Socio-economic and Tribal Inequity in Healthcare Use and Out-of-Pocket Expenditure in Odisha

Odisha reports one of India's lowest out-of-pocket (OOP) expenditures per hospitalization and near-universal publicly funded insurance. Low spending may signal financial protection, but it may also reflect forgone care among poor and Scheduled Tribe (ST) households. Using NSS 75th Round (2017–18) and 80th Round (2025) unit-level data covering 19,078 and 22,315 persons in Odisha, with India as benchmark, this paper estimates Erreygers-corrected concentration indices, indirect need standardization, and Wagstaff decompositions to measure horizontal inequity (HI) in reported illness, outpatient treatment, hospitalization, public facility use, OOP spending, and catastrophic health expenditure (CHE). After adjusting for need, hospitalization was concentrated among better-off people in both rounds (HI = 0.015, SE 0.003), even as government-funded insurance rose from 15% to 67% of the population. The sources of inequity shifted: the contribution of consumption fell from 107% to 55% (not significant), while ST status and tribal-district residence rose significantly from −0.0001 to 0.0043 (p = 0.006). Hospitalization in ST-majority districts fell from 28.3 to 25.5 per 1,000 while rising elsewhere from 34.1 to 47.6. Insurance contributed almost nothing. Among people reporting illness, outpatient treatment showed no significant inequity in 2025, but reported illness became steeply pro-rich (E from 0.044 to 0.137). CHE was concentrated among the better-off (E = 0.067), unlike India as a whole. Low OOP spending among Odisha's poor reflects both free public care and lower inpatient use than need warrants. Closing the gap requires supply-side investment and earlier recognition of illness in tribal communities, not further expansion of coverage alone.