The Telegraph
Monday , August 18 , 2014
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Neediest gain least from health care drive

- Burden on poor pockets outpaces that on rich despite govt insurance schemes

New Delhi, Aug. 17: India’s poorest and socially underprivileged people seem to have benefited the least from a set of government programmes launched over the past decade to reduce personal expenses on health care, research suggests.

A team of health economists has found that the financial burden of health care on India’s poorest 20 per cent, Scheduled Castes, Scheduled Tribes and Muslims has outpaced that on the richest 20 per cent and households that are not Dalit, tribal or Muslim.

Their study has found that personal, or the so-called out-of-pocket (OOP), spending on health care services — whether on doctors’ fees, medicines or hospital costs — rose 8 per cent faster among the poorest 20 per cent than among the richest 20 per cent between 2005 and 2012.

It has also found that the proportion of OOP spending out of the total household expenditure rose 0.9 per cent faster among Muslim families than among non-Muslim ones.

Similarly, the financial burden of OOP spending on health care increased 0.5 per cent faster among Dalit and tribal households than among other households. The findings have just been published in the journal PLOS One.

“For some reason, these groups of disadvantaged households haven’t gained as much from health and insurance plans as have their better-off counterparts,” said Anup Karan, associate professor at the Indian Institute of Public Health, Gandhinagar, and the study’s lead author.

The UPA government had launched the National Rural Health Mission in 2005 to boost rural health care services. Since then, the Centre and several states have also introduced government-funded health insurance plans to cover hospitalisation expenses.

These initiatives were aimed at reducing personal expenses on health care amid concerns that over 70 per cent of health care costs in India were OOP funds.

Karan and his co-authors at the Public Health Foundation of India, New Delhi, and Monash University in Australia used national consumer expenditure surveys from 1999-2000, 2004-2005, and 2011-12 to study patterns in households’ health care expenditure.

Their analysis has shown a rising share of OOP health care spending in total household expenditure among the three sets of disadvantaged households relative to their better-off counterparts. The researchers said their findings probably reflected “serious gaps” in existing government health schemes.

The findings have surprised sections of health sector analysts who say there are ample data to suggest that both the National Rural Health Mission and the insurance plans have helped reduce OOP spending among the poor.

“The insurance schemes are working. They have helped reduce in-patient (hospitalisation) expenditure among the poor,” said Charu Garg, a visiting professor and director of the population health programme at the Institute for Human Development, New Delhi.

This study itself, Garg said, has shown that in-patient expenditure has dropped across population groups, including the poorest 20 per cent. But these insurance plans do not cover outpatient healthcare.

“It is possible that more people now seek healthcare and find themselves having to spend more because outpatient costs are not covered,” she said.

But the researchers say that other factors too may explain why some disadvantaged groups have missed out.

Some poor households may find themselves excluded from insurance schemes because they cannot access cards certifying them as living below the poverty line. The insurance plans’ exclusive focus on hospitalisation may also explain some of the study’s findings.

“Households may need to pay for medicines and post-discharge medical bills,” Karan told The Telegraph.

“Poor and underprivileged households are more likely to be detrimentally affected by such costs than better-off households.”

The researchers also suspect that the National Rural Health Mission, intended mainly to strengthen public health care facilities across rural areas, has focused on maternal and child health without devoting comparable resources to other aspects of health care.

This “relative neglect” of the other elements of primary care, including the management of chronic illnesses, could have contributed to the observed increase in the financial burden on the poor and other disadvantaged groups, the researchers wrote in their paper.

They said their findings relating to Muslim households could be explained by the lack of specific emphasis in either the National Rural Health Mission or in the government-funded insurance plans on reaching out to Muslim families.

But some economists have cautioned that the observed increases in OOP spending on health care by households need not mean they had poorer access to free public health care services.

“We cannot directly link the increasing share of personal medical expenses to poor access to health care facilities,” Poulomi Roy, assistant professor of economics at Jadavpur University, told this newspaper.

“We need to consider households’ other demographic features and the trends in public health care facilities in their geographic locations. These could also explain why households are spending more OOP.”

A senior Delhi University economist said that OOP spending on health might increase either because some households have no government health facility to approach or because some households now have more money to spend on health care.