Social consumption of health – what does the data show?

Insights from data

It is noteworthy that 98% of women reported receiving ante-natal care, and around 92% received post-natal care. Over 95% of childbirths are now occurring in institutions across India. Considering that institutional childbirth is strongly associated with better outcomes for mother and child, this is heartening. The percentage of unskilled personnel attending childbirth is very low in nearly every state except Nagaland where it is 13.5% in the rural areas and 11.5% in the urban areas. Deliveries taking place in private institutions account for nearly 51% in urban areas, and 29% in rural areas on an all-India basis, with attendant high costs: an all-India average of ₹37,630.

The morbidity data, collected for 62 ailments, tabulated and presented in 16 broad categories, shows a peculiarly high morbidity in Kerala, West Bengal and Andhra Pradesh. In Kerala it spans all age groups, while in West Bengal and Andhra Pradesh, high morbidity is seen in people above the age of 60. What explains this somewhat strange finding considering that Kerala has better public health outcomes than other States according to other data sources? Is it due to the perception of what illness is in different States, or more stoic behaviour in some States, or is it a data collection issue? This merits deeper research. It is unsurprising that infections are common across all age groups, and, lifestyle diseases such as diabetes mellitus and hypertension appear around age 40 and continue to increase thereafter. It is a matter of concern that injuries, which are a largely preventable problem is the second or third highest cause of morbidity from the age of 15 onwards.

Health consumption trends

Around 35% of patients in urban areas and 25% in rural areas utilise government hospitals for treatment. Utilisation has not changed significantly compared to the earlier round (July 2017 – June 2018), when it was 33% and 26% in urban and rural areas respectively. Less than 1% of care is delivered by charitable hospitals.

How do people pay for treatment? There is a remarkable increase in the percentage of the population covered by insurance. It was only 14% in rural areas and 19% in urban areas in the last survey. It has increased to 47.4% in rural areas and 44.3% in urban areas. Is this an advance? Given the high out-of-pocket costs in private institutions for hospitalisations (an all-India average of ₹50,508), and the fact that about 65% of in-hospital care is still privately accessed, insurance appears to have had limited impact. Even the lowest quintile of income earners pays around ₹25,000 for private care, which explains why treatment for illness is an important cause of indebtedness.

There used to be a time when government institutions treated patients without requiring insurance. Whatever was available was free at the point of service to any patient. Universal medical care funded through general taxation is a goal worth pursuing. Tamil Nadu presents the paradox of among the lowest out-of-pocket expenditure in government hospitals and, simultaneously, some of the highest costs for private care.

It is also noteworthy that most medical care is provided by qualified medical practitioners with only 3.6% of people in rural areas and 1.4% of people in urban areas reporting accessing care through informal medical practitioners. There is no disaggregation by type of qualified medical practitioner, although this information has been collected in the questionnaire, so it is not clear what percentage access modern medicine.

Data issues

There are some problems with the data. For example, in Tamil Nadu and West Bengal, average out-of-pocket medical expenditure in charitable hospitals (₹1,68,697 and ₹1,51,540) far exceeds the average in private hospitals (₹72,979 and ₹55,389 respectively). As a rule, one expects that charitable hospitals will be less expensive. Some entries also seem to be erroneous, for instance, the entry of obstetrics under the ‘male’ category, as obstetrics pertains to pregnancy and childbirth, and a gastrointestinal entry in West Bengal of ₹7,84,991 in Table A10 of the data. These anomalies require clarification.

There is rich data about people’s perceptions of health care available for analysis and interpretation. The questionnaire attached as Appendix E in the data shows that considerably more data have been gathered than have been published. It would be an even more valuable resource if the raw data were released in the public domain.

(Dr. George Thomas is an orthopaedic surgeon in Chennai. george.s.thomas@gmail.com )