Rural-urban differential in health care utilisation among elderly population
The rural-urban differential of rate of seeking treatment among the elderly population (aged 60 years and above) in India by select background characteristics is presented in Table 1. At the all India level, 92% of the ailing elderly population reported to have sought treatment on medical advice for an episode of illness. However, a smaller share of ailing elderly in rural India (89%) sought medical treatment compared to their urban counterparts (96%). The distribution of rate of seeking medical treatment across different demographic variables indicated that elderly persons who are aged between 80 years and above have the highest rate of healthcare utilization compared to the younger-olds (60–69 years) and the old-olds (70–79 years). Likewise, higher percentage of male elderly persons have sought medical treatment in comparison to the female elderly persons across rural and urban India. While OBCs had the highest rate of healthcare utilization among all the caste groups at the overall country level and in rural India, ‘other’ castes had the highest treatment seeking rate in urban India. The rural-urban difference, disfavoring those residing in rural India is the widest among Scheduled Tribes with a rural/urban ratio of 0.87. Never married, widowed, divorced or separated older persons had a lower rate of treatment seeking than the currently married ones. Also, with respect to religion, Hindu elderly had the least rate of healthcare utilization compared to Muslims and other religious groups.
The distribution of rate of health care utilization across different socio-economic groups showed that the elderly persons with some level of education utilized health care at a higher rate than the illiterate older persons. There is a 9-percentage point difference between the rates of health care utilization of the rural illiterates and the urban illiterates, in favour of the urban. Also, the economically independent older persons and those belonging to the richest wealth quartile had a higher rate of seeking medical treatment than those who are fully or partially dependent economically or belong to the poorest wealth quartiles. Older persons living alone or in a larger household (sized more than 5) seek medical treatment for an illness at a lower rate than those living with spouse and/or other members and in a household with size of 5 or less, respectively. There is an 11-percentage point difference between the rates of health care utilization of the older persons living ‘alone’ in rural and urban areas, in favour of the urban. This distribution pattern is uniform across rural and urban India wherein older persons residing in rural India, regardless of their demographic, social or economic attributes, have a lower rate of treatment seeking when compared to their urban counterparts. However, there is one deviation from this general pattern in case of elderly with education of ‘higher secondary or above’ residing in rural India having a higher rate of treatment seeking than their urban counterparts with the same level of education. Older persons who have health insurance have a higher rate of treatment seeking than those who are not insured in both urban and rural India.
The rural-urban differential in rate of healthcare utilization is consistently in favour of the elderly persons residing in urban India across various regions of India. While the rural-urban difference is the widest in case of Northeast region (rural-urban ratio of 0.72), this difference is the smallest in Central and Southern India (rural/urban ratio of 0.98 and 0.96 respectively).
Rural-urban differences in disease burden and untreated morbidities
The most common ailment reported by the urban and rural elderlies alike were hypertension and diabetes. However, hypertension was most common in rural area while diabetes was the most reported ailment in urban areas. Table 2 presents the varying disease burden of the elderly population in India by age and place of residence (rural/ urban). The top ten most reported ailments constitute roughly 82% and 84% of the total disease burden in rural and urban India respectively. Table 3 presents the rural-urban differential of the unmet need of healthcare. Of all the ailing elderly persons in India that received no treatment, an overwhelming majority (70%) belonged to the rural area. Further, the ailing elderly people who sought treatment but not on medical advice also majorly belong to the rural India (63.4). Likewise, the majority of the sick elderly persons who sought treatment from informal healthcare service providersFootnote 8 are concentrated in the rural areas (69.6%). Table 4 gives the distribution of the untreated morbidities among the elderly population for rural and urban India separately. Joint and bone disease was the most neglected ailment in rural areas while diabetes was the most commony untreated ailment in urban areas. The top-ten listed untreated morbidities together constitute roughly 74% and 76% of the total untreated morbidities in rural and urban areas respectively.
Rural-urban differentials in the use of health facilities
Public facilities were the most commonly utilised healthcare services accounting for roughly 40% of the services utilised by the elderly in rural India. In contrast, urban elderly people mostly avail the services of the private doctors/ clinics (43.5%). However, utilisation of the private sector facilities (comprising both private hospitals and private doctors/ clinics) outweighed use of the rest of the sources of healthcare services in both rural and urban areas accounting for 58% and 72% respectively. Nevertheless, the urban older population relies on the private sector facilities more than their rural counterparts (Table 5). Preference for a trusted doctor/ hospital and unsatisfactory quality of services in public facilities were the two most commonly cited reasons for not availing healthcare services from government sources in both urban and rural areas albeit constituting a varying proportion (Table 6).
Table 7 presents the rural-urban differential in accessibility of health facilities among the elderly population in India. Roughly 44% of the ailing older population in the rural India had to seek treatment from a facility in the urban area in the same district of residence. Further, 4.4% of the rural ailing elderly persons also had to travel to an urban facility located in a different district to seek treatment for their illnesses. This is in contrast to the 91.6% ailing elderly in the urban areas who received treatment for their illnesses at the place of their residence.
Determinants of inequalities in health care utilisation among elderly population
In this section, the crude and adjusted odds ratios have been computed through logistic regression to assess the effect of place of residence on the health seeking behaviour of the ailing elderly population in India. The results of the logistic regression have been presented in Table 8. The crude analysis in model 1 indicated that the odds of seeking medical treatment for urban elderly persons is 3 times higher than their rural counterparts and this difference is highly significant (at 99% confidence level).
In model 2, controlling of the effect of a range of demographic, socio-economic, social support, institutional and regional covariates, did not change the pattern of rural-urban differential in rate of treatment seeking. However, the inclusion of the covariates in the model, resulted in a contraction of the magnitude of the rural-urban differences. The odds of urban elderly seeking medical treatment remained very high nonetheless, i.e. twice that of their rural counterparts, significant at 99% confidence level.
Further, religion, education level and living arrangement emerged as statistically significant determinants of health care utilization among the elderly population India. Hindu elderly had almost 50% lower odds of utilizing health care than the Muslims (significant at 95% confidence level). An elderly with educational attainment of higher secondary or above was twice as likely as an illiterate elderly to seek medical treatment for an episode of illness (significant at 95% confidence level). Also, an elderly living with their spouse and/or any other member were 70% more likely to seek medical treatment than those living alone (significant at 90% confidence level). The regional variable was also a significant determinant of an elderly person’s rate of treatment seeking. With respect to the elderly residing in the Northeast region, elderly persons living in all other regions of India- Southern, Western, Northern, Central and Eastern regions, had higher odds of seeking treatment for an illness. The Southern region had the highest odds (6.65, significant at 95% confidence level) while the Eastern region had the lowest odd (2.79, significant at 95% confidence level) compared to the Northeast region.
Major contributory factors of rural-urban difference in health care utilization among elderly population: decomposition analysis
This section investigates the separate contributions from the rural-urban differences in each set of predictor variables to the rural-urban gap in the rate of seeking medical treatment for an illness among the elderly population in India by employing Fairlie’s decomposition technique (1999). The results of the decomposition analysis have been presented in Table 9. The rural and urban gap in healthcare utilization among the elderly population is − 0.0708, i.e. 7.1 percentage points higher for the urban elderly persons. The range of covariates considered in the model together explain 47.4% of the overall rural-urban gap, using the pooled estimated coefficients of the two groups- rural and urban. Using the rural coefficients as the reference, 39.3% of the gap could be explained while taking the urban coefficients as the reference, 35.1% of the differences could be explained (Appendix 2).
The decomposition results reveal that the rural-urban differences in the socio-economic factors vis a vis education (p < 0.01) and economic status (p < 0.05) together contribute to roughly 41% of the overall rural-urban gap in utilisation of health care by the elderly population in India. Regional differences (p < 0.05) explain 2.2% of the rural-urban inequality. The rest of the covariates have statistically insignificant contribution to the rural-urban differential in healthcare utilisation. As per NSS (2019), 38% of the rural elderlies belong to the lowest wealth quartile (poor) while only 7% of the urban dwellers belong to the poorest wealth quartile. On the other hand, 49% of the urban elderly belong to the highest wealth quartile (rich) compared to only 8% of the rural elderly in the same category. This rural-urban disparity in the distribution of income translates into a large negative effect (− 0.0128) on the rate of healthcare utilisation of the rural elderly people. The rural-urban gap in economic status, thus, contributes to 18% of the rural-urban difference in health care utilisation. Moreover, low levels of education among the rural elderly in comparison to their urban counterparts shows a negative effect (− 0.0160) on their likelihood to seek medical treatment for an illness. In rural India, 55% of the older population is ‘not literate’Footnote 9 as opposed to a much smaller proportion (25%) in the urban areas; while 24% of the urban dwellers have education level of higher secondary or above compared to only 4% of the rural elderly with the same level of education. This disparity in the level of educational attainment has a contribution of roughly 23% in explaining the rural-urban differential in health seeking behaviour among the older population in India. Thus, an improvement in the economic status and level of education among the rural elderly population has the potential to diminish the rural-urban gap in healthcare utilisation significantly.
The predictor variables- social group, living arrangement and sex also contribute 3.6%, 2% and 1.8% to the rural-urban gap, respectively. However, these contributions in explaining the rural-urban inequalities are not statistically significant. Marital status, religion, economic dependence, household size and health insurance have marginal contribution in the inequality between rural and urban dwellers but the results are statistically insignificant. Roughly 52.6% of the rural-urban difference remains unexplained due to ommitted variables.