Broad Conclusions and Policy Directions




(1)
Institute of Economic Growth, Delhi University, Delhi, India

 



Abstract

Drawing upon a set of comprehensive field-based data and an in-depth analysis of the OOP health payments by a cross-section of households from selected rural and urban areas of three different states—UP, Rajasthan and Delhi—there appear to be major challenges ahead for both the planners and administrators of health-care services. This can easily be noticed from the discussion so far. While this chapter however does not intend to replicate most of that discussion or its underlying messages in a conventional setting, it does attempt to cull out briefly a few of the major observations after piecing them together from different chapters as reference points. As regards directions of policy, this chapter sets out to provide scores of considered opinion given by the respondents on issues of critical concerns, e.g. recent increase in health-care charges, overprescription of medicines and/or diagnostics by medical professionals and role of drugs in making health care expensive. This will be followed by another set of respondents’ reactions covering issues in a policy framework such as health insurance and the extent respondents would be willing to go for such a product on a payment basis. Most of these questions and their responses are expected to help in deriving a host of policy recommendations based on considered judgments of those who really matter. It may nevertheless be noted that in no way these recommendations may be treated as out of the box.


Drawing upon a set of comprehensive field-based data and an in-depth analysis of the OOP health payments by a cross-section of households from selected rural and urban areas of three different states—UP, Rajasthan and Delhi—there appear to be major challenges ahead for both the planners and administrators of health-care services. This can easily be noticed from the discussion so far. While this chapter however does not intend to replicate most of that discussion or its underlying messages in a conventional setting, it does attempt to cull out briefly a few of the major observations after piecing them together from different chapters as reference points.1 As regards directions of policy, this chapter sets out to provide scores of considered opinion given by the respondents on issues of critical concerns, e.g. recent increase in health-care charges, overprescription of medicines and/or diagnostics by medical professionals and role of drugs in making health care expensive. This will be followed by another set of respondents’ reactions covering issues in a policy framework such as health insurance and the extent respondents would be willing to go for such a product on a payment basis. Most of these questions and their responses are expected to help in deriving a host of policy recommendations based on considered judgments of those who really matter. It may nevertheless be noted that in no way these recommendations may be treated as out of the box.

Most of the analysis was broadly directed to focus on the following concerns:

1.

OOP health payments and attendant issues of poverty and inequality

 

2.

Catastrophic health payments and some of its correlates

 

3.

Decomposition of health payments and share of drugs/medicines in the total health expenditure

 

4.

Share of public health services in hospitalisation and outpatient care

 

5.

Public health-care utilisation and catastrophic payments

 

6.

Extent of untreated ailments mainly because of high health-care costs

 

7.

Attention generated by the NRHM among the rural households and their views on improvements in delivery of health services over the past few years, etc.

 


8.1 Highlights of Major Findings


As has already been pointed out, a number of observations have been cited in the preceding chapters, and barring a few, most of them have not been repeated here to ensure brevity. Among the notables, one of the more critical observations perhaps relates to the role played exclusively by the OOP health payments in adding to the overall poverty level. We have culled a table on the basis of certain earlier exercises to show the role of health payments in poverty enhancements. Table 8.1 gives poverty levels both before and after the OOP health expenditure. This table clearly shows the vulnerability of a significant fraction of the rural and slum households to health payments. In addition to deepening poverty of those who are already below the poverty line, health payments, for instance, bring an additional 10–14 % of households under the poverty net (see painted numbers in Table 8.1). In addition, there appears to be another significant policy message from this table—households at the fringe of poverty level may easily experience a shift in their economic status from above to below poverty level due to no or very limited affordability in terms of health payments. It may further be construed that the declining poverty in many situations remains deceptive as a good fraction of fringe level households, both rural and urban, may remain vulnerable to situations like self or family ailments. An analysis of household indebtedness in Chap. 3 (Sect. 3.​3) has shown that more than a quarter of indebted urban households had borrowed to meet medical exigencies. The same in rural areas turns out to be little over 19 %. Chapter 3 also indicates a big share of private moneylenders in those borrowings. Does it mean to suggest that the health-care services in the country are not affordable in their present form for a significant percentage of households? While a categorical answer to this question may need further and more in-depth studies, this is indeed an issue that warrants a greater consideration, especially from health policy mandarins.


Table 8.1
Increase in poverty due to the OOP health expenditure: sample households (%)














































































































 
PCMCE 1

PCMCE 2 = PCMCE 1 – OOP

Increase in poverty due to OOP health payments
 
Poverty head count: 1a

Poverty head count: 2b

Rural: 2(a) – 1(a)

Urban: 2(b) – 1(b)
 
1(a): Rural

1(b): Urban

2(a): Rural

2(b): Urban
   

Total sample (n = 2,010)

33.0

18.8

46.5

24.9

13.5

6.1

UP (n = 1,000)

36.0

25.6

49.6

29.6

13.6

4.0

Unnao (n = 600)

34.7

20

48.89

22

14.2

2.0

Jhansi (n = 400)

38.0

34.0

50.7

41.0

12.7

7.0

Rajasthan (n = 650)

28.4

28.6

41.8

38.0

13.4

9.4

Dausa (n = 300)

21.6

38.0

34.0

56.0

12.4

18.0

Dungarpur (n = 350)

35.2

24

49.6

29.0

14.4

5.0

Delhi (n = 360)


10.0


16.1


6.1

Slums (n = 102)


26.5


41.2


14.7

Non-slum (n = 258)


3.4


6.2


2.8


aPoverty head count 1 = PCMCE of a household—state-wise poverty line (z) given by the Planning Commission (for details, see Chap. 3)

bPoverty head count two deducts the OOP health expenditure from the PCMCE before computing poverty

A related point in the underlying context that arose from the preceding discussion is that antipoverty measures in the country, and particularly in areas under study, may not work to their real potential unless the health services are scaled up to a considerable extent—that too in every health domain. It also requires taking into account the needs of persons or households forced to borrow money from private sources on coercive conditions at the time of ailments. Could there be a role for the community-based micro-credit institutions to lend small amounts to the poor and needy during certain health emergencies? This is indeed a significant issue and may be considered from its different perspectives. A major stumbling block in raising such institutions would be the intra-regional diversities requiring appropriate changes in organisational matters. To be precise, perhaps a perfect replication of a particular system or mode of organisational structure may not be possible across different places. Civil society institutions may have to be propped up to work on a system amenable with local conditions and environment.

An interesting point to note from most of our poverty analysis is the non-­emergence of a well-specified target group that could become most eligible for health subsidies. In the context of poverty and inequality, for example, health expenses remain critical to most of the sample households—irrespective of their residential or socio-economic and religious characteristics. While these factors, particularly caste and place of residence, do matter in many ways, it cannot be argued conclusively that a particular segment or group of households must bear an overriding public concern over others. When it comes to health, a great deal of both rural and urban populations suffers from serious issues and faces inequalities. In many cases, a fraction of even higher-income people suffer from non-affordability (or lack of capacity to pay) problems. Despite that, our results do indicate the worsening state of the rural and slum households. A couple of Lorenz curves separately for the rural (UP and Rajasthan) and the urban (UP, Rajasthan and Delhi including the slums and non-slums) areas (Figs. 8.1 and 8.2 respectively) illustrate the points argued here. Health payments clearly bring inequality issues more sharply in urban areas, and logically the slum households bear most of the brunt. Certain higher-­income categories also appear to pay for health care in excess of their affordable limit. In case of the rural sample, OOP inequality is seemingly less sharp (OOP Gini = 0.707), though the differences between the two are marginal. Two points may therefore be made. First, inequalities and critical nature of health issues remain more or less of equal importance for the households, irrespective of their place of residence. Second, inequalities in health payments are much larger than the consumption inequalities, implying inaccessibility of health services for a number of the poorest rural and urban households. A third point may be made that a segregation between the above- and the below-poverty households as claimants of public subsidies may not work as in many situations, both remain vulnerable to an equal measure.
Nov 25, 2016 | Posted by in PHARMACY | Comments Off on Broad Conclusions and Policy Directions
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