly healthcare spending, shopping, and other necessities. OOPE for outpatient care was calculated using a one-month recall period, whereas OOPE for inpatient care and total household expenditure were assessed over a six-month due to recall constraints. These definitions guided the analysis, ensuring clarity and consistency in interpreting financial burdens related to healthcare utilization.

Data entry and analysis

Data entry was performed using Epicollect 5 across five distinct levels: household, individual, hospitalization, illness, and outpatient consultation details, supplemented by a wealth assessment branch. The entered data underwent data cleaning in MS Excel 2023, after being merged in STATA ver 17, before being exported to SPSS version 23 for analysis. Socio-demographic variables are summarized as frequencies and percentages. The prevalence of households incurring OOPE and experiencing CHE is presented with 95% confidence intervals (CI). OOPE and CHE amounts in Indian Rupees (INR) are summarized using the median and interquartile range (IQR). Furthermore, comparisons between the prevalence of households incurring OOPE/CHE in this study and the previous one were made.

Results

Descriptions of heads of households, households, and individuals

Table 1 provides the socio-demographic characteristics at the household level with no major differences observed between urban and rural settings. The majority of household heads were aged 40–59 years, predominantly male, high school educated, and employed. Most households were Hindu, lived in rental houses, and had 4–6 members. Vulnerable groups included young children, the elderly, pregnant women, and individuals with disabilities. Median monthly income was INR 8250, with significant differences in health insurance coverage between urban (29.1%) and rural areas (43.4%), predominantly through government insurance.

Table 1.

Socio-demographic characteristics of the households in Urban and Rural field practice areas of JIPMER, Puducherry, India, 2023. (n=378, Urban=189, Rural=189)

Characteristics	Urban n (%)	Rural n (%)	Total n (%)
Age categories of the head of household (in years)
18-39	26 (13.8)	28 (14.8)	54 (14.3)
40-59	111 (58.7)	107 (56.6)	218 (57.7)
≥60	52 (27.5)	54 (28.6)	106 (28.0)
Gender of the head of household
Men	135 (71.4)	146 (77.2)	281 (74.3)
Years of schooling of the head of household
0 years	39 (20.6)	47 (24.9)	86 (22.8)
1-7 years	37 (19.6)	29 (15.3)	66 (17.5)
8-12 years	79 (41.8)	85 (45.0)	164 (43.4)
>12 years	34 (18.0)	28 (14.8)	62 (16.4)
Occupation of the head of household
Working	136 (72.0)	149 (78.8)	285 (75.4)
Religion
Hindu	161 (85.2)	181 (95.8)	342 (90.5)
Caste
OBC/MBC	108 (57.1)	114 (60.3)	222 (58.7)
SC/ST	62 (32.8)	62 (32.8)	124 (32.8)
Others	19 (10.1)	13 (6.9)	32 (8.5)
Income of the head of the family per month in rupees#	8000 (3250, 15000)	8500 (4000, 12750)	8250 (3875, 15000)
Type of residence
Rented house	144 (76.2)	143 (75.7)	287 (75.9)
Presence of at least one vulnerable group*
Children under the age of 5 years	30 (15.9)	52 (27.5)	82 (21.7)
Elderly (≥60 years)	82 (43.4)	74 (39.2)	156 (41.3)
Pregnant women	10 (5.3)	11 (5.8)	21 (5.6)
Person with disability**	9 (4.8)	10 (5.3)	19 (5.0)
Households that availed any type of health services in the past 6 months	96 (50.7)	96 (50.7)	192 (50.7)
Size of household##	4 (3,5)	4 (3,5)	4 (3,5)
Coverage of any Health insurance***	55 (29.1)	82 (43.4)	137 (36.2)
Govt	44 (80.0)	79 (96.3)	123 (89.7)

*Multiple responses possible. ***At least any one member in the household is covered by health insurance. **Self-reported disabilities of at least any one of the family members by the head of the household. ^# Median with IQR. ^## In Median IQR

“Descriptives of Individuals” are provided in Supplementary Material 2. Detailed information on healthcare service utilization patterns, including frequency of visits, types of facilities accessed, and the reasons for seeking care are provided in the Supplementary Material “Healthcare Utilization Patterns” [Tables 3,4 and Figures 1,2].

Figure 1.

Flow diagram Visualizing OOPE Patterns at illness episodes level among the Households who availed of any healthcare services *(The figures provided may not necessarily reconcile to the total due to the possibility of individuals experiencing multiple episodes of illness within the specified data set)

Figure 2.

Change in the proportion of OOPE among the households in urban and rural Puducherry from the year 2016 to 2023

OOPE of households in Puducherry

Out of a total of 378 households, 192 (50.8%) availed health services, with 109 (56.7%) choosing government facilities and 94 (48.9%) opting for private ones. In the government facilities, 49 (44.9%) households required inpatient care and 70 (64.2%) accessed outpatient services. Among these, for inpatient care, 36 households (73.5%) incurred OOPEs, with 35 (71.4%) facing direct medical costs and 47 (95.9%) direct non-medical costs. For outpatient services in government facilities, 31 households (44.2%) incurred OOPE, with 21 (30%) facing direct medical costs and 23 (32.8%) non-medical costs. In private facilities, all households, both inpatient (30.8%) and outpatient (73.4%), incurred 100% OOPE, covering both direct medical and non-medical costs, the details of which are included in Supplementary Material 3 “OOPE” [Figures 3 ^{(726.2KB, tif)} and 4 ^{(722KB, tif)} ].

Among the 326 health service episodes recorded, a significant proportion involved OOPE across various healthcare settings. In the inpatient department (IPD), 38.9% of households sought care, with a higher prevalence of these households (92.7%) incurring OOPE in government hospitals, although both government and private hospitals incurred OOPE. In the OPD, utilized by 76.3% of households, OOPE was also prevalent in both government (78.9%) and private hospitals (100%). Even among households that did not seek formal healthcare, 94.7% incurred OOPE, mainly through medical shop expenses (78.9%) [Figure 1 ^{(668.7KB, tif)} ].

Overall, 46.6% of households (95% CI: 41.6–51.6) experienced OOPE, with urban areas at 46.5% and rural areas at 46.4% (95% CI: 39.6–53.7). This study also focuses on households with healthcare needs in the past 6 months, revealing that 91.6% (95% CI: 86.9–94.8) incurred OOPE, almost similar in urban and rural areas. Interestingly, while direct medical costs were higher in urban households compared to rural households in both total households (40.7% vs. 32.3%) and among those availing healthcare services (80.2% vs. 63.5%), direct non-medical costs were higher in rural households in both contexts (44.4% vs. 38.6% among total households; 87.5% vs. 76% among those availing healthcare services). This data highlights the prevalence of out-of-pocket health expenditure, direct medical cost, and direct non-medical cost among urban and rural households, both in terms of total households and those who availed healthcare services in the past 6 months included in the Supplementary Material [Table 5].

Median direct medical costs were higher in rural areas (₹3000, IQR: ₹1000–₹21000) compared to urban areas (₹2000, IQR: ₹700–₹5500) among all surveyed households. Among households accessing health services, median direct medical costs were ₹1250 (IQR: ₹500–₹3950) in urban areas and ₹500 (IQR: ₹0–₹5000) in rural areas. Overall OOPE was higher among households utilizing health services, indicating a significant financial burden associated with healthcare access, particularly in urban areas [Supplementary Material Table 6]. “Prevalence of OOPE among Individuals” [Supplementary Material Figure 5 ^{(453.6KB, tif)} ].

Catastrophic health expenditure of households in Puducherry

Across the entire sample of 378, 13.2% experienced CHE. When broken down by urban and rural areas, urban households had a slightly lower CHE prevalence of 10.1%, while rural households experienced a higher prevalence of 16.4%. Among households that utilized healthcare services within the past six months (n = 192), the incidence of CHE rose substantially to 26.0%. Notably, rural households incurred higher median expenditures compared to their urban counterparts, with both groups exhibiting a wide range of expenditures.

In urban areas, the median expenditure on CHE is ₹10,800, with an IQR of ₹2,000 to ₹35,200. Rural populations, on the other hand, face a higher median expenditure of ₹17,500, with a wider IQR ranging from ₹3,400 to ₹43,399. When considering the entire population, the median INR spent on CHE is ₹16,800, with an IQR spanning from ₹2,875.1 to ₹41,247. Supplementary Material [Table 7].

Association of various factors of households with OOPE and CHE

The analysis reveals several significant associations with OOPE in healthcare. Notably, the second wealth index class displays a significant association (P = 0.03) with higher OOPE, suggesting that households in this wealth category tend to incur greater out-of-pocket healthcare expenses compared to those in the highest wealth index class.

The analysis of CHE and its associations with demographic and socio-economic variables has yielded significant findings. Prominently, the presence of chronic diseases within households is significantly associated with higher CHE. Specifically, households with at least one member afflicted by a chronic disease face a 1.9 (1.1–3.4) times higher risk of experiencing CHE compared to households without any member affected by chronic disease, the details of which are provided in Supplementary Material [Tables 8 and 9].

Change in the proportion of OOPE on healthcare in Puducherry from 2016 to 2023

The results of the 2016 and 2023 studies were comparable, reflecting similar descriptive profiles of participants across various socio-economic indicators. Both studies revealed consistency in demographic characteristics such as age and gender distributions, indicating a similar participant profile over time. Additionally, comparable trends were observed in education levels and median income, suggesting similar socio-economic backgrounds among participants in both years. While fluctuations were noted in the presence of vulnerable groups and healthcare coverage, also some notable changes were found such as the increase in median monthly income and the health insurance coverage. The overall descriptive profile remains consistent, underscoring the reliability of the comparative analysis between the two studies. A comparison of morbidity patterns between the studies is included in the Supplementary Material 4 [Tables 10 and 11].

In the 2016 study, urban households spent 65.8% (95% CI: 57.0–73.7) and rural households 68.3% (95% CI: 59.5–76.0) on healthcare, with a combined proportion of 67.1% (95% CI: 60.9–72.7) among total households, based on a sample size of 340 households. However, in the current study, both urban and rural areas saw a notable reduction in OOPE, with both recording 46.5% and 46.4% (95% CI: 39.6–53.7) and a combined proportion of 46.6% (95% CI: 41.6–51.6) among total households, based on a sample size of 378 households. This indicates a convergence in healthcare expenditure patterns between urban and rural areas over time, alongside a narrowing of confidence intervals in the 2023 study, suggesting potentially more precise estimates [Figure 2 ^{(741.7KB, tif)} ].

Furthermore, concerning households that availed of any health services, the OOPE percentage, with a 95% CI, was 79.3% (73.2–84.3%) in the 2016 study, based on 203 households. In the current study (2023), the OOPE percentage among households that availed of any health services was 91.6% (86.9–94.8), based on a sample size of 192 households, the details of which are provided in [Supplementary Material Figure 6 ^{(957.6KB, tif)} ].

Discussion

This study delves into the contemporary dynamics of household health expenditure in Puducherry, India, against the backdrop of global concerns regarding OOPE and CHE. By building upon the groundwork laid by a previous study in 2016,[10] this research provides updated insights into expenditure patterns within urban and rural households. Through a multifaceted approach encompassing both urban and rural dynamics, the study aims to inform the development of targeted policies aimed at enhancing financial protection and accessibility to healthcare services, contributing to the broader dialogue surrounding UHC and promoting household financial resilience in the face of healthcare-related financial burdens.

The findings of this study reveal significant insights into healthcare financing, service utilization, and health trends in urban and rural areas of Puducherry, India. Despite government hospitals being the primary choice for care, a substantial proportion of households continue to face OOPEs, especially in private healthcare settings. Non-communicable diseases (NCDs) prevail in urban areas, while accidents are more common in rural regions, reflecting diverse healthcare needs across different settings.

In comparing our study with the 2016 research,[10] significant shifts in healthcare dynamics among rural and urban households in Puducherry emerge. While both studies reported high illness incidence, with specific ailments prevalent in each setting, the current research indicates a notable increase in overall health service episodes, suggesting heightened healthcare utilization over time. Despite a decrease in healthcare visits in rural areas, the demand for healthcare services remains substantial, underscoring evolving patterns in healthcare access and demand.

Regarding out-of-pocket health expenditure (OOPE), our investigation uncovered that 46.6% of households faced OOPE, consistent across urban and rural areas. This contrasts with previous research, indicating a significant decrease in OOPE rates over time. Notably, despite an overall decrease in OOPE percentages, a higher proportion of households faced OOPE even when healthcare services were not accessed, highlighting persistent financial strain. Government hospitals remained the primary choice for healthcare services, indicating continued reliance on public healthcare facilities.

Our study revealed that 13.2% of households in Puducherry experienced CHE, with a higher prevalence in rural areas, underscoring the significant economic burden faced by these households in accessing healthcare services. Comparing this with Bangladesh (2016-17), where 87.9% of households with healthcare expenses faced OOPE on medicines, the poorest households spent nearly double the percentage of their income on medicines compared to the wealthiest. Chronic diseases, particularly cancer, significantly increased these expenses, leading to 26% of households experiencing CHE. In Puducherry, 46.6% of households incurred OOPE, with a higher prevalence in urban areas, and a notable decrease in OOPE from 2016 to 2023. However, chronic diseases continue to drive higher costs, especially in rural areas. These findings underscore the evolving dynamics of healthcare expenditure and the need for tailored policy interventions to alleviate the financial burden on households.[15]

Additionally, our findings shed light on the impact of COVID-19 on the healthcare expenditure landscape. While previous studies documented catastrophic expenditure associated with COVID-19 hospitalizations, our research indicates a stabilization in healthcare financing post-pandemic, reflecting Puducherry’s more balanced expenditure landscape. These comparisons underscore the diverse healthcare expenditure landscapes across different contexts, emphasizing the need for targeted interventions to alleviate financial strain and ensure equitable access to healthcare services for all.[16]

The study’s strength lies in its comparison with a 2016 study, revealing trends in healthcare financing over time. Robust methodology, including systematic random sampling and Epicollect 5 data collection, ensured reliability. Analysis of out-of-pocket expenses informed targeted policy recommendations, building upon previous research for a nuanced understanding of healthcare dynamics. However, reliance on self-reported data may introduce reporting bias, impacting the accuracy of reported healthcare expenditures. Additionally, findings may be context-specific to Puducherry, limiting generalizability. Recommendations include raising awareness about health schemes, involving private healthcare facilities, enhancing insurance coverage utilization, investing in rural primary healthcare, and exploring innovative approaches like telemedicine to improve accessibility. These interventions aim to alleviate financial burdens and enhance healthcare access in Puducherry.

Conclusion

This research illuminates healthcare financing and expenditure patterns in Puducherry, India, revealing significant financial burdens for urban and rural households. The prevalence of out-of-pocket expenses highlights the need for targeted interventions. Addressing these disparities and implementing evidence-based policy reforms can ensure equitable access to healthcare, enhancing health outcomes and household financial resilience. Further research into healthcare spending determinants is crucial for guiding future policy initiatives towards UHC and equitable access in Puducherry and beyond.

Key messages

A significant healthcare spending pattern is observed in Puducherry, with 46.6% of households facing out-of-pocket health expenditure, and 13.2% experiencing catastrophic health expenditure (CHE), notably higher in rural areas. This highlights the need for interventions to improve healthcare affordability and reduce economic burdens, especially in rural settings.

Conflicts of interest

There are no conflicts of interest.

Figure 1

Flow diagram Visualizing Healthcare facility utilization Patterns Among the Households

Figure 2

Flow diagram Visualizing Healthcare utilization Patterns at illness episode level Among the Households who availed of any healthcare services *(There were multiple episodes of illness within individual in the households)

Figure 3

Flow diagram Visualizing Out-of-Pocket Expenditure (OOPE) Patterns Among the Households who availed Healthcare services from the Government facilities*(The figures provided may not necessarily reconcile to the total due to the possibility of individuals experiencing multiple episodes of illness within the specified data set)

Figure 4

Flow diagram Visualizing Out-of-Pocket Expenditure (OOPE) Patterns Among the Households who availed Healthcare services from the Private facilities*(The figures provided may not necessarily reconcile to the total due to the possibility of individuals experiencing multiple episodes of illness within the specified data set)

Figure 5

Graph representing the Distribution of out-of-pocket expenditure % among the individuals in Urban and Rural Puducherry.

Figure 6

Change in the proportion of OOPE among the households that availed any health services in Puducherry from the year 2016 to 2023.

Supplementary material 1

Sample size and Sampling:

Considering the prevalence of households with out-of-pocket expenditure in Puducherry as 67% and Absolute precision - 5%, d=0.05, Level of confidence- 95%, Margin of error- 5%, Significance level- 5%, Expected non-response rate- 10%, the sample size was calculated using OpenEpi Version 3.0. The initial sample size was 340. Corrected estimate (after considering losses). After considering a 10% non-response rate, the final sample size obtained was 378. Out of which 50% of the sample was taken from the JIRHC and JUHC areas. The sample sizes for UHC and RHC areas were considered 189 and 189, respectively.

The determination of the sample size at the village and ward levels within the RHC and UHC service areas was based on the proportion of each village or ward to the total number of households in RHC or UHC, respectively. In the RHC service area, with a total of 3,003 households, the villages of Ramanathapuram, Thondamanatham, Thuthipet, and Pillayarkuppam comprised 25.07%, 42.32%, 6.79%, and 25.08% of the total, respectively. These proportions were used to calculate the sample size, resulting in the enrolment of 47, 80, 13, and 49 households from the villages mentioned, contributing to a total sample size of 189 households for RHC.

Similarly, in the UHC service area, with a total of 2,405 households from the wards Kurusukuppam, Vaithikkuppam, Vazhaikulam, and Chinnaiyapuram, proportions of 45.32%, 9.77%, 31.60%, and 13.30% were applied for sample size calculation. This led to the enrolment of 86, 18, 60, and 25 households from the respective wards, forming a total sample size of 189 households for UHC.

Table 1.

A proportionate number of households selected from each village of JIRHC

Service area	Total number of households	The proportion of households (%)	Number of households required
Ramanathapuram,	753	25.07	47
Thondamanatham	1271	42.32	80
Thuthipet	204	6.79	13
Pillayarkuppam	775	25.08	49
Total	3003	100	189

Table 2.

A proportionate number of households selected from each ward of JUHC

Service area	Total number of households	The proportion of households (%)	Number of households required
Kurusukuppam	1090	45.32	86
Vaithikkuppam	235	9.77	18
Vazhaikulam	760	31.60	60
Chinnaiyapuram	320	13.30	25
Total	2405	100	189

The enumeration register provided the household lists used in the study. To initiate the systematic random sampling process, the initial household was chosen randomly from the list. A sampling interval of 11 was estimated, and subsequently, every 11th household from the list was included in the study. In cases where a selected household was found locked during the first visit, two additional attempts were made to visit the household. If the household remained inaccessible after these attempts, it was deemed unavailable for inclusion in the study.

Supplementary material 2

Descriptives of Individuals

The socio-demographic characteristics of the total 1500 individuals revealed notable differences between urban (726) and rural (774) study areas. In terms of age distribution, rural areas had a higher proportion of children (13.2%) compared to urban areas (8.4%), while urban areas showed a higher prevalence of early adults (31.5%) than rural areas (37.2%). Gender distribution was relatively balanced between males and females in both settings, with a slight female predominance. Education levels indicated that the majority had attained education up to high school or higher, with a slightly higher proportion of individuals lacking formal education in rural areas (18.5%) compared to urban areas (16.9%). Occupationally, there was a similar distribution between urban and rural areas, with a notable portion not engaged in employment. Health-related factors demonstrated disparities, with urban areas exhibiting a higher prevalence of chronic diseases (24.2%) compared to rural areas (17.3%) and a greater uptake of health services (18.6% in urban vs. 16.0% in rural). Income distribution was comparable between the two settings, with a median income of 2000 rupees and an interquartile range of 0 to 8000 rupees.

Healthcare Service Utilization Patterns

Table 3.

Healthcare utilization pattern of study participants at the Household level who availed of healthcare services (N = 192, Urban = 96, Rural = 96)

Details	Urban n (%)	Rural n (%)	Total n (%)
Inpatient care	28 (29.2)	46 (47.9)	74 (38.5)
Outpatient care	81 (84.4)	64 (66.7)	145 (75.5)

Table 4.

Reasons for utilization of health care services in Urban and Rural Areas of Puducherry over the last 6 months

Variables	Urban n (%)	Rural n (%)	Total n (%)
Among the total inpatient care services [N= 101 (Urban=42, Rural=59)]
NCD and complications	26 (61.9)	15 (25.4)	41 (40.6)
Accidents	3 (7.1)	24 (40.7)	27 (26.7)
RCH related	7 (16.7)	6 (10.2)	13 (12.9)
Allergies	3 (7.1)	5 (8.5)	8 (7.9)
Miscellaneous*	4 (9.5)	8 (13.5)	12 (11.9)
Among the total OPD illness [N= 244 (Urban = 143, Rural= 101)]
NCD and complications	27 (18.9)	6 (5.9)	33 (13.5)
Fever, cough & allergies	59 (41.3)	42 (41.6)	101 (41.4)
Pain	17 (11.9)	12 (11.9)	29 (11.9)
Eye, ear, and dental	12 (8.4)	12 (11.9)	24 (9.8)
Accidents and injuries	7 (4.9)	10 (9.9)	17 (7.0)
Stomach infections, pain and ulcers	6 (4.2)	9 (8.9)	15 (6.1)
Miscellaneous**	15 (10.4)	10 (9.9)	25 (10.2)
Among the 19 with illness but not availed any health services [N=19 (Urban= 17, Rural= 2)]
Fever & cold	10 (58.8)	1 (50)	11 (57.9)
Pain	5 (29.4)	-	5 (26.3)
Accidental falls	1 (5.9)	1 (50)	2 (10.5)
Jaundice	1 (5.9)	-	1 (5.3)

* Includes fever of unknown causes and pain **Includes RCH, Nutrition, Nerves, Veins related reasons, and infections

Supplementary material 3

OOPE:

Prevalence of OOPE and Average amount of OOPE in INR

Table 5.

Prevalence of Out-of-Pocket Expenditure among households in urban and rural field practice areas of JIPMER Puducherry, India, 2023. (N=378, urban=189, rural=189)

Out-of-pocket health expenditure	Urban		Rural		Total
	n	Prevalence (95% CI)	n	Prevalence (95% CI)	n	Prevalence (95% CI)
Among the total households (N= 378, urban = 189, Rural= 189)
OOPE	88	46.5 (39.6-53.7)	88	46.4 (39.6-53.7)	176	46.6 (41.6-51.6)
Direct medical cost	77	40.7	61	32.3	138	36.5
Direct non-medical cost	73	38.6	84	44.4	157	41.5
Among households availed of any healthcare services in the past 6 months (N=192, U= 96, R=96)
OOPE	88	91.5 (84.4-95.7)	88	91.4 (84.4 - 95.7)	176	91.6 (86.9 - 94.8)
Direct medical cost	77	80.2	61	63.5	138	71.8
Direct non-medical cost	73	76	84	87.5	157	81.7

Table 6.

Average INR of OOPE at household level in urban and rural Puducherry among the total and those households availed of any health services in the past 6 months.

Out of Pocket Expenditure			Urban		Rural		Total
			Median IQR		Median IQR		Median IQR
Among the total households (N= 378, U= 189, R=189)
Direct medical cost			K 2000 (700, 5500)		K 3000 (1000, 21000)		K 2000 (800, 10000)
Direct non-medical cost			K 0 (0, 200)		K 0 (0, 200)		K 0 (0, 200)
Overall			K 0 (0, 1750)		K 0 (0, 1150)		K 0 (0, 1500)
Among the households availed of any health services in the past 6 months (N= 192, U=96, R=96)
Direct medical cost			K 1250 (500, 3950)		K 500 (0, 5000)		K 1000 (0, 4150)
Direct non-medical cost			K 200 (100, 800)		K 200 (35, 500)		K 200 (100, 575)
Overall			K 2050 (625, 5500)		K 950 (100, 5725)		K 1400 (200, 5500)

Prevalence of OOPE among Individuals:

We also analyzed to provide insights into the prevalence of out-of-pocket health expenditure among individuals in urban and rural areas, based on a sample size of 1500 individuals (urban=726, rural=774). The results indicate that 14.6% (95% CI: 12.2-17.3) of individuals in urban areas and 9.6% (95% CI: 7.6-11.8) in rural areas reported out-of-pocket health expenditure. Collectively, 12% (95% CI: 10.4-13.7) of the total population experienced such expenditures. Notably, the prevalence of out-of-pocket health expenditure is higher in urban areas compared to rural areas (Figure 5).

The data on the prevalence of out-of-pocket expenditure among individuals who sought healthcare services in the past six months in urban and rural areas, with a total sample size of 259 individuals (urban=135, rural=124). The findings reveal that 68.1% (95% CI: 59.8-75.4) of urban and 72.6% (95% CI: 64.1-79.6) of rural individuals incurred out-of-pocket health expenses, resulting in an overall prevalence of 70.3% (95% CI: 64.4-75.7) among the total population availing healthcare services.

Catastrophic Health Expenditure of Households in Puducherry

Prevalence and Average amount of CHE in INR

Table 7.

Prevalence and the average amount of Catastrophic Health Expenditure among households in urban and rural field practice areas of JIPMER Puducherry.

Catastrophic health expenditure		N= 378* Urban=189 Rural= 189	N= 192** Urban=96 Rural=96	N= 176*** Urban=88 Rural= 88	Average INR in Median IQR
	n	% (95% CI)
Urban	19	10.1 (6.5 -15.2)	19.8 (13.1-28.8)	21.6 (14.3-31.3)	^10800 (2000,35200)
Rural	31	16.4 (11.8- 22.3)	32.3 (23.8-42.2)	35.2 (26.1-45.6)	^17500 (3400,43399)
Total	50	13.2 (10.2 -17.0)	26.0 (20.3-32.7)	28.4 (22.3-35.5)	^16800 (2875.1,41247)
*Among the total households **Among households availed of any healthcare services in the past 6 months ***Among households incurred OOPE

Association of various factors of households with OOPE and CHE

Table 8.

Factors associated with OOPE on healthcare among the households in urban and rural field practice areas of JIPMER, Puducherry, India 2023. (N=378, urban=189, rural=189)

Variables	Households with OOPE n (%)	Households without OOPE n (%)	Unadjusted PR (95% CI)	P-value
Occupation
Not working	49 (52.7)	44 (47.3)	1.2 (0.9 - 1.5)	0.2
Working	127 (44.6)	158 (55.4)	-ref-
Area of residence
Urban	88 (46.6)	101 (53.4)	1 (0.8 - 1.2)	>0.9
Rural	88 (46.6)	101 (53.4)	-ref-
Presence of Chronic diseases (at least one member in the family)
Yes	105 (48.4)	112 (51.6)	1.1 (0.8 - 1.4)	0.4
No	71 (44.1)	90 (55.9)	-ref-
Covered by any health insurance (at least one member in the family)
No	111 (46.1)	130 (53.9)	1.03 (0.8 - 1.3)	0.7
Yes	65 (47.4)	72 (52.6)	-ref-
Wealth index class
Lowest	30 (39)	47(61)	1.07 (0.7 - 1.6)	0.7
Second	108 (51.7)	101 (48.3)	1.4 (1.0 - 2.0)	0.03*
Fourth	14 (53.8)	12 (46.2)	1.5 (0.9 - 2.4)	0.1
Highest	24 (46.6)	42 (63.6)	-ref-

*p value <0.05 is considered as significant

Table 9.

Factors associated with CHE on healthcare among the households in urban and rural field practice areas of JIPMER, Puducherry, India 2023. (N=378, urban=189, rural=189)

Variables	Households with CHE n (%)	Households without CHE n (%)	Unadjusted PR (95% CI)	P-value
Occupation
Not working	8 (15.7)	43 (84.3)	0.9 (0.5 - 2.0)	0.9
Working	22 (16.3)	113 (83.7)	-ref-
Area of residence
Urban	19(10.1)	170 (89.9)	0.6 (0.4 - 1.0)	0.07
Rural	31 (16.4)	158 (83.6)	-ref-
Presence of Chronic diseases (at least one member in the family)
Yes	36 (16.6)	181 (83.4)	1.9 (1.1 - 3.4)	0.02*
No	14 (8.7)	147 (91.3)	-ref-
Covered by any health insurance (at least one member in the family)
No	31 (12.9)	210 (87.1)	0.9 (0.5 - 1.5)	0.7
Yes	19 (13.9)	118 (86.1)	-ref-
Wealth index class
Lowest	11(14.3)	66 (85.7)	0.9 (0.4 - 2.1)	0.8
Second	27 (12.9)	182 (87.1)	0.8 (0.4 - 1.6)	0.6
Fourth	2 (7.7)	24 (92.3)	0.5 (0.1 - 2.2)	0.3
Highest	10 (15.2)	56 (84.8)	-ref-

Supplementary material 4

Change in the proportion of OOPE on healthcare in Puducherry from 2016 to 2023

Table 10.

Difference in the distribution of sociodemographic characteristics among the households in urban and rural Puducherry from the year 2016 to 2023.

Comparison	2016 study		2023 study
	Urban n (%)	Rural n (%)	Urban n (%)	Rural n (%)
Religion
Hindu	114 (95)	114 (95)	161 (85.2)	181 (95.8)
Christian	6 (5)	6 (5)	26 (13.8)	8 (4.2)
Caste
General	7 (5.8)	6 (5)	19 (10.1)	13 (6.9)
Scheduled Caste	13 (10.8)	41 (34.2)	62 (32.8)	62 (32.8)
Other Backward Castes	100 (83.3)	73 (60.8)	108 (57.1)	114 (60.3)
Presence of any vulnerable group
Presence of child (<5 years)	22 (18.3)	29 (24.2)	30 (15.9)	52 (27.5)
Presence of elderly (>60 years)	52 (43.3)	44 (36.7)	82 (43.4)	74 (39.2)
Presence of pregnant woman	3 (2.5)	6 (5)	10 (5.3)	11 (5.8)
Presence of disability	3 (2.5)	4(3.3)	9 (4.8)	10 (5.3)
Covered by any health insurance	2 (1.7)	3 (2.3)	55 (29.1)	82 (43.4)
Median monthly income (IQR)	^ 2,000 (1,281-3,000	^ 2,387 (1,507-3,552)	^ 8000 (3250.0, 15000.0)	^ 8500 (4000.0, 12750.0)

Table 11.

Morbidity pattern of households incurred out-of-pocket expenditure- A comparison between the 2016 and 2023 study.

Comparison	2016 study	2023 (Current) study
Illness Patterns	• Respiratory disorders (such as wheezing and common cold) were the highest proportion of ailments reported in rural areas (21.2%) •Diabetes (25%) and cardiovascular disorders (25.6%) were more prevalent in urban areas.	• Non-communicable diseases (NCDs) emerge as a significant driver of hospitalization, constituting 40.6% of cases, with a higher prevalence in urban areas (61.9%) compared to rural areas (25.4%). •Accidents are more prevalent in rural areas, accounting for 40.7% compared to 7.1% in urban areas.
Healthcare Service Utilization	• 83.3% of rural households and 85.8% of urban households reported availing IP/OP/Pharmacy services.	• 38.9% sought care in the Inpatient Department (IPD), and 76.3% utilized Outpatient Department (OPD) services.
	• Government hospitals were the primary choice for both IPD and OPD services, with a majority incurring OOPE.
Trends in Healthcare Accessibility and Utilization	• A high percentage of households reported availing IP/OP/Pharmacy services, indicating a significant reliance on formal healthcare services for illness management	• A notable proportion of illness episodes not receiving OPD treatment, particularly in urban areas, with fever and cold being the predominant reasons (57.9%). This suggests a reliance on self-medication or alternative treatments.
Insights into Health Trends	• Both studies provide insights into health trends and healthcare accessibility, with non-communicable diseases emerging as a significant concern in urban areas and accidents being more prevalent in rural areas.
	• Disparities in the prevalence of NCDs between urban and rural areas underscore potential differences in lifestyle, healthcare access, or awareness levels among these populations.

OOPE:

We also analyzed to provide insights into the prevalence of out-of-pocket health expenditure among individuals in urban and rural areas, based on a sample size of 1500 individuals (urban=726, rural=774). The results indicate that 14.6% (95% CI: 12.2-17.3) of individuals in urban areas and 9.6% (95% CI: 7.6-11.8) in rural areas reported out-of-pocket health expenditure. Collectively, 12% (95% CI: 10.4-13.7) of the total population experienced such expenditures. Notably, the prevalence of out-of-pocket health expenditure is higher in urban areas compared to rural areas.

The data on the prevalence of out-of-pocket expenditure among individuals who sought healthcare services in the past six months in urban and rural areas, with a total sample size of 259 individuals (urban=135, rural=124). The findings reveal that 68.1% (95% CI: 59.8-75.4) of urban and 72.6% (95% CI: 64.1-79.6) of rural individuals incurred out-of-pocket health expenses, resulting in an overall prevalence of 70.3% (95% CI: 64.4-75.7) among the total population availing healthcare services.

Funding Statement

Nil.