Brijesh C. Purohit

Inter-State Disparities in Health Care and Financial Burden on the Poor in India

Abstract Over five decades of independence, India has made rapid strides in various sectors. However, its performance in social sectors and particularly the healthcare sector has not been too rosy. Being the States responsibility the healthcare has traditionally been influenced by individual States budgetary allocation. Consequently inter-state disparity in availability and utilization of health services and health manpower are distinctly marked. This has implications for achievement of Health for All for the nation as a whole. Keeping in view the significance of studying inter-state variations in healthcare, this study focuses on the performance of healthcare sector in 15 major States in India. This is attempted through a comparative analysis of various parameters depicting availability of health services, their utilization and health outcomes. Our analysis depicts the prevalence of considerable inequity favoring high income group of States. In terms of healthcare resources, for instance, it indicates that the high income States hold a superior position in terms of: per capita government expenditure on medical and public health, total number of hospitals and dispensaries, per capita availability of beds in hospitals and dispensaries and health manpower in rural and urban areas. These parameters of availability have an impact on utilization levels and health outcomes in these States. A comparative profile of high and low income States as well as middle and low income States, both in rural and urban areas, reaffirms a greater financial burden in availing treatment at OPD and inpatient in low income States. In line with the higher financial burden and low per capita health expenditure, the health outcome indicators also depict a disconcerting situation in regard to low income States. These States are marked by lower life expectancy and higher incidence of diseases as well as high mortality rates. In this regard, demand as well as supply side constraints are observed which restrain the optimum utilization of existing health services. Among the low income States the main constraints on the demand side include illiteracy, malnutrition, and lack of infrastructure in accessing the facilities. Certain state specific supply side factors add significantly to under-utilization in low income States. In some of the States, however, corrective actions have been initiated to overcome the problem of the quality and low utilization of health facilities. In due course of time, it is likely that proper implementation of these measures may result in improved utilization level of existing health services, which may be useful to improve health status indicators. Nonetheless, overcoming the current levels of regional disparities in healthcare across three income groups of States may also require additional resources. The latter could be mobilized through assistance of donor agencies and appropriate mix of social and private insurance. Ultimately mitigating the problem of regional disparities in healthcare and protecting the poor and vulnerable from financial burden may require establishing and maintaining proper linkages between socio-economic development and healthcare planning.

Efficiency of Health Care System at the Sub-State Level in Madhya Pradesh, India

This paper attempts a sub-state–level analysis of health system for a low-income Indian state, namely, Madhya Pradesh. The objective of our study is to establish efficiency parameters that may help health policy makers to improve district-level and thus state-level health system performance. It provides an idealized yardstick to evaluate the performance of the health sector by using stochastic frontier technique. The study was carried out in two stages of estimation, and our results suggest that life expectancy in the Indian state could be enhanced considerably by correcting the factors that are adversely influencing sub-state–level health system efficiency. Our results indicate that main factors within the health system for discrepancy in interdistrict performance are inequitable distribution of supplies, availability of skilled attention at birth, and inadequate staffing relative to patient load of rural population at primary health centers. Overcoming these factors through additional resources in the deficient districts, mobilized partly from grants in aid and partly from patient welfare societies, may help the state to improve life expectancy speedily and more equitably. Besides the direct inputs from the health sector, a more conducive environment for gender development, reducing inequality in opportunities for women in health, education and other rights may provide the necessary impetus towards reducing maternal morbidity and mortality and add to overall life expectancy in the state.

Budgetary Expenditure on Health and Human Development in India

This study aims at analyzing the differentials across rich and poor states and across rich and poorer strata and rural urban segments of 19 major Indian states. The study indicates that besides individual health financing policies of the respective state governments, there are significant disparities even between rural and urban strata and rich and poorer sections of the society. These are indicated by high inequality coefficients and an emerging pattern of life style second generation health problems as well as levels of utilization of both preventive and curative care both in public and private sectors. Our results emphasise that there is a need to increase public expenditure on health, improve efficiency in utilization of existing public facilities, and popularize government run health insurance schemes meant primarily for the poor. These steps may help to mitigate partly the inequitable outcomes.

Expenditure Reassignment and Fiscal Decentralisation: An Empirical Study of State and Local Government in India

Reassignment of local functions to state government and fiscal decentralisation seem to be contradictory. Whether these fiscal strategies are compatible policy packages is an empirical question. The crucial issue is as to how local governments respond to reassignment, a response which may be reflected in their willingness to spend on remaining functions. If reassignment stimulates local expenditure such that the extent of decline in fiscal decentralisation (the local share in total state–local expenditure) is less than the amount warranted, the two fiscal strategies can be taken to be compatible. To test this hypothesis, conditions for compatibility are postulated in terms of tax efforts of state and local governments. With use of Indian fiscal data, state and local tax efforts are computed and compared for selected states, as a first approximation. There is no conclusive evidence to show that reassignment has invariably exerted any dampening impact on local expenditure.

Various Approaches to Inequity: A Review of Literature

This chapter reviews various theoretical and empirical studies related to health care. It covers both Indian and various countries’ experience. The countries other than India include European countries, African nations, American and Latin American countries and Asian nations. Various dimensions across geographical regions, healthcare inputs and input utilization and health outcome aspects have been synthesized through this review chapter.

Data and Methodology

This chapter provides main conceptual and analytical tools and methods adopted by us in this book for further analysis, which is carried out in Chaps. 4 to 6. We provide basic definitions as well as formulas or tools used by us in the measurement of inequity in health care. We also discuss the numerous databases used by us in the chapters that follow.

Demand Elasticities for Health Care

In this chapter, we look into demand elasticities for public and private health care in India. We analyse using data from National Family Health Survey (NFHS). We cover all India and 13 Indian states (including eight north-eastern states and five major Indian states across rich-, poor- and middle-income categories) using the household survey data from NFHs. We estimate healthcare demand elasticities across these states and with respect to availability, quality and socio-economic status both in rural as well as urban areas of the states covered in the analysis. We also look into inequities that are estimated using these healthcare demand elasticities.

District-Level Inequity in Selected Indian States

In this chapter, we focus on district-level data for five major Indian states which include poor and rich states across different geographical directions in India. The district-level data thus used include the states of Assam, Bihar, Orissa, Gujarat and Tamil Nadu. We discuss various aspects of health care namely medical facilities, medical manpower, utilization, efficiency and equity. We use different inequity coefficients including Gini coefficients, Theils T and L measures, concentration curve, concentration index and Erryger’s index.

Conclusions and Policy Imperatives

In this chapter, we bring together major findings as discussed in details in earlier chapters. Based on our analysis in this book, we also suggest possible policy imperatives that could help to reduce inequity in health care at different levels.

Health Expenditures and Health Facilities in India

In this chapter we discuss aggregate all-India and state-level data. We provide a synoptic view of state-level scenario for sixteen major Indian states. We discuss the situation in regard to budgetary expenditure on health care on its various components including primary, secondary and tertiary care. We use National Sample Survey latest round data to discuss utilization pattern across states in India. We highlight dimensions of inequity through various socio-economic classifications and different inequity measures.