Health care utilization and health expenditure in a tribal area of thane district

 

Yogita Bavaskar^1*, Mohan Doibale², Purushottam Giri³, Ganesh Lokhande⁴, Abhilasha Nair⁵

 

^1,4,5Assistant Professor, ²Professor and HOD, Department of Community Medicine, Government Medical College, Aurangabad, Maharashtra.

³Professor, Department of Community Medicine, IIMSR Medical College and Hospital, Badnapur, Jalna, Maharashtra.

 

Abstract               Background: The information about morbidity pattern, health care utilization preferences and expenditure on health care is essential to provide need based services to community. The present study was planned to analyses health care preferences of tribal community and economic burden of health expenditure on them. Objectives: 1) To know the morbidity pattern and utilization of health care services in community. 2) To estimate burden of healthcare expenditure on household. Methods: A house to house cross sectional study was conducted in the field area of a tribal PHC, Khardi in Thane district using a predesigned, pretested questionnaire. Households were selected using 30 cluster sampling, in total 210 households were surveyed from thirty different clusters. Morbidity is divided as acute morbidity in last one month, chronic morbidity of last one year and hospitalization of last one year. Results: About 210 households consisting of 1431 individuals were surveyed. There were 369 episodes of acute morbidities, 27 chronic morbidities and 12 episodes of hospitalization in surveyed population. Every fourth person was having an ailment. Fever was most common ailment. 78% of total morbidities were in very poor and poor population and 63% of acute illnesses were treated by private practitioners. Very poor people accessed private healthcare in 73% of episodes as compared to middle class who accessed it in only 37% of episodes. Average percent of total family income spent on health care was 4.7%. Conclusion: Private providers are an important source of health services not only for those who are better off but also for poor households. The costs for health care are substantial for households.

Key Words: Health care utilization, Health expenditure, Tribal area.

 

 

INTRODUCTION

Private hospitals and private medical practitioners play a significant part in delivering health care services in India. As the demand for health care has increased, institutions in this sector have expanded widely in both urban and rural areas.¹ Health care services in India are provided mainly by the government and the private health sector, with the private sector provision having a larger share. For more than three-fourths of the episodes, private health care facilities were used. Non-utilisation was higher in rural areas. For more than 81% of the episodes, private health care facilities are used. The burden of health care is inversely related to economic status of the household and the poorer households are found to be victims of inefficient health care system. Another analysis on health expenditure by household showed that about 6% of household income is being spent on curative care which amounts to rupees 250 per capita per annum.² Though health expenditure in India is approximately 6% of GDP, the health care spending (excluding water supply) by the government is only 1% of GDP and the remaining 4.6% is spent privately i.e. by individuals or households. The high incidence of morbidity in poors cuts their household budget both ways i.e. not only do they have to spend a large amount of money and resources on medical care but are also unable to earn during the period of illness. Very often they have to borrow funds at very high interest rate to meet both medical expenditure and other household consumption needs. Estimates show health expenditure as a percentage of annual income is varying from 3 to 20%. This type impact of expenditure on health care is likely to affect economic condition of the household, and more drastically on the poorer households making them even poorer.³ Information on the existing morbidity pattern, pattern of health care utilization and the per capita health expenditure is essential to provide need-based health care delivery to a rural population. To obtain the information, this study was conducted in tribal area of Thane district.

MATERIALS AND METHODS

A cross sectional study was carried out in the field practice area of PHC, Khardi in Thane district during the period of September to November 2013, catering to 30 villages with total population of 28,000. It is a tribal PHC with majority of tribal population living in padas and daily wages is the major source of income. The Multistage cluster sampling technique was used during data collection. The area was divided in 30 different clusters and 7 consecutive households were selected randomly from each cluster. In all 210 households, head of the family or any elder person who can give authentic information was interviewed, using a pre-tested and pre-designed questionnaire. Information about demographic profile, self-perceived morbidities, healthcare facility utilization and health care expenditure were collected. Morbidities were divided into three categories viz; Acute/minor morbidity in last one month; chronic morbidity in last one year and hospitalization in last one year. Following case definitions were used in the study; Morbidity or Ailment - means any deviation from the state of physical and mental well-being. An ailment may not cause any necessity of hospitalization, confinement to bed or restricted activity. For the purpose of survey, one has been considered as sick if one feels sick. Acute morbidity is any ailment lasting for less than 15 days and which have occurred in last one month. Chronic morbidity is any illness which lasted for more than 15 days and which have occurred in last one year. One was considered hospitalized if one had availed of medical services as an indoor patient in any hospital in last one year. The institutional ethics committee permission was obtained. The collected data was entered in MS excel and analyzed by using SPSS version 19.0.

 

RESULTS

All 210 households consisting of 1431 individuals were surveyed. There were 6.8 individuals per household. Out of total households surveyed, 72 (35%) were tribal and 138 (65%) were non tribal. Around 80% of total household belonged to very poor class according to B.G. Prasad classification. The average per capita income was Rs. 1449/-.

Morbidity pattern

Out of 1431 individuals, 377 were having either acute/chronic morbidity, i.e. every fourth person was having an ailment. There were 369 episodes of acute morbidities, 27 chronic morbidities and 12 episodes of hospitalization in surveyed population. Total number of persons hospitalized any time during a period of one year was 12.

 

Figure 1: Age and gender wise distribution of morbidity     Figure 2: Distribution of minor ailments according to socio-economic status

Out of 377 individuals, 158 (42%) were male and 219 (58%) were female. Average episode of acute morbidity per household was 1.75 (mean). Morbidity was highest among children <15 yrs constituting around 43% of episodes (As shown in Fig. 1).

Around 78% of total morbidities were in very poor and poor population as per B. G. Prasad classification (As shown in Fig. 2). As shown in Fig. 3 that 43.08% of the study subjects were suffering from or had an episode of fever, 31.9% individuals had respiratory infection. Gastrointestinal infection, musculoskeletal disorders and skin disorders were present in 8.4%, 6.2%, and 6.5% of individuals respectively. Fever was most common ailment followed by illnesses due to respiratory and gastrointestinal infections.

         

                   Figure 3: Various morbidities amongst study population            Figure 4: Treatment Sought from in Acute Morbidity

As shown in Fig. 4 and 5, in case of acute ailments, 63% of episodes were treated by private practitioners. In 78% of ailments treatment was sought from private practitioners. All hospitalization was in private hospitals.

 

 

 

 

 

 

 

 

 

 

 

              Figure 5: Treatment Sought from in Chronic Morbidity    Figure 6: Per Capita Income Wise Variation in Treatment Sought From

 

It was seen from Fig. 6 that very poor people accessed private healthcare in 73% of episodes as compared to middle class who accessed it in only 37% of episodes. Tribal and non tribal people did not show significant difference in health care utilization pattern.

 

Table 1: Association between treatment sought from and per capita income

(Chi square value =29.2, df=2, p<0.01)

 

As seen from Table 1 that out of 288 illnesses which occurred in poor people, for 201(69.8%) episodes of illnesses the treatment was sought from private sector while in middle class people, out of 81 illnesses the private care was sought only for 30(37%) episodes. The association between per capita income and treatment sought from government and private sector was found to be statistically significant (p<0.5).

Health expenditure: Average percentage of total family income spent on health care was 4.7%. Average cost of treating each illness episode was Rs. 181/- in acute illnesses, Rs. 4777/- per year in chronic morbidities and Rs. 1925/- per hospitalization. Average monthly health expenditure is directly related to income of the family.

Table 2: Health expenditure according income class (As per BG Prasad classification)

B.G. Prasad classification	Average monthly family income (Rs)	Average monthly health expenditure	Percentage of income spent on healthcare
Very poor	3688	93	2.5%
Poor	6372	368	5.7%
Lower middle	13504	516	3.8%
Upper middle	21500	692	3.2%

 

As shown in Table 2 that very poor people spent average Rs. 93/- per month on health care which was 2.5% of average monthly family income. While poor people spent Rs. 368/- which was 5.7%, on the contrary lower middle and upper middle class people spent 3.8% and 3.2% respectively.

DISCUSSION

The studies on the use of health care services show that the poor and other disadvantaged sections such as scheduled castes and tribes are forced to spend a higher proportion of their income on health care than the better off. The burden of treatment is unduly large on them when seeking inpatient care. The high incidence of morbidity cuts their household budget both ways i.e. not only do they have to spend a large amount of money and resources on medical care but are also unable to earn during the period of illness. Very often they have to borrow funds at very high interest rate to meet both medical expenditure and other household consumption needs.³

Morbidity Pattern: It is found in the study that, out of 1431 individuals, 377 were having either acute/chronic morbidity i.e. 26.29% of all study participants suffered illness. When enquired about number of episodes of illnesses, there were 369 episodes of acute morbidities in previous one month, 27 chronic morbidities in previous one year and 12 episodes of hospitalization in a previous year in surveyed population. Similarly study conducted by Rajaratnam J et al⁴ in rural population of Tamil Nadu, 825 of the 1440 persons (57.3%) did not have any illness. Another study conducted by Divakar SV et al⁵ in tribal community in mysore district, about 47.52% of tribal population had suffered once from one or other type of illness and 27.24% had suffered from more than one illness during last 12 months. In the present study, out of 377 ailing individuals, 158(42%) were male and 219(58%) were female and there was not a significant difference in presence of morbidities according to gender. About 43.08% of the study subjects were suffering from or had an episode of fever in previous one month followed by that 31.9% individuals had respiratory infection and GI infection, musculoskeletal disorders and skin disorders were present in 8.4%, 6.2% and 6.5% of individuals respectively. Fever was most common ailment followed by illnesses due to respiratory and gastrointestinal infections. Similarly findings were observed by study done by NCAER.⁶ The probable reason for this may be the seasonal variation as the data was collected in the rainy season.

Utilisation of health care services: In case of acute ailments, 63% of episodes were treated by private practitioners, while in the data of NSSO, 2004 for 78% of episodes the treatment was sought from private health care provider.³ All hospitalization were in private hospitals. Similarly study done by Duggal R et al⁷ also found that public hospitals provide 60% of all hospitalizations, while the private sector provides 75% of all routine care. Another study done by Kulkarni RR et al⁸ in Belgum district, 37.75% of study participants preferred private or AYUSH practitioners and 18.25% opted government doctors in case illness. When enquired the reasons for non utilization of Government health care facility were as follows - 54% of study participants said quality of healthcare is not good in Govt. hospital as compared to private. 35% individuals did not go to Govt. hospital as the timing of OPD in government hospital was not comfortable for them. The other reasons given were drugs/ facilities not available (26%), doctors not available in hospital (11%), distance far away (7%). The rural primary health centers are woefully underutilized because they fail to provide their clients with the desired amount of attention and medication and because they have inconvenient locations and long waiting times.⁷ Very poor people accessed private healthcare in 73% of episodes as compared to middle class who accessed it in only 37% of episodes. When the data was further anlysed to find the association of income status and utilization of care by private or government sector it was found that out of 288 illnesses which occurred in poor people, for 201(69.8%) episodes of illnesses, the treatment was sought from private sector, while in middle class people out of 81 illnesses, the private care was sought only for 30(37%) episodes. The association between per capita income and treatment sought from government and private sector was found to be statistically significant (p<0.5). Similarly study done by Ray TK et al⁹ the private health sector was utilized in 59.4% of total episodes. Utilization of the private sector was directly associated with a higher socioeconomic status (p = 0.002). Thus due to various reasons mentioned above the poorer section of community was using the private health care sector than there better offs.

Health expenditure: Average percentage of total family income spent on health care was 4.7%. Average cost of treating each illness episode was Rs. 181/- in acute illnesses, Rs. 4777/- per year in chronic morbidities and Rs. 1925/- per hospitalization. Average monthly health expenditure was directly related to income of the family. Similarly study done by Duggal R et al⁸, and Ray TK et al⁹ the mean per capita annual out-of-pocket expenditure on health was Rs. 139/- and Rs 131/- respectively and the median expenditure per episode was Rs. 15/-. Another study done by Archana R et al¹⁰, the mean per visit expenditure for acute illness, chronic diseases, and hospitalization were Rs. 72.7±143.6, 135.7±196.2 and 1340±1192.9 respectively and Government facilities were availed for 175 (75.7%) visits. Fees and medicine together account for 60% of total health care expenditure and 8% of total household had to borrow money for healthcare needs; all of them were from poor families. National Council of Applied Economic Research (NCAER)⁶ conducted a study in 1992 brought out that the average household expenditure for treatment worked out to Rs.142.60 per illness episode in urban areas and Rs.151.81 per episodes in rural areas. The findings make it evident that a substantial financial burden of the household is borne for meeting health care needs. Many a times they need to borrow money or cut short the other expenses to meet the need of money for health care.

 

CONCLUSION

Private providers are an important source of health services not only for those who are better off but also for poor households. The costs for health care are substantial for households, and lower income groups spent a significantly higher proportion of their income on health care than the rich did. A burden of high cost for treatment implies high risks for families to fall into a ‘medical poverty trap’. Health-seeking behaviour of the population can be changed only if efficient services are rendered through government primary health centers and subcenters. Private health care providers needs to be regulated PHCs catering to tribal community should be 24x7 PHC. There is a need for developing risk-sharing schemes (community based insurance), special health insurance schemes should be designed and marketed in poor communities.

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