understanding healthcare access in india
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- 1. June 2013Understanding Healthcare Access in India What is the current state?
- 2. 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 todays 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 Indias 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 Study This 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 policiesMethodology of the Study At 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. Household sample distribution split by geographiesDoctor sample distribution split by geographies19% 50%30%35% All India 1,000All India 14,74631%35%SEC A2,802 15%4,571 15%7,373 20%R1SEC B25%25%25%R2SEC C25%25%30%R3SEC D20%20%15%15%MetroSEC EOther Urban25% RuralTNR4MHWBUPPrivate Doctors45% 50% 50% 50%47% 50% 50%Govt Doctors55% 50% 50% 50%53% 50% 50%RegionsMetro Other Rural UrbanIn 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.
- 3. Defining Healthcare Access Access 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.1 Physical accessibility/ locationAv ai la bi 2 lit y/ Q Ca ua pa lit ci y/ 3 ty Fu nc tio na lit yStages of healthcare accessLocation: Rural vs Urban IP vs OP Acute vs Chronic4Components: IP vs OP Acute vs Chronic Income levelsChannels: Private vs Public Impact on usageHealthcare Access Study. Findings from Primary and Secondary ResearchKey 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. Distance travelled to seek OPD treatment No. of episodesLess than 5km19,81310,1129,70168%80%92%Over 5km32%20%8%All IndiaUrban6,49813,31583%79%17%21%RuralPoorSource: Household Healthcare Access Survey Conducted by IMS Consulting Group, 2012 An increasing proportion of the population is using private healthcare facilities for both in-patient and out-patient treatments. Choice of in-patient service provider - Rural (% patients)4060565861444239Choice of in-patient service provider - Urban (% patients)40601986-1987586242381995-1996 Private2004 Public6931 2012Source: NSSO Data 2004; Household Healthcare Access Survey Conducted by IMS Consulting Group, 2012
- 4. are forced to seek treatment in private care. Total spend/episode of illness in absolute (INR) and as % of average monthly HH expenditure Average spend/Event (INR)247251678728667 1,0964.5x 1,481 2,575 13,485 11,6052,255 2,325217%44% 121% 23%21% 54%14% 3%5%8%7%GovernmentPrivate16%GovernmentAcute CarePrivateGovernmentPrivateChronic Care OPD TreatmentIPD TreatmentPoor 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. Key reasons cited for selecting private sector for OP treatment To get quickly attended to56%Lack of specialist in Govt.14% 13%Less waiting2.6 than Govt Hosp4.8 62%29% All India11%3.8 13%62%60%60% 6.263%49%50%50%52%3.9Rural13%27%Poor35%Acute30%27%32%Urban12%18% 6.446% 1.326%22%13%16%6.1 60%1.4 54%50%No free medicines in Govt.imsexecutivesummaryindiae-versionfinal2-130722213510-php10%16%61%Doctor availability in private sector15%13%56%56%56%57%56%56%ChronicSource: Household Healthcare Access Survey Conducted by IMS Consulting Group, 2012 Due to the lack of physical reach, availability of quality treatment and other practices, patients are00Channel diversion due to lack of availability of quality healthcare resources00bnGovernment Sector26%Doctor ConsultationPatients00%2veDi niors1More patients are using high cost private channelDiagnostics/ Medicine0000bn 3.3%Doctor ConsultationPatients0510Diagnostics/ Medicine The majority of out-of-pocket expenses are incurred title from medicines purchased from public or private Key title Key healthcare facilities. % split of OOP spend on OPD treatment (including episodes where free treatment was given)2,296Total episode spend (INR)All other state spending5% 13%US Federal Budget 2011 $3.6 TrillionMedicaidSocial Security842Total of States Budgets 2011 $1.6 TrillionDefenseHigher EducationSource: National Association of State Budget O5% 14% 17% 1%63%Elementary & Secondary Education5% 19% 13% 1%6%All India250 73% GovernmentAll other spending94162% Private61%1%69% GovernmentAcute DiseasesMedicines20% 1%, State Expenditure Report, 2010-2012; Congressional Budget O7110% 20% 1%6% 2% 23%Minor sugeriesPrivateChronic DiseasesDiagnostics00b00bn 00bn00bn Further diversion when Govt. doctors send patients for diagnostics to private facilities or when patients have to purchase essential medicines from private channelsPrivate Sector74%00bn00ConsultationSource: Household Healthcare Access Survey Conducted by IMS Consulting Group, 2012Others1520253035
- 5. exist for the Indian population across all dimensions of access, especially in rural areas.Urban PoorHC services Availability of HC services;RuralPhysical reach, availability, qualityPoor Physical reachAvailabilityQualityNo concernSome concernLarge gaps in accessConcern areasNo gaps in access 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. 100 4 1151Expected change in OOP expenditure on OP ailments 97 Assumption: OOP on diagnostics can be brought down by 75% in Govt. HC facilities1151188Assumption: OOP on drugs can be brought down by 90% in Govt. HC facilities through disbursement of subsidized essential medicines511 2 Assumption: Additional 15% patients shift to Govt. HC facilities due to A and B78 4334343429Current statusA: Diagnostic facilities available in public HC facilitiesB: Subsidized essential medicines available in public HC facilitiesImpact of A+BPrivate othersPrivate medicine4 2Government medicineAssumption: 40% Private HC patients shift to Govt. facilities due to improvement in availability and quality of healthcare resources61 733021Improvement in quality of public HC FacilitiesGovernment others The largest impact possible can come from improvements in the availability and quality of public facilities, as demonstrated above.RECOMMENDATIONS Recent 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
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