Beyond Coverage: Recomposition, Mechanism, and Divergence in Health Equity in Odisha, India

This paper departs from the standard question of whether low out-of-pocket (OOP) spending in Odisha reflects financial protection or forgone care. It asks instead whether the architecture of inequity has been rebuilt as insurance expanded, whether tribal exclusion is produced by supply-side or demand-side failures, and whether the standard equity indicators used to monitor universal health coverage (UHC) are internally consistent. Using NSS 75th Round (2017–18) and 80th Round (2025) unit-level data on 19,078 and 22,315 persons in Odisha, the paper applies Erreygers-corrected concentration indices, indirect need standardization, and Oaxaca-type decompositions of change. Three findings emerge. First, the level of need-adjusted inequity in hospitalization was stable (HI = 0.015 in both rounds), but its composition changed: the contribution of consumption fell from 107% to 55%, while the combined contribution of Scheduled Tribe (ST) status and tribal-district residence rose from −0.0001 to 0.0043 (p = 0.006). Second, the mechanism of tribal exclusion is dual: bypassing of public facilities is driven by quality and staffing failures (40.7% cite poor quality or absent doctors), while untreated illness is driven by low recognition (89.9% of untreated ailments were "not considered serious"). Third, the indicators diverge: catastrophic health expenditure (CHE) is concentrated among the better-off (E = 0.067), while hospitalization is pro-rich (HI = 0.015). A state can therefore improve its CHE statistics by suppressing use. The paper argues that equity monitoring must treat spending and use as complementary but non-substitutable indicators, and that policy must address the mechanisms of exclusion rather than coverage alone.