understanding healthcare access in india
TRANSCRIPT
June 2013
Understanding Healthcare Accessin IndiaWhat is the current state?
IMS-Institute-report-IHA-26June13F3.indd 1 27/06/2013 07:20
Expanding healthcare access is a critical priority for India today. Despite numerous efforts made to address this problem and the progress made to date, the gap between the aspiration - providing quality healthcare on an equitable, accessible and affordable basis across all regions and communities of the country — and today’s reality still remains.
The inception of National Rural Health Mission (NRHM) and the implementation of other policies over the last decade have shown a positive improvement in India’s healthcare system. To do more, and at a faster rate, it is important to understand the current state of healthcare. This understanding will play a pivotal role in determining priorities, resource allocation and goals for the future, as well as plugging the existing gaps in the system.
This report brings fresh, objective perspective to the status of healthcare in India, and offers the most comprehensive view of this issue since 2004.
Objectives Of the studyThis study has been undertaken for the benefit of all healthcare, including the government; pharmaceutical, payer, and provider companies; civil society organizations and non-governmental organizations. the study has the following objectives: 1. Map the current status of healthcare access to gain a comprehensive view on successes and key areas of challenge 2. Prioritize challenges or gaps in terms of their relative impact on healthcare access 3. Provide a roadmap to guide future improvements
this study is intended to help drive the following: • Educate all relevant stakeholders in the healthcare community about the true status of healthcare access in India • Clearly establish that healthcare access is multi-dimensional in nature and hence to truly address current gaps, all dimensions need to be considered and not just one • Provide clarity on the priorities required to improve healthcare access • Highlight the need for more effective implementation of existing healthcare policies
MethOdOlOgy Of the studyAt the core of the research is an extensive nationwide survey covering 14,746 households representative of the country in terms of economic and healthcare parameters, while ensuring proper regional representation. Interviews were also conducted with over 1,000 doctors and a panel of healthcare experts to provide qualitative inputs.
In addition to the primary survey, an extensive review of current healthcare policies, various healthcare schemes (both at the central and state level), and available data in public domain was taken into consideration to better understand challenges in India.
Household sample distribution split by geographies Doctor sample distribution split by geographies
50%
19%
31%
30% 35%
35%
7,373
25%
30%
25%
20%
15% 15%
20% 20%
25% 25%
25%
15% 4,571
25%
15%2,802
45% 50% 50% 50% 47% 50% 50%
50% 50% 53% 50% 50%
TN MH
GovtDoctors
WB UP
PrivateDoctors
55% 50% SEC E
SEC D
SEC C
SEC B
SEC A
R4
R3
R2
R1
All India 14,746 All India 1,000
Metro MetroRural RuralRegionsOtherUrban
OtherUrban
defining healthcare accessAccess is multi-dimensional in nature as it is shown in the illustration below. For a person to have access to healthcare in India, a healthcare facility must be reachable within a 5 kms and must offer available doctors, drugs and treatment options that satisfy both acceptable cost and quality-of-care standards.
Even if only one of the components is missing, a patient is unlikely to receive he right treatment in the most appropriate and efficient manner. It is therefore essential to consider all four dimensions in order to assess the state of healthcare access.
Key findings Of the study • The physical accessibility of public or private healthcare facilities is a challenge in rural areas. By contrast, in urban areas, physical accessibility is less of a challenge due to the overall higher number of available facilities.
• An increasing proportion of the population is using private healthcare facilities for both in-patient and out-patient treatments.
Healthcare Access Study. Findings from Primary and Secondary Research
Stages of healthcare access
2
Availabilit
y/Capacity
3
Quality/Functio
nality
1Physical
accessibility/location
4
Location:Rural vs Urban
IP vs OPAcute vs Chronic
Channels:Private vs PublicImpact on usage
Components:IP vs OP
Acute vs ChronicIncome levels
Source: Household Healthcare Access Survey Conducted by IMS Consulting Group, 2012
Distance travelled to seek OPD treatment
20%
80%
19,813
8%
92%
10,112
32%
68%
9,701
17%
83%
6,498
21%
79%
13,315
PoorRuralUrbanAll India
Over 5km
Less than 5km
No. of episodes
All other state spending
Source: NSSO Data 2004; Household Healthcare Access Survey Conducted by IMS Consulting Group, 2012
Choice of in-patient service provider - Rural (% patients)
Choice of in-patient service provider - Urban (% patients)
Private Public1986-1987 1995-1996 2004 2012
60
40
42
58
38
62
31
69
60
40
44
56
42
58
39
61
• are forced to seek treatment in private care.
• Long waiting times, lack of available doctors, absence of diagnostic facilities, and lower quality of care are among the main reasons cited by patients for choosing private treatment over public facilities.
• Due to the lack of physical reach, availability of quality treatment and other practices, patients are
• The majority of out-of-pocket expenses are incurred from medicines purchased from public or private healthcare facilities.
Total spend/episode of illness in absolute (INR) and as % of average monthly HH expenditure
Poor
Government Private
Acute Care
Government Private
Chronic Care
Government Private
IPD TreatmentOPD Treatment
Average spend/Event (INR)
247 251 678 728 667 1,096 2,255 2,325 1,481 2,575 13,485 11,605
3% 5% 16%
54%
7%
14%8%
23% 21%
44%
121%
217%
4.5x
Source: Household Healthcare Access Survey Conducted by IMS Consulting Group, 2012
Key reasons cited for selecting private sector for OP treatment
All India Urban Rural Poor Acute Chronic
56%
14%
13%
61%
50%
29%
56%
13%
16%
62%
54%
26%
56%
15%
10%
60%
46%
32%
57%
16%
18%
62%
52%
27%
56%
13%
11%
60%
49%
30%
56%
12%
13%
60%
50%
27%
56%
22%
13%
63%
50%
35%
To get quickly
attended to
Lack ofspecialist
in Govt.
Doctoravailability
in privatesector
Lesswaiting than
Govt Hosp
No freemedicines
in Govt.
Source: Household Healthcare Access Survey Conducted by IMS Consulting Group, 2012
% split of OOP spend on OPD treatment (including episodes where free treatment was given)
Medicines Minor sugeries Diagnostics Consultation Others
842
250
711
941
2,296
All India Government Private Government
Acute Diseases Chronic Diseases
Private
63%73%
62%69%
61%
5%
13%
20%1%
5%
19%13%1%6%
0%20%
1%
6%2%
23%
1%
5%14%
17%1%
Total episode spend (INR)
Source: National Association of State Budget O , State Expenditure Report, 2010-2012; Congressional Budget O Source: National Association of State Budget O , State Expenditure Report, 2010-2012; Congressional Budget O
Higher Education All other spendingDefense Elementary & Secondary EducationMedicaid Social Security
All other state spending
00%
50 10 15 20 25 30 35
00bn 00bn 00bn
00
00
00
00bn 00bn 00bn
00bn
US Federal Budget 2011 Total of State’s Budgets 2011
$3.6 Trillion $1.6 Trillion
Key title Key title
2.6 1.4 1.3
3.9 6.2
4.8 6.1
6.4 3.8
Channel diversion due to lack of availability of quality healthcare resources
3.3%
26%
74%
Government Sector
Private Sector
More patients are using high cost private channel
Further diversion when Govt. doctors send patients for diagnostics to private facilities or when patients haveto purchase essential medicines from private channels
12
Patients
Diversion
DoctorConsultation
Diagnostics/Medicine
DoctorConsultation
Diagnostics/MedicinePatients
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• exist for the Indian population across all dimensions of access, especially in rural areas.
• When asked, patients in our study claimed they would readily switch to public healthcare centres if these issues were addressed. • From a patient cost of treatment perspective, by improving each of the dimensions of access, there could be a potential cumulative reduction in out-of-pocket expenditure by ~40% for out-patient treatments and ~45% for in-patient treatments.
• The largest impact possible can come from improvements in the availability and quality of public facilities, as demonstrated above.
RECOMMENDATIONSRecent progress and commitments by the public and private sectors suggest the willingness exists to invest in and operationalize the changes needed to broaden healthcare access across the entire Indian population. However, active collaboration between the public and private sectors is necessary in order to truly improve the quality of care and healthcare services.
Overcoming barriers needs a sustainable, policy-level strategy involving a coordinated approach with the following three priorities:
• Improve availability • Raise performance levels by improving availability of healthcare services and augmenting the governance system to drive higher performance• by improving the penetration of health insurance at an accelerated pace
Recognizing that not everything can be changed at once and that the timescale is long, a roadmap is essential to ensuring gaps are prioritized, interconnections and dependencies recognized, resources directed to the right areas,
Visit our website to download the full report: www.theimsinstitute.org
No concern Some concern Concern areas
No gaps in access
Physical reach Availability Quality
Large gaps in access
Urban
HC servicesPoor
Rural
Availability of HC services;
Physical reach, availability, quality Poor
Expected change in OOP expenditure on OP ailments
Private others Private medicine Government medicine Government others
10097
88
78
61
Currentstatus
A: Diagnostic facilitiesavailable in
public HC facilities
B: Subsidized essential medicines available in
public HC facilities
Impact ofA+B
Improvement inquality of
public HC Facilities
11
51
34
411
51
34
1
51
2
2
3
34
1
43
29
7
30
21
4
Assumption:OOP on
diagnosticscan be
broughtdown by 75%
in Govt. HCfacilities
Assumption:Additional 15%
patients shiftto Govt. HC
facilities dueto A and B
Assumption:40% PrivateHC patients shift to Govt.
facilities due toimprovementin availabilityand quality of
healthcareresources
Assumption:OOP on
drugs can bebrought downby 90% in Govt.
HC facilitiesthrough
disbursementof subsidized
essentialmedicines
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