Patterns of a Lopsided Edifice
The constitution of India obliges the government to ensure the ‘right to health’ for all citizens, irrespective of gender, creed, caste or any other aspect of a person's background. Each state of India is required to provide free universal access to healthcare. Nonetheless, the fact remains that the poorer classes of society in India have struggled to get healthcare for decades as Indian healthcare has been dreadfully underfunded. Most health expenditures in India are OOPE (out-of-pocket expenditures) and ironically, paying for healthcare is among the leading things that push people below the poverty line. Here to analyse the situation is Perspectoverse's Anthahkarana.
A 2017 study by the Public Health Foundation of India found that health expenses were responsible for driving 55 million Indians into poverty between 2011 and 2012. As many as 90% of the poor have no health insurance.
Though studies have examined poverty and the impoverishment effect of health spending in India, there is limited research on the regional patterns of health spending by type of health centers. But an interesting study by Anjali Dash and Mohanty S.K casts light on this. The paper tests the hypothesis that the poor people from the poorer states of India pay significantly more for hospitalisation in public health centers than those in the richer states of India.
According to their study, The penurious people in the more poverty-stricken states in India pay significantly more to avail hospitalisation in public health centers than those in the developed states. Provision of free medicines, surgery and free diagnostic tests in public health centers may reduce the high OOPE (out-of-pocket expenditure) and medical poverty in India.
The high OOPE on healthcare affects the poor and vulnerable the most, and has drawn considerable attention from researchers and policy makers in developing countries. Despite all this, a significant proportion of the population does not avail healthcare because of the increasing costs.
The main feature of India's health system is the co-existence of public and private healthcare providers. Public health facilities are provided by the central government, the state governments, and local bodies. Public health centers provide low cost care, are generally overcrowded, and largely used by the poor. Despite the low cost of healthcare in public health facilities, the poor households suffer a high CHS (catastrophic health spending) and bear a higher burden of diseases.
In India, rising healthcare costs are affecting the poor and vulnerable the most. Recent studies suggest that the state variations in CHS are large and the CHS has increased among the poor and marginalised. The public health centers in India are intended to provide free and affordable health services to the poor. But, the cost and quality of services in public health centers vary largely across and within the states.
Using the health survey data on hospitalisation care, this study examined the inter-state variations of OOPE on hospitalisation by level of poverty and type of health centers in India. The following are the salient findings of the paper.
First, usage of public health centers is higher among the poor than among the non-poor across the states. More than half of the poor people in the poorer states of Assam, Odisha, Madhya Pradesh, Bihar, Jharkhand and Chhattisgarh were hospitalised in public health centers, significantly higher than those in the developed states of Kerala and Andhra Pradesh.
Second, the OOPE accounts for over 95% of the cost of hospitalisation in India. It varies from 85% in Delhi to 99% in the poorer states of Uttar Pradesh, Bihar and Jharkhand.
Third, the state pattern of OOPE in the public and private health centers is distinct. The mean OOPE per episode of hospitalisation in public health centers of Tamil Nadu was lowest among all states of India, while it was twice that of Tamil Nadu in the poorer states of Odisha, Assam and Bihar.
This study concludes that the poor people in poorer states have not benefited adequately from public healthcare services and are not protected against unanticipated healthcare costs. Some of the best practices of the health system within the country, as illustrated by Tamil Nadu, may be adopted in the poor performing states to reduce inter-state variations in health spending among the poor.
Written by Anthakarana
Illustrated by Rishita Banerjee
Dash, A., Mohanty, S.K. Do poor people in the poorer states pay more for healthcare in India?. BMC Public Health 19, 1020 (2019). https://doi.org/10.1186/s12889-019-7342-84
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