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HealtHcare expenditure in india in tHe Global context

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HealtHcare expenditure in india in tHe Global context

Abstract and Figures

As nations progress along the epidemiological transition, the nature of healthcare expenditure changes drastically. Communicable diseases are containable through simpler public health strategies and when requiring intervention, require urgent and short-term treatment. In contrast, non-communicable diseases (NCDs) require longer-term and more expensive treatment, which may include laboratory testing as well. Different regions of the world are in different stages of epidemiological transition process. The World Health Organisation (WHO) estimates of the causes of death in 2008 indicate that in the 'more developed regions, excluding Eastern Europe' , a majority of all deaths (80 per cent) were attributable to NCDs (UN 2012). Together with the high life expectancy at birth, the pattern of deaths by cause reveals that this group of countries as a whole is in the advanced stages of the demographic and epidemiologic transitions. In stark contrast, death due to communicable diseases as well as maternal, perinatal and nutritional conditions continue to be responsible for a large proportion of mortality in several regions, where life expectancy at birth is also substantially lower than in the more developed regions. In Africa, the region of the world with the lowest life expectancy at birth of 55 years, the majority of deaths in 2008 (61 per cent) was due to communicable diseases as well as maternal, perinatal and nutritional conditions. While coping with each of either communicable or NCDs poses considerable challenges, India is confronted with both simultaneously. India is in the middle stage of this epidemiological transition with a dual burden of diseases—communicable diseases among younger age population and NCDs among population of age 45 years or more. Growing importance of NCDs will only rise as the population continues to age. Healthcare systems in India are ill-equipped to address these challenges. Health expenditure around the world is highly asymmetrical in nature. Developed countries in the Europe and Central Asian region have the highest healthcare expenditure, 9.6 per cent of the gross domestic product (Figure 5.1). Healthcare spending (as a per cent of GDP) is also higher in the Latin America and Caribbean region (7.6 per cent) and East Asia and Pacific region (6.8 per cent). In contrast, countries in the South Asian region spend barely 3.8 per cent of the GDP on healthcare. In spite of a rapid economic growth in the last two decades, healthcare spending in India has not gone up significantly. Healthcare spending in India (3.9 per cent) is slightly higher than the average spending of her South Asian neighbours, but considerably lower than the developed nations. Even compared to other middle income nations, per capita spending on health in India is the lowest among the BRICS (Brazil, Russia, India, China and South Africa) countries as reflected in the World Bank World Development Indicators (Table 5.1). All other countries in this group spend higher share of their GDP 5
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Hea lt Hc ar e expenditure i n india
in tHe Global context
As nations progress along the epidemiological transition,
the nature of healthcare expenditure changes drastically.
Communicable diseases are containable through simpler
public health strategies and when requiring intervention,
require urgent and short-term treatment. In contrast,
non-communicable diseases (NCDs) require longer-
term and more expensive treatment, which may
include laboratory testing as well. Dierent regions
of the world are in dierent stages of epidemiological
transition process. e World Health Organisation
(WHO) estimates of the causes of death in 2008
indicate that in the ‘more developed regions, excluding
Eastern Europe’, a majority of all deaths (80 per cent)
were attributable to NCDs (UN 2012). Together with
the high life expectancy at birth, the pattern of deaths
by cause reveals that this group of countries as a whole
is in the advanced stages of the demographic and
epidemiologic transitions. In stark contrast, death due
to communicable diseases as well as maternal, perinatal
and nutritional conditions continue to be responsible
for a large proportion of mortality in several regions,
where life expectancy at birth is also substantially lower
than in the more developed regions. In Africa, the region
of the world with the lowest life expectancy at birth of
55 years, the majority of deaths in 2008 (61 per cent)
was due to communicable diseases as well as maternal,
perinatal and nutritional conditions.
While coping with each of either communicable or
NCDs poses considerable challenges, India is confronted
with both simultaneously. India is in the middle stage
of this epidemiological transition with a dual burden of
diseases—communicable diseases among younger age
population and NCDs among population of age 45 years
or more. Growing importance of NCDs will only rise as
the population continues to age. Healthcare systems in
India are ill-equipped to address these challenges.
Health expenditure around the world is highly
asymmetrical in nature. Developed countries in the
Europe and Central Asian region have the highest
healthcare expenditure, 9.6 per cent of the gross
domestic product (Figure 5.1). Healthcare spending
(as a per cent of GDP) is also higher in the Latin America
and Caribbean region (7.6 per cent) and East Asia and
Pacic region (6.8 per cent). In contrast, countries in
the South Asian region spend barely 3.8 per cent of the
GDP on healthcare. In spite of a rapid economic growth
in the last two decades, healthcare spending in India has
not gone up signicantly. Healthcare spending in India
(3.9 per cent) is slightly higher than the average spending
of her South Asian neighbours, but considerably lower
than the developed nations.
Even compared to other middle income nations,
per capita spending on health in India is the lowest
among the BRICS (Brazil, Russia, India, China and
South Africa) countries as reected in the World Bank
World Development Indicators (Table 5.1). All other
countries in this group spend higher share of their GDP
5DETERMINANTS OF PRIVATE
HEALTHCARE UTILISATION AND
EXPENDITURE PATTERNS IN INDIA
Debasis Barik and Sonalde Desai
Determinants of Private Healthcare Utilisation and Expenditure Patterns in India 53
on health than India. Health outcome in terms of life
expectancy at birth (LEB) also reveals India in a relatively
disadvantageous position, just higher than South Africa.
e poor LEB in South Africa is largely attributable
to the loss of life years due to opportunistic infections,
mainly tuberculosis due to HIV/AIDS since the 1990s.
What makes Indian healthcare pattern unique is
the importance of household out-of-pocket (OOP)
expenditure. A majority of the illnesses are treated by
private healthcare providers and with the exception
of Rashtriya Swasthya Bima Yojana (discussed later)
health insurance coverage is negligible, a majority
of spending tends to be out-of-pocket. In spite of
the higher prevalence of poverty, 61 per cent of total
healthcare expenditure is met through OOP spending
by the households (Table 5.1). is OOP health
spending is the key source of healthcare nancing in
India and this leads to catastrophic level of spending
for healthcare to many households and push them into
poverty (Ghosh 2011; Pal 2010; Berman et al. 2010).
e proportion of households facing catastrophic
OOP health payments during 2004–05, as measured
by Ghosh (2011) was 15.37 per cent. is varied
widely among states, from 3.46 per cent in Assam to
32.42 per cent in Kerala.
twelftH five Year plan on HealtH :
Some raYS of Hope
e Eleventh Five Year Plan (2007–12) made only
minor progress on achieving service provision goals.
During the Eleventh Plan, funding for health by Centre
and state together has increased from earlier 0.94 per
cent of GDP to 1.04 per cent of GDP in 2011–12
(Planning Commission 2013). Healthcare facilities
are still inadequate and the Eleventh Plan has failed
to achieve the desired levels. Despite considerable
improvement in recruitment of health personnel the
gap between need for health personnel and availability
remains large (ibid.). Underperformance in creating
resources and inecient management has contributed
in widening the gap in actual and desired levels of health
outcome during the Eleventh Plan period.
However, the Twelfth Five Year Plan (2012–17)
contains a lot of promise and hope. e Twelfth Plan
strategy has been set up based on a comprehensive
discussion by a High Level Expert Group (HLEG)
formulated by the Planning Commission of India.
e Twelfth Plan is set to roll out Universal Health
Coverage (UHC) to achieve the long-term health goals.
e HLEG has dened UHC as, ... ensuring equitable
access for all Indian citizens, resident in any part of the
country, regardless of income level, social status, gender,
caste or religion, to aordable, accountable, appropriate
health services of assured quality (promotive, preventive,
curative and rehabilitative) as well as public health services
addressing the wider determinants of health delivered to
individuals and populations, with the government being
the guarantor and enabler, although not necessarily the
only provider, of health and related services’. Due to
nancial constraint, the HLEG has recommended the
prioritisation of primary healthcare, while ensuring that
fiGure
5.1 Healthcare Expenditure as a Percentage
of GDP by World Regions and India, 2011
Source: World Development Indicators (2011).
table
5.1 Life Expectancy at Birth, GDP Per-Capita and Share of Healthcare Expenditure
on GDP among BRICS Countries, 2011
BRICS Countries LEB (Years) PCHE GDP per capita HCE as % OOP as % of
(current US $) (PPP US $) of GDP total HCE
Brazil 73 1,121 11,634 8.9 30.6
Russia 69 807 22,408 6.2 31.4
India 65 59 3,714 3.9 61.2
China 73 278 8,408 5.2 36.6
South Africa 53 689 11,028 8.5 16.6
Note: LEB: Life Expectancy at Birth, PCHE: Per Capita Health Expenditure, OOP: Out-of-pocket, ppp: Purchasing Power Parity, HCE:
Healthcare Expenditure
Source: World Development Indicators (2011).
6.8
9.6
7.6
4.4 3.8 3.9
6.5
East
Asia
& Pacific
Europe
& Central
Asia
Latin
America
& Caribbean
Middle
East &
North Africa
South
Asia
India Sub-
Saharan
Africa
% Share of GDP on Health
10
8
6
4
2
0
54 India Infrastructure Report 2013|14
the Essential Health Package (EHP) includes essential
services at all levels of care. Government allocation
(both central and state) on healthcare, broadly dened,
has been set to achieve 2.5 per cent of GDP by the end
of the Twelfth Plan. At the same time, it emphasises
the need to refocus the nancial and managerial
system to ensure more ecient utilisation of available
resources. Public-Private Partnerships (PPPs) have
been encouraged to provide ecient care to people in
reasonable price.
Below, we examine empirical data on use of
healthcare services and healthcare expenditure by
households to see how experiences of households on-
the-ground varies by their socio-economic conditions
and availability of healthcare.
morbiditY Scenario in india:
prevalence o f diSeaSeS and
treatment rate
e asymmetric demographic transition among
Indian states has contributed to the co-existence of
communicable as well as non-communicable diseases
NCDs across wide geographic region. Poor and
inadequate supply of public health services, including
safe drinking water and sanitation, along with broad
base of younger age population particularly in the high
fertility states have contributed to the higher prevalence
of communicable diseases. Again, states in the southern
part of India and some other states, who are leading in
the demographic transition process, are burdened with
long-term chronic morbidities, such as diabetes, cardiac
ailments, etc. Both types of morbidities have dierent
healthcare needs. e minor morbidities such as fever,
respiratory infection and diarrhoea are subject to
frequent out-patient visit, which although inexpensive
per visit, can be cumulatively onerous with higher
frequency of occurrence and are mostly not covered
by the insurance schemes. On the other side, with
major morbidities, people require long-term intense
care, which may be less frequent but expensive when
encountered.
e prevalence of various minor and major
morbidities and treatment seeking behaviour, as noted
in the India Human Development Survey-I (2004–
05), are depicted in Table 5.2. IHDS-I is a nationally
representative, multi-topic survey of 41,554 households
in 1503 villages and 971 urban neighbourhoods across
India. Along with the rich content on education,
employment, income, it has collected information on
reproductive health, and broader health and health
beliefs of the Indian population with an intention to
follow them up over time.
e survey reveals that, as many as 124 per 1,000
people in India suered from fever, cough and cold or
diarrhoea during the 30 days prior to the survey (Table
5.2). Fever is the most frequently observed among all
minor morbidities. Almost half (45 per cent) of all
Indian households had someone who suered from
one of these minor illnesses. e prevalence of any
long-term morbidities in the last 365 days prior to
the survey was half that of the prevalence of minor
morbidities with a 30 day reference period. e
most frequently reported long-term illness was the
unspecied ‘other’ category (23 per 1,000), which
mostly includes accident. Prevalence of high blood
pressure (14 per 1,000) is the second highest among
all long-term morbidities. Among the other long-
term morbidities, diabetes, asthma, cataract and heart
disease share a fair prevalence. Multiple morbidities
were reported by 14 per cent of these populations.
Twenty-seven per cent of the Indian households
had at least one person suering from any long-term
illness. However, these reported prevalence rate are
lower than the actual prevalence, mainly because the
survey collected information from the members of the
household, who were present during the interview and
the morbidities include the diagnosed ailments only
(Desai et al. 2010).
People often seek treatment for minor morbidities (or
fail to report a minor illness for which no treatment is
sought), but non-treated ailment is higher for the major
morbidities. Nearly 6 per cent of the minor morbidities
are not treated compared to 9 per cent of the long-term
morbidities. 42.5 per cent of the polio cases, reported
in the IHDS survey, were not treated in the year prior
to the survey. One in every four patients suering from
mental illness was not treated. Non-treatment was also
higher in case of cataract (20.7 per cent), paralysis (18.2
per cent) and epilepsy (14.7 per cent).
e statistics on source of provider for the patients,
who sought treatment, gives a gloomy picture about the
use of public facilities for both minor and major illnesses.
In spite of higher treatment cost, people overwhelmingly
prefer to use private healthcare providers rather than
public facilities. ree-fourth of the patients visited
private facilities for treatment for both type of illnesses.
Visit to public facilities were comparatively higher for
long-term illnesses than short-term illnesses.
Determinants of Private Healthcare Utilisation and Expenditure Patterns in India 55
While long-term illnesses are more devastating,
short-term illnesses are more prevalent. Short-term
morbidity accounts for substantial time loss from
usual activities. A person suering from any short-
term illness was incapacitated, or unable to perform
his or her usual activities for four-and-a-half days in 30
days prior to the survey. Although short-term illnesses
are more common for children, days lost per illness
increases with age, somewhat counterbalancing the
lower prevalence at younger ages. A person who was ill
with a long-term disease was, on an average, unable to
perform his or her normal activities for almost 60 days
during the previous year. e elderly were more aected
than others. ey lost 71 days of normal activity if sick
with one of these diseases. Across the entire population,
long-term illnesses accounted for about four days (per
person-per year) of lost activity, compared with seven
days for short-term illnesses. is dierence is due to
the lower prevalence of long-term than short-term
morbidity (ibid., 2010).
e working age adults (15–59 years) lose about 5.5
days per year because of fevers, coughs and diarrhoea,
school-age children lose seven days, and the elderly lose
10 days per year respectively. On the other hand, long-
term illness results a loss of four days for working age
adults, one day for school-going children and 15 days
for elderly. Days lost in long-term major morbidities
are more pronounced than short-term morbidities for
the older population as both the prevalence and days
incapacitated due to long-term illnesses are higher
among this age group.
Hea lt Hc ar e expenditure
and financinG
As discussed earlier, healthcare in India is dominated
by the private healthcare providers. Over two-thirds
of the patients, suering from either type of morbidity
seek private care. But, private healthcare is subject to
large OOP expenditure since health insurance coverage
is negligible.
At the same time, in spite of the ostensibly free
nature of government healthcare, substantial costs are
involved in the form of medication costs or tips. Average
treatment cost of minor morbidity in government
table
5.2 Treatment Rate for Short- and Long-term Morbidities in India, 2004–05
Treated in (in percentage)
Prevalence Government Private Other Percentage Numbers
(’000) not treated
Any short-term morbidity 124 16.2 73.2 10.6 5.7 25,505
Fever 107 16.4 74.6 9.1 4.7 21,848
Cough 86 15.3 75.5 9.2 5.6 17,585
Diarrhoea 30 12.2 76.3 11.5 5.5 6,140
Any long-term morbidity 64 20.2 74.9 4.9 9.0 12,704
Cataract 6 31.5 63.3 5.2 20.7 1,243
Tuberculosis 4 22.3 74.5 3.2 12.2 722
High BP 14 21.5 74.4 4.2 3.7 2,728
Heart disease 5 22.2 74.4 3.4 8.7 1,085
Diabetes 8 24.3 72.1 3.7 3.2 1,554
Leprosy 1 20.1 76.0 3.9 9.7 143
Cancer 1 18.3 73.0 8.8 2.7 143
Asthma 7 16.8 78.7 4.5 4.7 1,363
Polio 1 17.5 75.1 7.5 42.5 241
Paralysis 2 20.2 73.5 6.3 18.2 308
Epilepsy 1 15.7 73.1 11.3 14.7 245
Mental illness 2 21.5 69.5 9.0 25.0 304
STD or AIDS 1 18.5 76.2 5.3 13.8 128
Other long-term 23 16.5 78.3 5.2 6.0 4,518
Source: India Human Development Survey (2004–05).
56 India Infrastructure Report 2013|14
facilities was Rs 319 and in private it was Rs 350 (Table
5.3), not a large dierence. e dierence between
public and private facilities is larger when it comes to
major illnesses. Average annual cost of treatment for
long-term illnesses is Rs 4,569 in public facilities and Rs
6,139 in private. Both of these are substantially higher
than minor illness related expenditure.1 Heart disease,
cancer, paralysis are the few among the long-term
diseases noted in IHDS-I survey, which demands for a
huge spending on treatment.
Our observation of a small dierence between
government and private healthcare during minor
illnesses may be partly due to a huge variation in the
quality and the cost of private healthcare. e private
medical sector in India is extremely heterogeneous
in nature. People usually go to traditional healers for
minor illnesses, who prescribe relatively cheap ayurvedic
or homeopathic medicines. However, when it comes to
major illnesses, the dierence in doctors’ costs between
public and private providers is greater, possibly because
this is where patients visit more qualied and expensive
private doctors (ibid., 2010).
Since the cost of treatment of both minor and major
illnesses is not exceptionally lower in government
facilities than private, people opt for private treatment
over government, mainly for easy access and exible
visiting hour. Moreover, the cost of treatment was
signicantly lower while using some provider, such as
pharmacist (ibid., 2010).
Indian households spend a surprisingly large
proportion of their income on medical care and medical
expenses are an important reason to push them into
poverty trap. Table 5.4 provides a comprehensive picture
of the toll of healthcare expenditure on household
income. e share of short-term morbidities is higher
in the share of total health expenditure on household
income.
e IHDS survey data shows that, about 6 per cent
of the monthly household income is spent on healthcare,
out of which 4.4 per cent is spent for minor illness and
1.6 per cent is for long-term illness. Higher share of
household income is spent on healthcare in rural areas
than urban areas. Again, among the urban dwellers,
share of income spent in healthcare is lower in metros
than their other counterparts. is nding is probably
attributable to the fact that healthcare expenditure is
more or less constant across various income groups,
while the income varies; the poor spend a greater
1 Reference period for short-term morbidity expenditure is 30 days while that for long-term illnesses is 12 months.
table
5.3 Average Healthcare Expenditure in
Government and Private Facilities by Type of Illness,
2004–05
Average Health Sample size
Expenditure (in Rs)
Govt. Pvt. Total Govt. Pvt.
Any short-term 319 350 294 5,235 17,111
morbidity
Fever 330 356 308 4,626 15,246
Cough 345 331 287 3,521 12,213
Diarrhoea 348 357 304 875 3,594
Any long-term 4,654 6,139 5,053 3,369 8,412
morbidity
Cataract 4,068 5,254 3,482 384 648
Tuberculosis 4,608 6,973 5,477 210 387
High BP 3,023 4,610 3,930 883 2,091
Heart disease 7,770 10,018 8,179 345 762
Diabetes 4,226 6,286 5,439 434 1,195
Leprosy* 7,777 5,175 4,445 31 81
Cancer* 14,578 19,670 15,399 47 99
Asthma 4,156 4,528 4,016 350 843
Polio* 7,949 6,677 3,761 41 110
Paralysis* 7,351 11,515 8,073 81 206
Epilepsy* 10,544 7,077 5,874 47 158
Mental illness* 7,920 7,531 6,036 74 169
STD or AIDS* 6,150 3,925 3,574 23 68
Other long-term 5,860 7,083 6,181 1,067 3,081
Note: e reference period for short-term morbidity is 30 days prior to the
survey and for long-term morbidity is 365 days prior to the survey. * Figures
not reliable due to small sample size.
Source: India Human Development Survey (2004–05).
percentage of their income on healthcare. e higher
availability and easy access to health facilities in the
urban areas make the healthcare cost cheaper in urban
areas than rural. e rural people, more often, have
to leave their local areas for treatment and are slightly
more likely to be hospitalised, which raise costs (ibid.).
Lower treatment cost along with higher household
income in the urban areas lead to spend lower share
of household income on health compared to the rural
households. Poor households spent 14.5 per cent
of their monthly income on healthcare expenditure,
compared to 0.7 per cent among the richest households.
e Adivasis and the Muslims spent a lower share
(3.9 per cent and 4.8 per cent respectively) of their
monthly income on healthcare. On the other hand, a
Determinants of Private Healthcare Utilisation and Expenditure Patterns in India 57
options, which physicians may hesitate to recommend
to poor patients, and poor households may be less likely
to undertake, even if recommended (ibid.). Whatever
may be the reason, Figure 5.2 reveals that the healthcare
expenditure variation across income groups is not very
large. Consequently, it implies a larger proportion of
income among the poor is spent on healthcare.
wHY do people uSe private car e?
e above analysis indicates that, despite a higher
treatment cost, average Indian patient opts for private
healthcare services. ere are two main components—
(1) structure of government healthcare, and (2) quality
of care.
Structure of government healthcare
In spite of attempts in every Five Year Plan to improve
public healthcare infrastructure, the shortfall remains
signicantly high. While urban residents generally have
a choice of public or private providers, rural residents
face far fewer choices. Currently, a sub-centre covers
an average radial distance of about 2.59 kms, whereas
primary health centres (PHCs) and community
health centres (CHCs) cover 6.42 kms and 14.33 kms
respectively (RHS 2012). is shows a relatively higher
access to sub-centres to the rural Indian population.
A CHC is supposed to provide minimum specialist
services to the rural population. As per minimum
norms, a CHC is required to be manned by four medical
specialists, i.e. surgeons, physicians, gynaecologists and
pediatricians supported by paramedical and other sta.
It is mandated to have 30 indoor beds with one operation
theatre, X-ray, labour room and laboratory facilities.
table
5.4 Share of Total Household Income,
Spend on Healthcare in India, 2004–05
Healthcare spending (%) on
monthly household income
Any Short- Long-
morbidity term term
All-India 6.02 4.43 1.59
Place of Residence
Metro 1.13 0.67 0.46
Other Urban 3.57 2.42 1.15
More developed village 7.73 5.72 2.01
Less developed village 6.87 5.18 1.69
Income  
Lowest quintile 14.53 11.15 3.38
2nd quintile 4.53 3.27 1.26
3rd quintile 2.44 1.74 0.70
4th quintile 1.44 1.02 0.42
Top quintile 0.65 0.37 0.28
Social Groups  
High caste Hindu 5.13 3.65 1.48
OBC 7.59 5.66 1.93
Dalit 5.32 4.06 1.26
Adivasi 3.88 2.78 1.10
Muslim 4.84 3.88 0.96
Other religion 9.19 4.36 4.83
Source: India Human Development Survey (2004–05).
larger share (9.2 per cent) of household income of people,
belong to other minority religious communities were
spent on healthcare during 2004–05. e prevalence
of short-term as well as long-term morbidity is lowest
among the Adivasi group. is may be due to under-
reporting of ailments among Adivasis. Again, a higher
proportion of sick Adivasis were treated in government
facilities, which resulted into a lower treatment cost.
e median treatment cost incurred by Adivasis for any
short-term and long-term morbidities are Rs 80 and Rs
600 respectively, which are far less than the national level
(Rs 120 for short-term and Rs 1,900 for long-term).
e healthcare spending by household income
category gives an interesting picture (see Figure 5.2).
When it comes to minor illnesses, the rich and poor
spend about the same. But the treatment cost for long-
term illnesses vary substantially, with a range of Rs
1,274 in the lowest income quintile to Rs 2,571 in the
highest income quintile, and a sharp increase between
the fourth and fth quintile. Since, primary costs for
short-term illnesses are related to medicine, these are
unlikely to vary by household income. However, major
illnesses require more expensive tests and treatment
fiGure
5.2 Median Medical Spending (in Rs)
for Short- and Long-term Morbidities by
Household Income Quintiles in India, 2004–05
Source: Authors’ calculation based on India Human Development Survey
(2004–05)
3000
2500
2000
1500
1000
500
0
1,274
182
1,343 1,478 1,610
2,571
200 179 188 196
Lowest Second Third Fourth Highest
Household Income Quintiles
Short-term Illness Long-term Illness
58 India Infrastructure Report 2013|14
It serves as a referral centre for 4 primary healthcare
centres ( PHCs) and also provides facilities for obstetric
care and specialist consultations. One CHC is to cover
a population of 80,000 in hilly/tribal/dicult areas and
1.2 lakh in plain areas. As of March 2012, 16 states/
UTs are serving more than 1.2 lakh population and
the situation in Bihar is the worst. A CHC in Bihar is
serving 13.2 lakh population, 11 times higher than the
specied norm (ibid., 2010).
PHCs are the cornerstone of the rural healthcare
delivery system. is is the rst contact point between
village community and the medical ocer. e PHCs
were envisaged to provide an integrated curative and
preventive healthcare to the rural population with
emphasis on preventive and promotive aspects of
healthcare. e activities of PHC involve curative,
preventive, promotive and family welfare services. One
PHC is to cover a population of 20,000 in hilly/tribal/
dicult areas and 30,000 in plain areas. As per minimum
requirement, a PHC is to be manned by a medical ocer
supported by 14 paramedical and other sta. Under
National Rural Health Mission (NRHM), there is a
provision for two additional sta nurses at PHCs on
contract basis. It acts as a referral unit for 6 sub-centres
and has 4–6 beds for patients. e latest statistics reveals
that, PHCs in 14 states/UTs are serving a population
higher than the limit suggested by Indian Public Health
Standards (IPHS). PHCs in most of the major states
are serving more than 30,000 population (ibid., 2010).
A health sub-centre in India usually covers a
population of 5,000 in plain area and 3,000 population
in hilly/tribal/dicult area. Each sub-centre is required
to be manned by at least one Auxiliary Nurse Midwife
(ANM)/Female Health Worker and one Male Health
Worker. Under NRHM, there is a provision to have one
additional second ANM on contract basis. Sub-centres are
assigned tasks relating to interpersonal communication
in order to bring about behavioural change and provide
services in relation to maternal and child health, family
welfare, nutrition, immunisation, diarrhoea control and
control of communicable diseases programmes. e
sub-centres are provided with basic drugs for minor
ailments needed for taking care of essential health needs
of men, women and children. Sub-centres in the rural
areas of 13 states/UTs are serving more than 5,000
population, the limit suggested by IPHS (ibid., 2010).
e Twelfth Five Year Plan (2012–17) has put a
strong emphasis on a very broad range of preventive,
promotive and curative care to be made available at the
sub-centre and PHC-level, with more than 70 per cent of
the total healthcare investment is expected to ow at this
level (Planning Commission 2013). A strict gate-keeping
at the sub-centre-level has been prescribed to ensure that
more than 95 per cent of the patients are fully cared at
this level (Mor 2013). A number of researchers have
expressed their doubt if the central or state budget will be
able to support the huge expenditure required to enhance
the existing healthcare system (Rao and Singh 2005, Rao
and Choudhury 2012). Moreover, if the money were to
become available, bringing about all the changes will take
a great deal of time and manpower.
However, access to a sub-centre is not enough to
encourage the use of a government facility for short-
term care, particularly if a private facility is also present
(Desai et al. 2010). In the absence of any health facilities,
16 per cent of the villagers go outside the village for
treatment in public facilities against a huge 69 per cent
in private facilities (Figure 5.3). In spite of having a sub-
centre in the village, 57 per cent go out of the village for
private treatment. e use of sub-centre is less by 17 per
fiGure
5.3 Use of Public/Private Facilities (in percentage) by Availability of Facilities in the Village, 2004–05
Source: India Human Development Survey (2004–05).
80.0
70.0
0.0
10.0
20.0
30.0
40.0
50.0
60.0
% of using Public/private facility
69.3
56.5 55.9
16.1
29.7 35.0
No clinics Sub-centre only PHC/CHC only
80
0
10
20
30
40
50
60
70
% of using Public/private facility
Private only Sub-centre PHC/CHC
74.9 74.8
66.3
9.1 12.6
26.6
In villages without private health facilities In villages without private health facilities
Public Private Public Private
Determinants of Private Healthcare Utilisation and Expenditure Patterns in India 59
cent and that of PHC/CHC by 8 per cent, when any
private medical facility co-exists.
Accredited Social Health Activist (ASHA) works
as a bridge between ANM and the community people.
e mandated qualication level for an ASHA worker
is formal education up to class 8. e criterion is also
relaxed if person with suitable qualication is not
available. But, whether education upto class 8 is sucient
for the tasks ASHA workers are expected to perform
is not clear. Since ASHA workers are expected to keep
records and advice patients about appropriate care,
their ability to read instructions is important to their
ability to perform their job. Keeping aside educational
qualication, the performance of the community health
workers like ASHA is highly dependent on the on-
the-job training received by them. Studies reveal that
a huge lack of introductory as well as regular training
of these low-educated ASHA workers has aggravated
the situation further which often results into a low level
of knowledge to perform the job eciently. A study
by Bajpai and Dholakia (2011) provides qualitative
ndings on the recruitment, responsibilities, training,
incentives and supervision of ASHA workers, in a few
states, using cross-sectional, mixed-method surveys and
focus group discussions. ey found that nearly half of
the ASHA workers in Assam could not specify their
job responsibilities, whereas ASHAs in Bihar receive
less than 10 of the 23 days recommended training.
Again, most of these ‘barefoot’ community workers have
received their on-the-job training from ANMs, who are
not ocially recognised as the supervisor or trainers
of the ASHAs. ese translate into very poor health
knowledge among these workers, and evidence suggests
that many ASHAs lack essential knowledge to perform
their jobs well (Bajpai et al. 2011).
Quality of Care
Judging by the overwhelming preference of Indian
consumers for private sector health services, we might
be tempted to assume that private providers oer far
superior care than public providers. However, this
appears not to be the case.
e Indian medical system is mainly managed by
three types of providers—trained (MBBS) public
sector doctors, trained (MBBS) private sector doctors
and untrained private sector doctors. e public
sector is vast, but is sorely underfunded and not nearly
large enough to meet the growing health needs of the
country. Moreover, it is overly centralised and rigid in
planning, politically manipulated, and poorly managed
and governed. However, private sector providers are
not signicantly better. e mushrooming private
sector is undirected and unregulated. It rarely meets
the standards of care populated by many unqualied
practitioners, and provides too many inappropriate
treatments (Preker et al. 2002).
A vast majority of private medical practitioners in
India are unqualied and lack proper training, especially
those in the rural areas (Rao 2012). IHDS (2004–05)
documented that 86 per cent of government doctors
had an MBBS (Bachelor of Medicine and Bachelor
of Surgery) degree, but only 60 per cent of the private
providers are so qualied. Das et al. (2008) pointed out
that the quality of medical advice, delivered by a medical
practitioner in low income countries including India
is very low. ey measured the variation in quality of
medical advice in a combination of variation i n competence
(dened as what doctors know) and variation in eort
(dened as how hard doctors work). e gap between
knowledge and practice is stark among Indian health
practitioners. e study reveals that private doctors
without an MBBS degree know only 20 per cent of the
essential tasks, but they do pretty much all they know to
do. e performance of this set of doctors is restricted by
competence. e private doctors with an MBBS degree
know 40 per cent of the essential tasks, but in practice,
they use 25 per cent of them. e constraint of their
performance is eort. e gap between competence and
practice is even higher among public sector doctors.
ese set of doctors knew 30 per cent of their essential
tasks but execute only 8 per cent in practice. Here also,
eort is the constraint in performance.
is suggests that, although most of the public health
facilities (PHCs/CHCs) are equipped with MBBS
doctors, their competence as well as eorts to put
knowledge into practice is negligible. e private sector,
dominating the health market is also poorly equipped.
Private hospitals are over-crowded by huge volume of
patients, mostly due to the weak government healthcare
delivery system and poor quality of care oered by it
(Rao 2012). Homan and ankappan (1999), based
on a study in Kerala showed that private city hospitals
had higher occupancy rate than public hospitals. Again,
the competence of private doctors need not be taken for
granted. Using vignettes, coupled with direct observation
of practice, Das and Hammer (2004) observed that the
competence necessary to recognise and handle common
and dangerous conditions is quite low among private
medical practitioners in Delhi. ey also commented
60 India Infrastructure Report 2013|14
that urban India pays a lot of ‘Money for Nothing’ in the
private health sector as there is a lot of expenditure on
unnecessary drugs (Das et al. 2007). A number of other
studies also noted poor health system and medically
unnecessary procedures in the private sector (Nandraj
et al. 1999).
However, this tends to disadvantage some sections
of Indian society who cannot aord high quality
private care and end up relying on poorly qualied and
motivated private providers. For example, IHDS data
records that households spend far less on women’s
healthcare than they do in men’s healthcare; for minor
illnesses, expenditure for men is Rs 126 compared to
Rs 105 for women, for major illnesses expenditure for
men is Rs 2,100 compared to Rs 1,700 for women
(Desai et al. 2010). us, higher quality government
services could be particularly important for the
disadvantaged populations. e role of government
services also remains important in control of vector-
borne diseases such as malaria and in screening services
such as organising dental and eye examination camps.
It is a well-established fact that India is lacking
required health infrastructure and the supply side gaps
need to be fullled to make the system ecient. ere has
been an increase in the number of public health facilities
over the 2007–11 period. Sub-centres have increased
by 2 per cent, PHCs by 6 per cent, community health
centres (CHCs) by 16 per cent and district hospitals
by 45 per cent. Yet, shortfalls remain by 20 per cent
for sub-centres, 24 per cent for PHCs and 37 per cent
for CHCs, particularly in Bihar, Jharkhand, Madhya
Pradesh and Uttar Pradesh. ough most CHCs and 34
per cent PHCs have been upgraded and operationalised
as 24 × 7 facilities, at least in theory, and First Referral
Units (FRUs) have doubled, yet the commitment of the
Eleventh Plan to make all public facilities meet IPHS
norms, and to provide emergency obstetric care at all
CHCs have not been achieved. Access to safe abortion
services is not available in all CHCs, and this gap is likely
to contribute to maternal mortality, as abortion becomes
essential during some pregnancy complications. ough
Mobile Medical Units (MMUs) have been deployed
in 449 districts of the country, their outreach medical
services are not enough to meet the need. Availability of
healthcare services from the public and private sectors
taken together is quantitatively inadequate. is is
starkly evident from the data on doctors or nurses per
lakh of the population. At the start of the Eleventh Plan,
the number of doctors per lakh of population was only
45 against the desirable number of 85. Similarly, the
number of nurses and ANMs available was only 75 per
lakh population against the desirable number of 255.
e overall shortage is aggravated by a wide geographical
variation in availability across the country with the
rural areas being poorly served in particular (Planning
Commission 2013). Today, rural India needs specialists
on a priority basis (Deo 2013). Seventy per cent posts
of specialists (surgeons, physicians, paediatricians,
gynaecologists, etc.) at the CHCs are lying vacant and
the shortfall has widened against 46 per cent in 2005
(RHS 2012).
But, one should also look into the demand side factors
of preference of private healthcare facilities over public.
Whatever may be the cause, the higher reliance on private
sector and the high expenses of medical treatment lead
to higher OOP expenditure, further leading to middle
and lower middle income people into poverty trap. e
Government of India is experimenting with dierent
aspects of healthcare nancing to protect households
from health trap. e Rashtriya Swasthya Bima Yojana
(RSBY) is one among them, which is beyond the scope
of this present paper. However, the mechanism of
the RSBY scheme has been criticised on a number of
grounds (Mor 2013; Krishnaswamy et al. 2011).
concluSion
Health policy in India has implicitly and often explicitly
envisioned a healthcare system dominated by the
public sector. Public policies have tried to live up to
these expectations. A vast network of PHCs and
sub-centres, as well as larger government hospitals
has been put in place, along with medical colleges to
train providers. Programmes for malaria, tuberculosis
control, and immunisation are but a few of the vertically
integrated programmes initiated by the government.
A substantial investment has been made in developing
community-based programmes, such as Integrated
Child Development Services (ICDS), and networks
of village-level health workers. In spite of these eorts,
growth utilisation of government services has failed to
keep pace with the private sector, particularly in the past
two decades. e results presented in this paper show
that Indian families, even poor families, receive most of
their medical care from private practitioners. Maternity
care is a partial exception here. For most other forms
of care, however, the public sector is dwarfed by the
reliance on the private sector, even though the quality
of private sector providers and services remains highly
variable (Desai et al. 2010).
Determinants of Private Healthcare Utilisation and Expenditure Patterns in India 61
One of the principles of Indian public health
philosophy, as outlined in the Bhore Committee Report
in 1946, emphasises that services should be placed
as close to the people as possible, in order to ensure
their maximum use by the community, which they are
meant to serve (Gangolli et al. 2005). is focus on
community-based services has been further amplied
in the recent years, particularly in the NRHM. Recent
policy discussions continue to emphasise the need to
strengthen service-delivery points located close to the
patients, for example, the use of sub-centres as rst
referral point is emphasised in the HLEG Report. Given
the shortage of medical personnel and costs involved in
providing almost door-step service delivery, attempts
are being made to use community health workers to
guide and motivate patients and nurses and paramedics
to provide some of the basic services. For example, the
allocation for ASHA workers has been substantially
increased in recent budgets.
ese observations present an interesting paradox.
e data presented above indicate that despite the
government’s eorts to deliver healthcare services at
the door-step, the utilisation of public health services
is far from the norm. People rush to private facilities
for both short-term as well as long-term illnesses,
irrespective of the availability of any government health
facility in the locality. is suggests that presence of
any public facility is not sucient; however, when a
somewhat better equipped facility like PHC or CHC
is present, patients are more likely to use them. e use
of sub-centres as the FRU is emphasised in the HLEG
Report. However, we suggest that sub-centre facilities
may not be adequate to attract patients. We may need
better equipped facilities with qualied doctors. is
may require a totally dierent approach to medical care.
Instead of door-step care, we may need to focus on more
centralised and well-equipped facilities. Will patients
travel to these centralised facilities to obtain better
quality care? We think they will. Striking increase in
hospital delivery rate, from about 50 per cent to over
70 per cent following the implementation of Janani
Suraksha Yojana (JSY) suggests that distance is less of
a concern than is typically assumed to be the case.
Another advantage of focusing on centralised
service delivery is that these facilities will be located
in slightly larger towns and hence will be attractive to
doctors and health technicians. Doctor absenteeism is
a serious problem in rural India and setting up facilities
where doctors may be willing to reside may reduce this
problem. Deo (2013) has pointed out that doctors are
reluctant to serve in the villages. Since, studies suggest
that the government facilities lack the eort rather
than competencies, any system that increases—or at
least does not decrease—provider motivation deserves
serious attention.
e ongoing demographic transition of the country
provides a further justication for moving away from a
door-step-based delivery system. With rising proportion
of the elderly and decline in communicable diseases, the
NCDs are increasingly emerging as the leading causes
of morbidity and mortality. Most of these NCDs are
not curable through simple interventions and require
long-term care and access to diagnostic and monitoring
facilities. ese require more laboratory tests and
specially-trained doctors. So, India has little choice but
to invest in training of more doctors and strengthening
public health delivery system.
Our arguments should not be taken to mean that we
move away from government services towards private
services. We actually argue the opposite; we suggest
that poor quality of government services drives patients
towards equally poor private services. Provision of
higher quality government services may help redress this
low-level equilibrium.
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