11 charts that explain how Indians access and spend on healthcare

The recent infant deaths at a government hospital in Kota has once again reminded us of the systemic neglect of public healthcare in India. The factors that scourge India’s state owned healthcare facilities are infrastructure, poor quality of care and inadequate (or often untrained) manpower. This has resulted in massive levels of distrust towards government healthcare services and providers among the people who, in hordes, are lining up at the private hospitals.

According to the latest NSSO report titled ‘Key indicators of social consumption in India: Health‘, more Indians are accessing private healthcare providers even though the private healthcare services are expensive.

Below are the 11 charts from the report that explains how Indians are accessing and spending on healthcare services.

* More Indians are accessing private health services than govt or public hospitals

Source: NSSO

In the above chart, we can see that maximum number of ailments are treated either by private hospital or by private clinic and private doctor. Government hospitals treat only 32.5% and 26.2% of ailments in rural and urban India respectively. In the absence of doctors and healthcare facilities, 4.3% of the rural respondents go to informal providers. This implies a massive trust deficit towards the public and government hospitals.

*The same trend continues in the hospitalisation cases or the cases in which people have to be admitted to the hospital as in-patient. According to the report, private hospitals corner the maximum number of hospitalisation cases, both in rural and urban India.

Source: NSSO

*Hospitalisation cases in India have a class angle to it. The richer you are, your probability to reach out to hospitals to get yourself admitted for your ailment is higher. The in-patient treatment is costlier than the out-patient treatment because of hospital bed and other costs. Hence, people from higher income quintile, both in rural and urban India, access hospitals more than the people from the lower income quintile.

Source: NSSO

For most of the Indians, the major source for financing hospital expenses is the household savings and income. This arrangement becomes more precarious for people in low income quintiles since one episode of illness in their family can wipe out most of the household savings. This is what Prof Anirudh Krishna calls the ‘One Illness Away’ phenomenon.

Source: NSSO

*More people have health expenditure coverage in higher income quintile than in lower income quintile. This could be because working people who come under government sponsored health insurance programs like ESIS and CGHS fall in higher income quintile.

The data, for this particular round of NSSO survey, was collected between July 2017 and June 2018, while the government sponsored health insurance scheme to cover hospitalisation costs for low income households, Ayushman Bharat was launched in August 2018. Hence some of these numbers would vary in the present context.

Source: NSSO

*Both in rural and urban India, the average medical expenditure per hospitalisation case is way higher in private hospitals than in government hospitals. This is like double whammy for people seeking treatment. On one hand we have a crippling public health system, on the other hand we have a private health system that offers health services but at very high costs. As a result people access private hospitals and care providers more than the public ones even though they are costly. And since the coverage of any kind of health insurance is low, the out-of-pocket expenditure for any illness episode for Indians is high.

Source: NSSO

In the previous post on this blog we have seen how cancer is slowly emerging as one of the biggest killers in India. Everyday nearly 2100 Indians die due to cancer. The treatment of cancer, according to the NSSO data, is the costliest one, both in government and in private hospital. While the average medical expenditure for cancer cases in public hospital is Rs. 22,520, the average medical expenditure in private hospital is Rs. 93,305. This is too big an amount for people in middle and low income quintiles.

Source: NSSO

*The average medical expenditure per treated ailment is being incurred more by private hospital and private clinic and doctor. Equally costly is getting aliment treated by informal health providers.

Source: NSSO

Stories of infant deaths come mostly from the government hospitals. This is because a large proportion of rural India go to the government hospitals and health centers for child birth as compared to urban India.

Within rural India, the dependence on government hospitals for childbirth is high across all the income quintile class. The share of private hospital increases only after the 4th income quintile. This implies that the rich in rural areas are tend to go to private hospitals for childbirth as compared to the rural poor.

Source: NSSO

The trend in urban India is very different from that in rural India. In urban areas, as the incomes increase people’s access to private hospitals increases while the access to government hospitals decreases. This clearly indicates that in urban areas, the rich have given up on the government hospitals and rely on private hospitals. The people from low income quintiles have no other choice but to go to the public hospitals for the childbirth.

And with poor quality of care, abysmal infrastructure and inadequate staff, the poor always get poor services in government and public hospitals.

Source: NSSO

Childbirth is more costly in private hospitals than in public hospitals. The average expenditure on hospital childbirth is almost double in private hospitals than in public hospitals in both rural and urban areas.

Source: NSSO

Cancer claimed 8 lakh lives in India in 2018

Source: New Scientist

According to a reply in the Lok Sabha, in 2018, nearly 8 lakh Indians died due to cancer. The estimated mortality due to cancer has increased by 20% since 2014, the data in the reply claimed.

The data used by the health ministry in this reply has been taken from the National Cancer Registry Program (NCRP) of Indian Council of Medical Research (ICMR).

Source: Lok Sabha

Six states- Uttar Pradesh, Bihar, Maharashtra, West Bengal, Madhya Pradesh and Rajasthan contribute to 55% of cancer related mortality.

Source: Lok Sabha

It is these same 6 states where the incidence of cancer or new cases of cancer was the highest in 2018. The overall incidence of cancer cases has increased by 9% since 2016 according to another data presented in the Lok Sabha.

Source: Lok Sabha
Source: Lok Sabha

The cancer cases among women have also increased marginally since 2016. The estimated breast and cervical cancer cases have gone up in the past couple of years.

Source: Lok Sabha

IMR in India drops by 40% in 10 years

According to the latest SRS data released by the Registrar General of India, the IMR in India in 2017 was 33 as compared to 55 in 2007. This implies that the IMR, which is considered as the most important indicator to gauge a country’s health, has declined by 40% in India in the past one decade.

This is still higher than the global average IMR of 29.

While the IMR has gone down from 55 to 33, at the same time rural IMR has gone down from 61 to 37 and urban IMR has gone down from 37 to 23. This indicates that fewer infants are dying both in rural and urban India.

However the gap between rural and urban India remains high in 2017. This pattern has been a consistent feature in the rural-urban IMR divide since 2007. This validates the fact that the state of healthcare in rural India is poor.

Bihar (35), Rajasthan (38), Chhattisgarh (38), Meghalaya (39), UP (41), Odisha (41), Arunachal Pradesh (42), Assam (44), MP (47) have IMR that are worse than the national average (33).

Nagaland (7), Goa (9), Kerala (10), Sikkim (12), Manipur (12), Mizoram (15) and TN (16) are the best performing districts with low IMR.

The worst performing states have the IMR equivalent to that of war and conflict ridden countries in North Africa and Middle East. The best performing states have the IMR equivalent to that European and high income South American countries.

Countries like Libya, Syria and Iraq that have been devastated by civil war, terrorism and constant bombings have better IMR than some of the Indian states. Yemen which is witnessing the worst humanitarian crisis due to civil war has lower IMR than Assam and MP.

If we take a closer look at the rate of decline of the IMR of the 9 worst performing states, we will find that at no point in time have their IMRs come below the national average since 2007.

The most curious case is that of Arunachal Pradesh. The IMR of Arunachal Pradesh was way below than the national average and also from the other states in 2007. It remained stubbornly steady till 2015. After 2015, while the other states and the national average saw significant declines, AP’s IMR started to rise. In 2017 it was above the national average and also from most of the worst performing states.

When compared with the South Asian region, except Pakistan and Myanmar, India’s IMR is higher than all its neighbouring countries.