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

imsexecutivesummaryindiae-version�nal2-130722213510-phpapp01

• 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

IMS HEALTH®

IMS INSTITUTE FOR HEALTHCARE INFORMATICS INDIA

24 Barakhamba Road,New Delhi 110001India

The IMS Institute for Healthcare Informatics provides key policy setters and decision makers in the global health sector with unique and transformational insights into healthcare dynamics derived from granular analysis of information. It is a research-driven entity with a worldwide reach that collaborates with external healthcare experts from across academia and the public and private sectors to objectively apply IMS’s proprietary global information and analytical assets. More information about the IMS Institute can be found at: http://www.theimsinstitute.org.

IMS Health is present in over 100 markets. F

Contact us for more information:Dr. Raghavan Gopa Kumar,Head of IMS Institute for Healthcare Information, India

graghavan@in.imshealth.comTlf: +91-11-33 58-25-50www.theimsinstitute.org

ABOUT THE IMS INSTITUTE FOR HEALTHCARE INFORMATICS