results of study in five states of india study conducted by study supported by oxfam india prayas,...
TRANSCRIPT
OUT OF POCKET EXPENDITURE
IN HEALTH CARE
Results of study in five states of India
Study Conducted by
Study supported by
Oxfam India Prayas, Rajasthan
Partner Organisations:
Rashtriya Grameen Vikas Nidhi, Assam
Child In Need Institute, Jharkhand
Rural Women’s Social Education Centre, Tamilnadu
Chirag, Uttarakhand
OoPE are non-reimbursable fees which a patient or family is responsible for paying directly to health practitioners or suppliers, without intervention of a third party. It often occurs, when publicly funded facilities are unable to provide the required health services and supplies for free or through insurance.
India was ranked as having the 42nd highest average OoPE, with 74.4% of private expenditure being paid as out of pocket. (WHS 2011)
OoPE accounts for an average increase in poverty by as much as 3.6 and 2.9 percent for rural and urban India respectively (Gupta 2009)
Out of Pocket Expenditure (Oope) in Health Care
Spending on Health in Different Economies of World
WHO, World Health Report 2008
Aim of the Study Assess the nature of out of pocket payments of
households in health care and examine its relationship with post 2004 new nation wide health initiatives viz. NRHM, RSBY and many state led programmes.
Objectives of Study Assess the change in out-of-pocket expenditure of households for
health care between 2004-10.
Examine the change in OoP expenditure in various social and economic groups.
Analyse the pattern of OoP expenditure in relation to various parameters of new post 2004 national health initiatives viz. NRHM & RSBY
6
Research questions Is there any reduction or increase in out-of-pocket
expenditure for households on health care post 2004?
Is there any reduction or increase in out-of-pocket expenditure on health care in proportion to total consumption expenditure of households?
Is there any difference in the pattern of OoP across different (a) social and (b) economic categories?
Is there any effect of post 2004 new national health programmes on the pattern of out-of-pocket expenditure on health care?
7
Sampling strategy Districts and village in states
were selected through PPS technique (Probability Proportional to Size Sampling Technique).
Sample size was fixed to 200 HH per district. This was obtained by selecting 10 villages per district and 20 households per village.
S. No. State District
1. Assam Kamrup
2. Sonitpur
3. Cachar
4. Jharkhand Sahibganj
5. Purbi Singhbhum
6. Rajasthan Bharatpur
7. Nagaur
8. Tonk
9. Baran
10. Tamilnadu Vellore
11. Coimbatore
12. Virudhunagar
13. Uttarakhand Tehri Garhwal
14. Nainital
Number of States : 5
Number of Districts : 14 Number of Villages : 140 Number of Households
surveyed : 2723
Sample design Stratified multi-stage design
The first stage units (FSU) were the 2001 census villages. The ultimate stage units (USU) were households in villages. In case of
large villages requiring hamlet-group (hg) formation, one intermediate stage was the selection of two hg’s from each FSU.
Formation of Second Stage Strata and allocation of householdsComposition of SSS No. of households to be
surveyed
Without hg formation
With hg formation (for each hg)
SSS 1 Households with at least one member hospitalized during last 365 days
8 4
SSS 2 From the remaining households, households having at least one child of age group 12-23 months
4 2
SSS 3 Other households 8 4
Survey tool
Survey tool was adapted from NSSO 60th round.
There were two schedules – for listing of households and for in-depth interview of selected households
Field data of the study was collected in the months from March to May 2011
Profile of the sample group Background
VariablesPercentage
Total Assam Jharkhand Rajasthan Tamil Nadu Uttarakhand
SexMale 50.2 51.3 50.1 52 49.4 45.3Female 49.8 48.7 49.9 48 50.6 54.7
Age Group0-14 32.4 32.5 39.5 32.7 25.3 31.915-29 28.6 27.7 25.5 31.2 27.6 28.630-44 19.5 23.3 18.7 16.9 23.1 17.045-59 11.5 10.1 9.8 11.7 14.3 11.260+ 8.0 6.4 6.5 7.4 9.7 11.3
ReligionHindu 82.5 67.1 51.2 93.9 94.5 100Islam 11.6 27.5 23.1 6.1 2.1 -Christian 2.2 5.4 4.1 - 3.4 -Others 3.7 - 21.6 - - -
Social GroupST 15.2 24.9 26.4 17.6 - 0.1SC 19.7 9.9 14.8 18.2 34.8 24.9OBC 40.0 26.4 53.5 51.3 54.9 0.7Others 25.1 38.7 5.3 12.8 10.9 74.2
LiteracyIlliterate 24.2 12 34.5 27.5 12.3 15.4Literate 75.8 88 65.5 72.5 87.7 84.6
Basic Household Amenities and Infrastructure
S.NoHousehold
Characteristics
PercentageTotal Assam Jharkhand Rajasthan Tamilnadu Uttarakhand
1.Household Type
Pucca 39.6 9.5 9 43.1 49.8 95.4Semi Pucca 22.6 25.3 23.7 15.4 42.4 1.3
Kachha 37.8 65.2 67.3 41.6 7.8 3.2
2Source of Drinking Water
Tap 38.9 1.9 0.3 21.5 99.0 79.0Tube
Well/Handpump36.1 41.1 74.0 56.4 0.0 3.0
Pucca Well 11.7 21.9 21.6 13.2 0.2 0.3Others 13.3 35.1 4.1 8.9 0.8 17.7
3. Bathroom Facility 38 47 4 13 67 664. Toilet Facility 31 56 5 12 27 66
5.Distribution of Household by MPCE (Monthly Per Capita Expenditure)
MPCE less than 500 15.4 19.9 23.7 18.7 8.8 3MPCE 500-1000 51.3 50.2 60.1 66.9 41.6 26.1MPCE 1000-2000 26 26.4 14.4 13.4 34.5 50.4MPCE 2000 and
above7.4 3.6 1.8 1 15.1 20.5
S.No Household Characteristics PercentageSC/ST OBC Others
1.Distribution of type of household by social group
Pucca 28.7 38.3 56.1
Semi Pucca 19.3 29.9 15.5
Kachha 51.9 31.8 28.3
2.
Distribution of main source of drinking water by social group
Tap 31.9 40 46.4
Tube Well/Handpump 43.2 38 23.6
Pucca Well 12.9 13 8Others 12 9 21.9
3 Distribution of household having bathroom facility by social group
27.2 35.2 57
4 Distribution of household having toilet facility by social group
17.8 27.1 56
Basic Household Amenities and Infrastructure
Morbidity and Health Care(Non-hospitalised case)
Proportion of Ailing persons (per 1000) during last 15 days
prior to the survey
Proportion of Ailing persons (per 1000) during last 15 days prior to the survey
(Comparison with NSSO 60th round)
020406080
70 6488
Proportion of Ailing Persons (per 1000) during last 15 days
by sex and age group
0-14 15-29 30-44 45-59 60+ All0
20
40
60
80
100
120
140
160
180
59
30
50
78
119
565061
96109
165
78
5446
72
93
141
70
Male Female Total
Proportion of Ailing Persons (per 1000) during last 15 days by socio-
economic characteristics
Less than 500
500-1000 1000-2000 More than 2000
ST SC OBC Others All
MPCE Class Social Group
0
20
40
60
80
100
120
140
46
58
91
125
55
69
51
97
70
Proportion (Per 1000) of persons ailing and Proportion of persons reported commencement of ailment one day
before the survey
Total Rajasthan Assam Tamilnadu Uttaranchal Jharkhan0
20
40
60
80
100
120
140
7062
89
44
130
41
29
12
31
9
107
14
PAPPAC
Proportion (per 1000) of ailing persons treated in outpatient
Proportion (per 1000) of ailing persons treated in outpatient
(Comparison with NSSO 60th round)
Study findings NSSO 60th round (rural) (Avg. of selected 5 states)
NSSO 60th round (rural) (Whole India)
780
800
820
840
860
880
900885
860
820
Proportion (per 1000) of untreated spells of ailment by reason for no treatment and comparison with NSSO 60th
round
No medical facility
Lack of faith Long waiting Financial problem
Ailment not considered
serious
Others0
50
100
150
200
250
300
350
400
450
155
419
54 54
162 156120
3010
280320
240
Study Findings
NSSO 60th round (rural) (Whole India)
Per 1000 distribution of treated spells of ailments during 15 days by source of
treatment for each MPCE class and social group
Less than 500
500-1000 1000-2000
More than 2000
ST SC OBC Others All0
100
200
300
400
500
600
700
581
498
581 576551
460 464
658
541
419
502
419 424449
540 536
342
459
Govt. Inst.Pvt. Inst.
Per 1000 distribution of treated spells of ailments during 15 days by
source of treatment (Comparison with NSSO 60th round)
Study
findin
gs
NSSO 6
0th ro
und (rura
l) (A
vg. o
f sele
cted 5
sta
tes)
NSSO 6
0th ro
und (rura
l) (W
hole In
dia)
0
200
400
600
800541
260 220
459
740 780
Govt. Inst.Pvt. Inst.
Average total expenditure (Rs.) , Average total medical expenditure (Rs.) and expenditure on medicine (Rs.) for non-hospitalized treatment per ailing person during last 15 days
All
Assam
Jharkhand
Rajasthan
Tamil Nadu
Uttarakhand
020
040
060
080
010
0012
0014
0016
0018
0020
00
1063
530
1059
588
1848
1732
832
374
804
528
1246
1443
345
245
424
336
454
382
Average Expenditure on MedicineAverage Total Medical Ex-penditureAverage Total Expenditure
Average total expenditure (Rs.) for non hospitalized treatment for each MPCE class
Less than 500 500-1000 1000-2000 More than 2000
Total0
200
400
600
800
1000
1200
1400
1600
407
625
1097
1494
1063
Average total expenditure (Rs.) , Average total medical expenditure (Rs.) and other expenditure
(Rs.) for non-hospitalized treatment per ailing person during last 15 days
(Comparison with NSSO 60th round)
0200400600800
10001200 1063
365 284
832
322 25723143 27
Average total expeditureAverage total medical expeditureOther Expenditure
Proportion (per 1000) of household expenditure on treatment during last 15 days by source of finance for each MPCE classH
H I
nco
me
/Sa
vin
g
Bo
rro
win
gs
Oth
ers
HH
In
com
e/S
avi
ng
Bo
rro
win
gs
Oth
ers
HH
In
com
e/S
avi
ng
Bo
rro
win
gs
Oth
ers
HH
In
com
e/S
avi
ng
Bo
rro
win
gs
Oth
ers
Less than 500 500-1000 1000-2000 More than 2000
0
100
200
300
400
500
600
700
800761
128 110
707
173121
642
210148
525
232 242
Morbidity and Health Care(Hospitalised case)
Proportion (per 1000) of population hospitalized during last 365 days
0-14 15-29 30-44 45-59 60+ All0
50
100
150
200
250
4656
88
127
220
81
37
62
105
131147
76
42
60
96
129
184
79
MaleFemaleTotal
Proportion (per 1000) of population hospitalized
during last 365 days (Comparison with NSSO 60th
round)
020406080
79
18 23
Proportion (per 1000) of population hospitalized by MPCE class
Less than 500 500-1000 1000-2000 More than 20000
20
40
60
80
100
120
140
5871
98
138
Per 1000 distribution of persons hospitalized by type of ailment
159
148
21
142
2782
27
395
Gastro-IntestinalCardio-VascularEye AilmentFebrile IllnessesDisabilitiesGynecologicalAccidents/InjuryAny Other
Proportion (per 1000) of hospitalized cases by type of
hospital
Proportion (per 1000) of hospitalized cases by type of hospital (Comparison with NSSO 60th round)
0
200
400
600
479 510420
521 490 580
Govt. Ins.Priv. Ins.
Proportion (per 1000) of hospitalized cases by type of hospital in each MPCE class
Less than 500 500-1000 1000-2000 More than 20000
100
200
300
400
500
600
700
521 508
450
345
479 492
550
655
Govt. Inst.Pvt. Inst.
Average Duration of Stay (in days) in Hospital by Type of
Hospital
Average Medical Expenditure (Rs.) per hospitalization by sex
and type of hospitalM
ale
s
Fe
ma
les
To
tal
Ma
les
Fe
ma
les
To
tal
Ma
les
Fe
ma
les
To
tal
Govt. Inst. Pvt. Inst. Total
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
20000
8183
10709
8703
18920
14112
17715
1370112617
13459
Average medical expenditure per hospitalization by type of hospital for each household
MPCE class
< 500 500-1000 1000-2000 > 20000
5000
10000
15000
20000
25000
75578336
9229
12038
9498
1815419130
20785
Govt. Inst.Pvt. Inst
Average total expenditure (Rs.) , Average total medical expenditure (Rs.) and expenditure on medicine (Rs.) for hospitalized case in last 365
days
All
Assam
Jharkhand
Rajasthan
Tamil Nadu
Uttarakhand
0 5000 10000 15000 20000 25000
14704
5562
9069
17620
18331
20905
13459
4849
8070
16385
16624
19168
6064
2441
3050
8498
2960
11140
Average Expenditure on MedicineAverage Total Medical ExpenditureAverage Total Expenditure
0
4000
8000
12000
1600014704
6967 6225
13459
6234 5695
1245 733 530
Average Total ExpenditureAverage Total Medical ExpenditureOther expediture
Average total expenditure (Rs.) , Average total medical expenditure (Rs.) and other expenditure
(Rs.) for per hospitalized case during last 365 days
(Comparison with NSSO 60th round)
Proportion (per 1000) of household expenditure on treatment during last 15 days by source of finance for each
MPCE classH
H I
nco
me
/Sa
vin
g
Bo
rro
win
gs
Oth
ers
HH
In
com
e/S
avi
ng
Bo
rro
win
gs
Oth
ers
HH
In
com
e/S
avi
ng
Bo
rro
win
gs
Oth
ers
HH
In
com
e/S
avi
ng
Bo
rro
win
gs
Oth
ers
Less than 500 500-1000 1000-2000 More than 2000
050
100150200250300350400450500
215
459
326 337382
281306
361333
368325 308
Maternal and Child Health
Proportion of children Immunized (per 1000)
Expenditure incurred on Immunization (in Rs.)
Per 1000 distribution of childbirth by place of delivery for each broad age group
15-19 20-24 25-29 30-34 35-39 40-44 45-490
100
200
300
400
500
600
700
800
900818
711659
595
400
500 500
0
105 125
240 0
500
182 184216
381
600
500
0
Government Institution
Private Institu-tion
Home
Average expenditure (in Rs.) per childbirth by place of delivery
All
Assam
Jhar
k...
Rajas
...
Tamil .
..
Uttara
k...
0
2000
4000
6000
8000
10000
12000
14000
1801
6891116
2042 2145 2497
8673
2500
7050 7428
12500
11100
6950
556 7100
13402166
832 1216
2440
3738 3489
Government Institution
Private Insti-tution
Home
Total
Proportion (per 1000) of women who availed antenatal care services (PWANC) by source of institution for availing the facilities
All
Assam
Jhar
k...
Rajas
...
Tamil .
..
Uttara
k...
0
100
200
300
400
500
600
700
800
900
1000
817
962
726
846 861830
888960
857
939
677
932
112
40
143
61
323
68
TotalGovernment InstitutionPrivate Institution
Average expenditure (Rs.) on antenatal care services (ANC) by
woman by source of service
All
Assam
Jhar
k...
Rajas
than
Tamil .
..
Uttara
k...
0
500
1000
1500
2000
2500
3000
3500
516
61
575 591825
165270
30 20
304
707
153
1744
400
1811
3175
1118
325
AllGovernment InstitutionPrivate Institution
Proportion (per 1000) of women who availed post-natal care services (PWPNC) by source of institution for availing the facilities
0
100
200
300
400
500
600
700
800
900
1000
634
826
531584
700
813882
1000
784
978
571
897
118
0
216
22
429
103
TotalGovernment InstitutionPrivate Institution
Average expenditure (Rs.) on post-natal care services (PNC) by woman by source of service
All
Assam
Jhar
k...
Rajas
than
Tamil .
..
Uttara
k...
0
200
400
600
800
1000
1200
1400
1600
1800
380
122
475
94
900
522
225 122122 70
850
353
964
0
763
500
1000
1625
All
Government Institution
Private Institu-tion
Change in oop spending and treatment seeking from public institutions between 2004 - 2011
Average expenditure (Rs.) for non-hospitalised per ailing person
All(avg. of 5
states)
Assam Jharkhand Rajasthan Tamil Nadu Uttrakhand
NSSO 60th round(2004)
365 261 370 436 208 551
NSSO 60th round after inflation adjusted
628 449 636 750 358 948
Prayas study(2011) 1063 530 1059 588 1848 1732% change 69.26 % 18.04 % 66.50% - 21.60 % 416.20 % 82.70 %
All(avg. of 5
states)
Assam Jharkhand Rajasthan Tamil Nadu Uttrakhand
NSSO 60th round(2004)
262 270 130 440 290 180
Prayas study(2011)
541 857 64 490 310 656
% change 106.48 % 217.40 % -50.76 % 11.36 % 6.89 % 264.44 %
Non –hospitalized ailing persons (per 1000) seeking care from public health institutions
Change in oop spending and treatment seeking by from public
facilities between 2004 & 2011 Average expenditure (Rs.) for hospitalised per ailing
personAll(avg. of five
states)
Assam Jharkhand Rajasthan Tamil Nadu Uttrakhand
NSSO 60th round(2004) 6967 4697 5338 8294 5775 10731
NSSO 60th round after inflation adjusted
11983 8079 9181 14266 9933 18457
Prayas study(2011) 14704 5562 9069 17620 18331 20905
% change 22.70 % - 31.15 % - 1.22 % 23.51 % 84.54 % 13.26 %
All(avg. of five
states)
Assam Jharkhand Rajasthan Tamil Nadu Uttrakhand
NSSO 60th round (2004) 514 742 466 521 408 431
Prayas study (2011) 479 847 195 553 271 408
% change - 6.80 % 14.15 % -58.15 % 6.14 % -33.57 % -5.33 %
Hospitalized persons (per 1000) seeking care from public health institutions
Chief findings of the study There is three fold increase in oope in
out patients and two fold increase in hospitalised patients.
Tamilnadu which supposedly has better public health system and free medicine scheme since 1995 has recorded highest increase in oope amongst out patients.
Maximum oope in Tamilnadu is on medical expenditure other than medicines.
Chief findings of the study Significant rise in out patients seeking care
from public health institutions but marginal decline in hospitalised patients.
Jharkhand showed highest decline in use of public health facilities both by hospitalised and non-hospitalised patients.
Lessons learnt Oope is an important indicator to determine
over all health services utilisation. Oope assessment assists in identification of
the components of health services which require improvement . For instance in Tamilnadu, there is a need to examine the quality and actual availability of public health services to arrest decline in utilisation of public health services.
RecommendationsUrgent need to reduce oope considerably. Expenditure on medicine ought to be completely
eliminated. other medical expenditure also should be close to
zero in all public and trust (charitable) hospitals. Oope relating to total medical expenditure should
be considerably reduced by increasing physical access.
Quality of care provided by the health institutions is required to be strictly as per IPHS guidelines both in public and private.
Recommendations
Private practice by the providers of public health system should be completely banned.
User fee completely aolished. Standard treatment guidelines are
required to be followed by all health service providers and directorates of rational therapeutics should be established at national and state headquarters.
Recommendations
Accessibility and quality of health services ought to be evaluated and monitored through community groups regularly for feedback and improvements.
Thank you