Inequity in Hospitalization Care: A Study on Utilization of Healthcare Services in West Bengal, India

Document Type: Original Article

Authors

1 Public Health Foundation of India, New Delhi, India

2 Department of Economics, University of Calcutta, Kolkata, West Bengal, India

Abstract

Background
Out of eight commonly agreed Millennium Development Goals (MDG), six are related to the attainment of Universal Health Coverage (UHC) throughout the globe. This universalization of health status suggests policies to narrow the gap in access and benefit sharing between different socially and economically underprivileged classes with that of the better placed ones and a consequent expansion of subsidized healthcare appears to be a common feature for most of the developing nations. The National Health Policy in India (2002) suggests expansion of market-based care for the affording class and subsidized care for the deserving class of the society. So, the benefit distribution of this limited public support in health sector is important to examine to study the welfare consequences of the policy. This paper examines the nature of utilizationto inpatient care by different socio-economic groups across regions and gender in West Bengal (WB), India. The benefit incidence of public subsidies across these socio-economic groups has also been verified for different types of services like medicines, diagnostics and professional care etc.
 
Methods
National Sample Survey Organization (NSSO) has collected information on all hospitalized cases (60th round, 2004) with a recall period of 365 days from the sampled households through stratified random sampling technique. The data has been used to assess utilization of healthcare services during hospitalization and the distribution of public subsidies among the patients of different socio-economic background; a Benefit Incidence Analysis (BIA) has also been carried out.
 
Results
Analysis shows that though the rate of utilization of public hospitals is quite high, other complementary services like medicine, doctor and diagnostic tests are mostly purchased from private market. This leads to high Out-of-Pocket (OOP) expenditure. Moreover, BIA reveals that the public subsidies are mostly enjoyed by the relatively better placed patients, both socially and economically. The worse situation is observed for gender related inequality in access and benefit from public subsidies in the state.
 
Conclusion
Focused policies are required to ensure proper distribution of public subsidies to arrest high OOP expenditure. Drastic change in policy targeting is needed to secure equity without compromising efficiency.

Keywords

Main Subjects


  1. Planning Commission of India. High Level Expert Group Report on Universal Health Coverage for India; 2011.
  2. Harris B, Goudge J, Ataguba JE, McIntyre D, Nxumalo N, Jikwana S, et al. Inequities in access to health care in South Africa. J Public Health Policy 2011; 32 Suppl 1: S102-23. doi: 10.1057/jphp.2011.35
  3. Garcia-Subirats I, Vargas I, Mogollón-Pérez AS, De Paepe P, da Silva MR, Unger JP, et al. Inequities in access to health care in different health systems: a study in municipalities of central Colombia and north-eastern Brazil. Int J Equity Health 2014; 13: 10. doi: 10.1186/1475-9276-13-10
  4. National Health policy of India. Ministry of Health and Family Welfare; 2002.
  5. O’Donnell O, Doorslaer EV, Wagstaff A, Lindelow M. Analyzing Health Equity Using Household Survey Data: A Guide to techniques & their Implementation. Washington DC: The World Bank; 2008.
  6. Sen A. Why Health Equity? In: Anand S, Peter F, Sen A, editors. Public Health, Ethics and Equity. Oxford: Oxford University Press; 2006.
  7. World Health Organization (WHO). World Health Statistics 2014 [internet]. 2014. Available from: http://www.who.int/mediacentre/news/releases/2014/world-health-statistics-2014/en/
  8. The Indian Census. Sample Registration System [internet]. 2013. Available from:  http://www.censusindia.gov.in/2011-common/Sample_Registration_System.html
  9. West Bengal State Drug Policy [internet]. 2004. Available from:  http://www.wbhealth.gov.in/download/state%20drug%20policy,%20west%20bengal%20-%202004.pdf
  10. Census of India [internet]. 2011. Available from:   http://censusindia.gov.in/Tables_Published/SCST/dh_st_westbengal.pdf
  11. National Sample Survey Organization (NSSO) [internet]. Available from:  http://mospi.nic.in/Mospi_New/Admin/publication.aspx
  12. Aday LA, Andersen R. A framework for the study of access to medical care. Health Serv Res 1974; 9: 208-20.
  13. Kirby JB, Kaneda T. Neighborhood Socioeconomic Disadvantage and Access to Health Care. J Health Soc Behav 2005; 46: 15-31. doi: 10.1177/002214650504600103
  14. Penchansky R, Thomas JW. The concept of access: definition and relationship to consumer satisfaction. Med Care 1981; 19: 127-40. doi: 10.1097/00005650-198102000-00001
  15. Davis K. Inequality and Access to Health Care. Milbank Q 1991; 69: 253-73. doi: 10.2307/3350204
  16. Dilip TR. Extent of Inequality in Access to Health Care Services in India. CEHAT; 2005.
  17. Lingam L. Emergent Issues beyond Equitable Access. Presentation made at Forum 11, Beijing, China, 2007.
  18. Sen G, Iyer A. Who gains, who loses and how: leveraging gender and class intersections to secure health entitlements. Soc Sci Med 2012; 74: 1802-11. doi: 10.1016/j.socscimed.2011.05.035
  19. Oliver A, Mossialos E. Equity of access to health care: outlining the foundations for action. J Epidemiol Community Health 2005; 58: 655-8. doi: 10.1136/jech.2003.017731
  20. Palmer N. Access and Equity: Evidence on the Extent to Which Health Services Address the Needs of the Poor. In: Bennett S, Gilson L, Mills A, editors. Health, Economic Development and Household Poverty. London: Routledge; 2008. p. 61-74.
  21. The MIT Dictionary of Modern Economics. 3rd edition. Cambridge: MIT Press; 1986
  22. McIntyre D, Ataguba JE. How to do (or not to do) ... a benefit incidence analysis. Health Policy plan 2011; 26: 174-82. doi: 10.1093/heapol/czq031
  23. Bose M. Access to In-Patient Healthcare in West Bengal: A Benefit Incidence Analysis. International Institute for Population Sciences; 2014.
  24. Wagstaff A. Benefit-incidence analysis: are government health expenditures more pro-rich than we think? Health Econ 2012; 21: 351-66. doi: 10.1002/hec.1727
  25. Halasa Y, Nassar H, Zaky H. Benefit-incidence analysis of government spending on Ministry of Health outpatient services in Jordan. East Mediterr Health J 2010; 16: 467-73.
  26. Demery L, Gaddias I. Social Spending, Poverty and Gender Equity in Kenya: A Benefit Incidence Analysis. Kenya: Support to Public Finance Management Reforms; 2009.
  27. Glick P, Razakamanantsoa M. The Distribution of Social Service in Madagascar – 1993-99. Strategies and Analysis for Growth and Access. Working Paper; 2002.
  28. Castro-Leal F, Dayton J, Demery L, Mehra K. Public Social Spending in Africa: Do the Poor Benefit? World Bank Res Obs 1999; 14: 49-72. doi: 10.1093/wbro/14.1.49
  29. Selden TM, Wasylenko MJ. Benefit Incidence Analysis in Developing Countries, No 1015, Policy Research Working Paper Serie. The World Bank; 1992.
  30. Mahal A, Yazbeck AS, Peters DH, Ramanan GN. The Poor and Health Service Use in India. Health, Nutrition and Population (HNP), Discussion Paper; 2001.
  31. Chakraborty L, Singh Y, Jacob JF. Public Expenditure Benefit Incidence on Health: Selective Evidence from India. New Delhi:National Institute of Public Finance and Policy; 2011.
  32. Acharya D, Vaidyanathan G, Muraleedharan V, Dheenadayalan D, Dash U. Do the Poor Benefit from Public Spending on Healthcare in India? Results from Benefit (Utilization) Incidence Analysis in Tamil Nadu and Orissa. CREHS; 2011.
  33. Thorat S, & Dubey A. Has Growth been Socially Inclusive during 1993-94 – 2009-10? Economic & Political Weekly [Serial on the internet]. [updated  March 2012]. Available from: http://www.epw.in/special-articles/has-growth-been-socially-inclusive-during-1993-94-2009-10.html  
  34. World Bank. World Development Report: Investing in Health. New York: Oxford University Press; 1993.
  35. Bose M, Dutta A. Access to Non-hospitalization Care in West Bengal: A Demand-side Assessment Based on NSS Data. Indian Journal of Human Development 2014: forthcoming.
  36. Prinja S, Kanavos P, Kumar R. Health care inequities in north India: role of public sector in universalizing health care. Indian J Med Res 2012; 136: 421-31.
  37. Lanjouw P, Ravallion M. Benefit incidence, public spending reforms, and the timing of program capture. World Bank Econ Rev 1999: 13: 257-73.
  38. Younger SD. Benefits on the Margin: Observations on Marginal Benefit Incidence. World Bank Econ Rev 2003: 17: 89-106.
  39. Shahrawat R, Rao KD. Insured yet Vulnerable: Out-of-Pocket Payments and India’s Poor. Health Policy Plan 2012; 27: 213-21. doi: 10.1093/heapol/czr029