Results of study in five states of India Study Conducted by Study supported by Oxfam India Prayas,...

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


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


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


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


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


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


100

200

300

400

500

600

700

521 508

450

345

479 492

550

655


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


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


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


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


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)


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)


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)


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

Results of study in five states of India Study Conducted by Study supported by Oxfam India Prayas,...

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