Understanding Healthcare Access in India


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While progress has been made in India over the past decade from both public and private sector initiatives, significant challenges persist in providing quality healthcare on an equitable, accessible and affordable basis across all regions and communities, according to a new IMS Institute for Healthcare Informatics study. A 40-45 percent reduction in out-of-pocket expenditures for both outpatient and inpatient treatments can be attained through a holistic approach addressing four critical, interrelated dimensions of healthcare access. Those components are: physical accessibility and the location of healthcare facilities; availability and capacity of needed resources; quality and functionality of service required for patient treatment; and affordability of treatment relative to a patient’s income.
The study – Understanding Healthcare Access in India: What is the Current State? – is the most comprehensive assessment of healthcare access undertaken since 2004 and is based on an extensive survey of nearly 15,000 households covering all socio-economic groups in rural and urban areas across 12 states. Information was gathered on more than 30,000 healthcare system interactions, supplemented by interviews with over 1,000 doctors and experts.

The full report is available at http://www.theimsinstitute.org for downloading.

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Understanding Healthcare Access in India

  1. 1. June 2013 Understanding Healthcare Access in India What is the current state?
  2. 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 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 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 policies Methodology 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 geographies Doctor sample distribution split by geographies 19% 50% 30% 35% All India 1,000 All India 14,746 31% 35% SEC A 2,802 15% 4,571 15% 7,373 20% R1 SEC B 25% 25% 25% R2 SEC C 25% 25% 30% R3 SEC D 20% 20% 15% 15% Metro SEC E Other Urban 25% Rural TN R4 MH WB UP Private Doctors 45% 50% 50% 50% 47% 50% 50% Govt Doctors 55% 50% 50% 50% 53% 50% 50% Regions Metro Other Rural Urban 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.
  3. 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/ location Av ai la bi 2 lit y/ Q Ca ua pa lit ci y/ 3 ty Fu nc tio na lit y Stages of healthcare access Location: Rural vs Urban IP vs OP Acute vs Chronic 4 Components: IP vs OP Acute vs Chronic Income levels Channels: Private vs Public Impact on usage Healthcare Access Study. Findings from Primary and Secondary Research 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. Distance travelled to seek OPD treatment No. of episodes Less than 5km 19,813 10,112 9,701 68% 80% 92% Over 5km 32% 20% 8% All India Urban 6,498 13,315 83% 79% 17% 21% Rural Poor Source: 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) 40 60 56 58 61 44 42 39 Choice of in-patient service provider - Urban (% patients) 40 60 1986-1987 58 62 42 38 1995-1996 Private 2004 Public 69 31 2012 Source: NSSO Data 2004; Household Healthcare Access Survey Conducted by IMS Consulting Group, 2012
  4. 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) 247 251 678 728 667 1,096 4.5x 1,481 2,575 13,485 11,605 2,255 2,325 217% 44% 121% 23% 21% 54% 14% 3% 5% 8% 7% Government Private 16% Government Acute Care Private Government Private Chronic Care OPD Treatment IPD Treatment Poor • 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 to 56% Lack of specialist in Govt. 14% 13% Less waiting2.6 than Govt Hosp 4.8 62% 29% All India 11% 3.8 13% 62% 60% 60% 6.2 63% 49% 50% 50% 52% 3.9 Rural 13% 27% Poor 35% Acute 30% 27% 32% Urban 12% 18% 6.4 46% 1.3 26% 22% 13% 16% 6.1 60% 1.4 54% 50% No free medicines in Govt. imsexecutivesummaryindiae-versionfinal2-130722213510-php 10% 16% 61% Doctor availability in private sector 15% 13% 56% 56% 56% 57% 56% 56% Chronic Source: 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 are 00 Channel diversion due to lack of availability of quality healthcare resources 00bn Government Sector 26% Doctor Consultation Patients 00% 2 ve Di n io rs 1 More patients are using high cost private channel Diagnostics/ Medicine 00 00bn 3.3% Doctor Consultation Patients 0 5 10 Diagnostics/ 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) 2,296 Total episode spend (INR) All other state spending 5% 13% US Federal Budget 2011 $3.6 Trillion Medicaid Social Security 842 Total of State’s Budgets 2011 $1.6 Trillion Defense Higher Education Source: National Association of State Budget O 5% 14% 17% 1% 63% Elementary & Secondary Education 5% 19% 13% 1% 6% All India 250 73% Government All other spending 941 62% Private 61% 1% 69% Government Acute Diseases Medicines 20% 1% , State Expenditure Report, 2010-2012; Congressional Budget O 711 0% 20% 1% 6% 2% 23% Minor sugeries Private Chronic Diseases Diagnostics 00b 00bn 00bn 00bn Further diversion when Govt. doctors send patients for diagnostics to private facilities or when patients have to purchase essential medicines from private channels Private Sector 74% 00bn 00 Consultation Source: Household Healthcare Access Survey Conducted by IMS Consulting Group, 2012 Others 15 20 25 30 35
  5. 5. • exist for the Indian population across all dimensions of access, especially in rural areas. Urban Poor HC services Availability of HC services; Rural Physical reach, availability, quality Poor Physical reach Availability Quality No concern Some concern Large gaps in access Concern areas No 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 11 51 Expected change in OOP expenditure on OP ailments 97 Assumption: OOP on diagnostics can be brought down by 75% in Govt. HC facilities 11 51 1 88 Assumption: OOP on drugs can be brought down by 90% in Govt. HC facilities through disbursement of subsidized essential medicines 51 1 2 Assumption: Additional 15% patients shift to Govt. HC facilities due to A and B 78 43 34 34 34 29 Current status A: Diagnostic facilities available in public HC facilities B: Subsidized essential medicines available in public HC facilities Impact of A+B Private others Private medicine 4 2 Government medicine Assumption: 40% Private HC patients shift to Govt. facilities due to improvement in availability and quality of healthcare resources 61 7 3 30 21 Improvement in quality of public HC Facilities Government 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 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
  6. 6. IMS HEALTH® IMS INSTITUTE FOR HEALTHCARE INFORMATICS INDIA 24 Barakhamba Road, New Delhi 110001 India Contact us for more information: Dr. Raghavan Gopa Kumar, Head of IMS Institute for Healthcare Information, India graghavan@in.imshealth.com Tlf: +91-11-33 58-25-50 www.theimsinstitute.org IMS Health is present in over 100 markets. F ABOUT THE IMS INSTITUTE FOR HEALTHCARE INFORMATICS 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.