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Economic Reforms and Health Sector in Indiawith Special Reference to Orissa,Karnataka and Maharashtra:Reflections from NSS 28 th , 42 nd and 52 nd RoundsNayanatara S. N.Series Editors:Aasha Kapur Mehta, Pradeep SharmaSujata Singh, R.K.TiwariP. R. Panchamukhi2006

Market Access For Agricultural Products

Table of Contents1 Introduction 123456789101112Morbidity and Utilisation 2Data Base 3NSSO Health Surveys: Morbidity and Utilisation of Health Care Facilities 4Earlier Research 6Morbidity Profile 8Untreated Ailments 13Source of treatment 15Type of Treatment 19How Much Do People Spend on Treatment? 21Loss of Household Income Due to Illness (Outpatient) 27Messages from NSS in the Light of Ongoing Economic Reforms 28

Market Access For Agricultural Products131415Summary and Insights for Policy Initiatives 33Annexures 36References 52List of Tables and ChartsList of Tables1. Morbidity Reporting (India) 82. Disease-specific morbidity rates for selected diseases in Indiafrom the NSS 28 th and 52 nd rounds 93 Percentage distribution of untreated ailments by reason for not taking treatmentin India - NSS 42 nd and 52 nd rounds 134 Percentage distribution of non-hospitalized treatment by source of treatment inIndia from 52 nd and 42 nd rounds 155 State wise percentage of ailments receiving non-hospitalized treatment fromgovernment sources (public hospital, PHCs & public dispensary) 166 Per 1000 distribution of hospitalized treatments by type of hospital in Indiaduring 1986–87 and 1995–96 177 Hospitalized treatments received from public provider 178 Hospitalized cases as per social groups under different sourcesof treatment in India 189 Percentage distribution of hospitalized cases during last 365 days bytype of ward in government & private hospitals 1910 Average total expenditure per hospitalization by type of hospitalin India from 52 nd round 2111 Average total expenditure per hospitalization by type of hospitalfor rural and urban areas (in constant prices with base year 1980-81) 2212–A: Average medical and other related non-medical expenditure pertreated ailment during 15 days by source of treatment and per capita publicexpenditure on health - Outpatient (OP) from 52 nd round (in current prices) 23

12–B: Cost of OP treatment - Average total expenditure per illness(in constant prices with base year 1980-81) 2413–A: Average total expenditure for hospitalized and non-hospitalizedtreatment for each State/U.T. in India (in constant prices with base year 1980-81) 2513–B: Average total expenditure for hospitalized and non-hospitalizedtreatment for each State/U.T. (in current prices) 2614 Loss of household income per ailment (52 nd Round) 27List of Charts1 Cost of IP treatment - Average total expenditure per illness (in constant prices) 222 Cost of OP treatment - Average total expenditure per illness (in constant prices) 24

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12–B: Cost of OP treatment - Average total expenditure per illness(in constant prices with base year 1980-81) 2413–A: Average total expenditure for hospitalized and non-hospitalizedtreatment for each State/U.T. in India (in constant prices with base year 1980-81) 2513–B: Average total expenditure for hospitalized and non-hospitalizedtreatment for each State/U.T. (in current prices) 2614 Loss of household income per ailment (52 nd Round) 27List of Charts1 Cost of IP treatment - Average total expenditure per illness (in constant prices) 222 Cost of OP treatment - Average total expenditure per illness (in constant prices) 24

Economic Reforms and Health Sector inIndia with Special Reference to Orissa,Karnataka and Maharashtra:Reflections from NSS 28 th , 42 nd and 52 nd Rounds1Nayanatara S. N.*IntroductionIndia is a signatory to the Alma Ata Declaration (1978) ofHealth for All by 2000 A.D. Even three decades after wecommitted to it, the progress made in the health sector isnot impressive. Despite the substantial fall in total fertilityrate and infant mortality rate along with increased life expectancy,eradication of small pox and guinea worm diseases,morbidity and mortality rates continue to be high inthe country. Malaria, which was eradicated, came back in the1980s. Water-borne diseases and Tuberculosis (TB) continueto be the major causes of morbidity. There is emergence ofnew diseases viz. AIDS and Hepatitis-A, which are communicableand for which there is no guaranteed remedy.Structural Adjustment introduced in the country over thelast decade has brought in changes in all sectors of the Indianeconomy. The health sector has been subjected to policychanges due to changes in pattern of resource allocation,health and drug policies, flow of technology, trade agreementsand flow of external assistance. In the light of thesedevelopments an attempt has been made in this paper toexamine the changes in morbidity and the utilisation of healthcare services in India with special reference to Karnataka,Maharashtra and Orissa using the National Sample SurveyOrganisation’s (NSSO) published survey results for the 28 th ,42 nd and 52 nd Rounds.The morbidity estimates reflect the overall health status of thepopulation. Morbidity in a population could be due to manyfactors, both controllable and uncontrollable (or natural). Morbiditythat occurs due to malnutrition, under nutrition, lack ofhealth education, lack of immunisation, lack of health care facilitiesand lack of other preventive and promotional measures, canbe reduced or avoided. Morbidity related to age and geneticfactors cannot be easily prevented, though the extent of sufferingcan be reduced or delayed with the help of modern technology.Morbidity or illness imposes a heavy burden on the individualand society. There is loss of earnings to the familyand loss of productivity to the society due to illness. Moreover,during illness, medical care and consumption are financedby disinvestments, loss of savings and borrowing.Prolonged illness can lead to serious debt and impoverishment.Morbidity can affect educational status in a family.Education often requires out–of–pocket expenditure andthe financial hardship reduces children’s opportunities foreducation both at home and in school (Mead et al, 1992).*The views expressed in this paper are those of the author and do not necessarily reflect the views of GOI, UNDP or IIPA.1

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And Maharashtra2Morbidity and UtilisationFoster (1986) refers to morbidity as the condition ofbeing diseased or morbid. It is the incidence of a diseaseor illness i.e., the ratio of sick to well persons in acommunity. A person is said to be sick when he is sufferingfrom a disease or reports illness. Illness may existin the absence of a diagnosed disease, as when a persondoes not feel well and is unable to fulfil his normal,social and economic roles. Illness is the state that is perceivedby the individual when he or she is suffering fromdisease and sickness is the state that develops as areaction to illness.Utilisation of health care facilities refers to the use of facilitiessuch as government hospitals, Primary Health Centres(PHCs), Employees State Insurance (ESI) clinics/hospitals,private doctors, private clinics, private hospitals and charitableinstitutions. The details are gathered on the basis of reportingby patients during a household survey. Utilisation data revealsthe people’s preference for a particular health care facilityand also the availability of health care services. Nonutilisationquestions the usefulness of existing health care services.Other factors like non-severity of illness, financial problemsand lack of awareness could also be reasons for nonutilisation.2

3Data BaseNational Sample Survey (NSS) data (28 th , 42 nd , 52 ndRounds) provides useful insights about the incidence andprevalence of morbidity across states according to fractilegroups, age, place of treatment, rural and urban category,attending adult education class, social groups, etc. Theseprovide a base for understanding inter–state variations inmorbidity conditions and utilisation of services over time.Morbidity surveys conducted by NSSO do not follow auniform pattern. Though the objectives are the same, thereare differences in the reference period, grouping of diseases,classification of the number of ailing persons accordingto fractile groups, source and type of treatmentetc. In the 28 th Round (1973-74), state wise all India informationis available only on temporary and chronic ailmentsby sex, age, area (rural and urban) and type of ailments. Inthe 42 nd Round (1986–87), the survey was conducted in asample of 8,346 villages and 4,568 urban blocks. The referenceperiod for hospitalised illness was 365 days precedingthe date of survey. For other ailments – treated anduntreated (outpatients) the reference period was 30 days.For hospitalised cases, incidence and prevalence rates areavailable. For outpatients, only the prevalence rate is given,i.e., the proportion of persons with ailments. In the 52 ndRound (1995–1996), the reference period for enquiry onmorbidity (non-hospitalised/outpatients treated or untreated)was 15 days preceding the date of enquiry. Forhospitalised treatment, information was collected for everyevent of hospitalisation of a member, whether livingor diseased, at the time of survey, during the 365 dayspreceding the date of enquiry.Published sources i.e., NSSO’s Sarvekshana for the 28 thand 42 nd Rounds and the Report on Morbidity and Ailmentsfor the 52 nd Round are used for descriptive andcomparative analysis. The present analysis for the 52 ndRound is based on the data collected by NSSO under theCentral Sample in 7,663 villages and 4,991 urban blockscovering 71,284 households in rural areas and 49,658 householdsin urban blocks.3

NSSO Health Surveys: Morbidity and Utilisation of Health Care Facilitiesinsignificant proportion (1 to 2%) of sick in urban andrural areas) during the 52 nd Round.PAP: Ratio or Proportion of Ailing Persons with ailmentsobserved during the reference period of 30 days precedingthe date of survey, to the total number of persons.Acute ailment: Short duration (less than 30 days) ailments.Chronic ailment: Long duration (30 days or more)ailments.Fractile group: Using the monthly per capita consumptionexpenditure (MPCE) based on the data collected forbroad heads of consumption expenditure for each samplehousehold, population was classified into fractile groupsseparately for rural and urban areas.Hospitalisation: A person is regarded as having beenhospitalised if he/she has availed of medical servicesas an inpatient (except childbirth) in any medical institution.5

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And Maharashtra5Earlier ResearchUsing the survey results of the NSS 42 nd Round, Krishnan(1999) reported that cost of treatment was highest for stateswhere facilities were least developed. Krishnan argues thatrural patients, particularly the bottom groups, paid morefor health care and the cost of outpatient treatment couldbe reduced if primary health care is readily accessible to therural population. Taking the average cost of treatment foreach state based on the information provided by the NSS,Krishnan has estimated the relative burden of treatment as aratio of average cost to the per capita state domestic income(only direct burden of treatment). Baru’s study (1999)using the 42 nd Round results, highlighted that more than 50percent of the bottom 20 percent and top 20 percent incomegroups in rural areas, in a majority of the states, usedpublic institutions for hospitalised cases and the larger percentageof only the top 20 percent in urban areas (in developedstates) used private hospitals during 1986-1987. Thisindicates that public institutions provide the major part ofinpatient care. Baru reported that the dependence on publichospitals for hospitalisation during 1986-1987 was 55 percentin rural areas and 60 percent in urban areas in the country.In poor states like Orissa the dependence on public institutionsfor hospitalised care was reported to be more than80 percent. In such a health care scenario, Baru says that itwould be difficult to cut back on public expenditure onsecondary and tertiary sectors both on welfare and politicalconsiderations, as both private and voluntary sector servicesare skewed in favour of urban and better-developed statesand provide more outpatient care.Studies also highlight that there is bias in terms of gender,class and social groups in morbidity and utilisation of health6care services. Poor and disadvantaged sections such asScheduled Castes (SCs) and Scheduled Tribes (STs) areforced to spend a higher proportion of their income onhealth care than the better-off sections (Gumber, 1997).The estimates worked out on the basis of NSS per capitaprivate expenditure details reveal that the share of per capitamedical expenditure in total per capita expenditure variedfrom Rs. 2.29 to Rs. 2.82 for people below the povertyline and from Rs. 9.03 to Rs. 11.61 for the top 10 percentof the expenditure class during 1986-87 to 1995-96 (seeAnnex – III, Table A-1). Sen, Gita and others (2002), useddata from NSS for the 42 nd and 52 nd Round and fromother empirical studies to examine the changes during thereform period addressing the question of health equity interms of gender biases and economic class differentials.They argued that there is significant gender bias as shownby the higher percentage of untreated diseases amongwomen in 1986-87. It is also argued that the percentage oftreated and untreated diseases reported by women is underestimatedin NSS Rounds, as sexual and reproductivediseases are not reported and reporting would be higherif trained female investigators collect information fromwomen after initial rapport building.Using the NSS (1973–74 & 1986–87), National Councilof Applied Economic Research [(NCAER) (1990 & 1993)]and Central Statistical Organisation (CSO) data, Shariff andothers (1999) have projected the burden of disease andcost of ill health for the Ninth Plan. Using the data onutilisation of health services and the cost of ill health,a case is made for new strategies for allocation of

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And Maharashtra6Morbidity Profile6.1 Morbidity Reporting(i) Overall Morbidity (per 1000)The overall morbidity rate, that is the number of personswho reported sickness (proportion of persons with ailmentsto total population) during the reference period of 30 days inthe 42 nd Round was 64 and 31 persons respectively for ruraland urban areas. In the 52 nd Round, the number of ailingpersons was 55 in rural areas and 54 in urban areas during thereference period of 15 days. The number of ailing personsfor 30 days recall period derived from the15 days recall period survey estimates, (derived to enable comparisonsbetween the 42 nd and 52 nd Round) reveals that thenumber of ailing persons in the 52 nd Round was 86 in ruralareas and 84 in urban areas. This indicates that there is an increasein morbidity episodes.Table 1 gives the prevalence rates (PR) of the ailment andthe number (per 1000) of ailing persons (PAP) over differentNSS Rounds.The prevalence rates given in Table 1 show that morbidityrates have increased over time (28 th to 52 nd Round) bothin rural and urban areas. The number of ailing personswas highest in 1961–62 (17 th Round), but declined in 1973-74 (28 th Round). The rate of decline in reporting was 76percent for urban areas and 51 percent for rural areas. Asper the derived estimates (for 30 days based on 15 daysdata) for the 52 nd Round, there is an increase in the numberof ailing persons. In all the Rounds, morbidity reportingis slightly higher in rural areas. The rate of increase inmorbidity reporting in urban areas is very high (171%) ascompared to rural areas (34%) over the 42 nd to 52 nd Rounds.Due to methodological differences in conducting the surveys,the differences in morbidity profile should be takenas a generalised scenario.During 1986-87, on an average 149 lakh persons werehospitalised in rural India and 26 lakh in urban India. About56 percent of the inpatients were males and 44 percent werefemales both in rural and urban areas. The prevalence rateTable 1: Morbidity Reporting (India)1961–62 1973–74 1986–87 1995–96 1995–9617 th Round 28 th Round 42 nd Round 52 nd Round 52 nd RoundPAP PR PAP PAP estimated derived PAP(30 days) (15 days) (30 days) (15 days) (30 days)Rural Person 132 43 64 55 86Male 139 47 64 54 84Female 123 40 63 57 89Urban Person 131 42 31 54 84Male 133 43 30 51 81Female 128 41 33 58 89Source: NSSO (1998), Morbidity and Treatment of Ailments, 52 nd round (1995 – 96), Report No.441, p–18.8

Morbidity Profileof hospitalised cases was 28 and 17 per 1000 persons respectivelyin rural and urban areas. During1995–96, about two percent of the urban population and 1.3percent of the rural population were hospitalised i.e., the prevalencerate of hospitalisation was 13 and 20 per 1000 personsrespectively for rural and urban sectors. This reveals thathospitalisation is increasing in urban areas and has declined inrural areas. These changes indicate the following possibilities.(a) There is a trend of admitting patients even for minorillnesses in urban areas. Acute and other diseases likediarrhoea, ulcers, bronchitis, heart problems, cancer,cataract etc., which require immediate attention andsometimes surgery are increasing in urban areas. The52 nd survey results indicate that there is increasing reportingof such type of diseases.(b) With increasing coverage by urban private doctors ofnearby villages facilitated by transport facilities or dueto increasing rural outpatients visiting private doctorsfor acute illnesses, the incidence of hospitalisation mighthave reduced in rural areas.(c) Rural patients might have avoided hospitalisation dueto lack of access and lack of finances. The same reasonscould be valid for rural inpatients also.(ii) DiseasesTable 2 presents the prevalence and incidence rate (per1,00,000) for major chronic and acute diseases respectivelyfor 28 th and 52 nd Round.Acute DiseasesInjuries due to accidents have increased both in rural andurban areas due to the increased use of vehicles. The incidenceof dysentery, diarrhoea and cholera is higher andhas increased (1995-96) both in rural and urban areas. Thisindicates that there is need for improvement in the supplyof safe drinking water and sanitation services both in ruraland urban areas. Due to non–reporting of illness separatelyfor these diseases in the 52 nd Round, it is not possibleto present the rate of change in the prevalence of thesediseases separately over the years.Table 2: Disease-specific morbidity rates for selected diseases in Indiafrom the NSS 28 th and 52 nd RoundsDisease Rural Urban1973–74 1995–96 1973–74 1995–96(28 th Round) (52 nd Round) (28 th Round) (52 nd Round)Chronic diseases: Prevalence rate (per 100,000)Tuberculosis 117 83 137 63Leprosy 40 11 25 9Epilepsy 28 14 17 24Piles 65 13 61 32Acute diseases: Incidence rate (per 100,000)Measles 17 11 14 14Cholera 3 * 3 *Dysentery 12 * 35 *Diarrhoea 27 * 22 *Diarrhoea & dysentery * 269 * 230(including cholera)Injuries due to 39 63 54 83accidentsNote: * indicates that data on the specific disease were as not collected separately in the survey.Source: NSSO (1998) Morbidity and Treatment of Ailments, the 52 nd round, (Report No. 441)9

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And MaharashtraChronic DiseasesIn the 28 th Round, in addition to diabetes and hypertension,which were prevalent in the urban areas of all threestates, in each state, there existed several other peculiarchronic diseases. In rural Maharashtra, reporting was morefor leprosy, peptic ulcer and arthritis. In Karnataka, diabetesand hypertension were also prevalent in rural areas. Orissahad a higher prevalence of mental illness, peptic ulcer, rheumatismand kidney stones both in rural and urban areas.Table 2 shows that of the chronic diseases, the prevalenceof epilepsy and piles has reduced (1973-74 to 1995-96)both in rural and urban areas, though it continues to be amajor problem in urban areas. There is increased reportingof epilepsy cases in urban areas. There is no change inthe incidence of measles cases in urban areas (1973-74 to1995-96). There is a good reduction in the reporting ofleprosy cases in rural and urban areas. Asthma was a majorchronic disease during the 28 th Round (not shown in Table2) with highest prevalence of 376 (per 1,00,000) in ruraland 355 (per 1,00,000) in urban areas in the country. Orissahad a comparatively lower prevalence of asthma both inrural and urban areas. Details of prevalence of asthmaduring the 52 nd Round are not given in NSSO reports.The other most common chronic disease that prevailedduring the 28 th Round in rural and urban areas in the countrywas TB, with a prevalence rate of 117 and 137 respectivelyper one lakh population. Though it has come downto 83 (rural) and 63 (urban) over the years (1995-1996), itis still a cause of concern in both the areas.(iii) AgeMorbidity prevalence is generally found to be higher amongchildren and the elderly. NCAER (1992) and National FamilyHealth Surveys [(NFHS) (1998-99)] also indicate this. Inthe 28 th Round, the incidence of acute ailments was higheramong infants and children in the age group one to fouryears and the elderly i.e., above 60 years in rural areas. Inrural Maharashtra, reporting was slightly higher for uppermiddle age groups (45-59 years). In the urban areas of allthe three states, morbidity reporting was slightly higheramong upper middle age groups than the elderly. Age wisereporting is not given for the 42 nd Round (published data).During the 52 nd Round also the reporting for any type ofailments in rural areas is higher for the elderly and children.The incidence of morbidity due to chronic diseases is loweramong the children (0–14 years). Children generally sufferfrom acute illnesses and receive immediate attention fromparents before they turn chronic. In urban areas also thereis a similar morbidity pattern. Child morbidity due to acutediseases is more in urban areas and more so in Orissa. Thiscould be due to lack of preventive measures likeimmunisation, sanitation and proper supply of drinkingwater. The number of persons suffering from chronic illnessesis higher among those above forty and the elderly.The incidence of morbidity for acute and other diseases inall the age groups and for both rural and urban areas ishigher in Orissa.As observed in the 52 nd Round, children suffer from acutediarrhoea, dysentery, cholera, fever, cough and bronchitisboth in rural and urban areas. Jaundice, epilepsy, locomotorand congenital deformities are the chronic diseases sufferedby children. In addition, rural children report TB and earproblems. Joint pain, hypertension, gastritis, amoebiasis, diseasesof the heart and leprosy are chronic ailments prevalentamong the middle aged in rural areas. In addition to theailments due to these diseases, urban middle-aged groupsalso suffered from diabetes. Cough, bronchitis, fever, diarrhoeaand gastroenteritis are the acute ailments suffered bythe middle aged both in rural and urban areas.The elderly suffer from all the acute ailments specifiedabove. Whooping cough and accidents due to injuries andviolence are also reported to a larger extent among theelderly. Joint problems, hypertension, diabetes, diseases ofthe eye, ear, heart and urinary tract, leprosy, gastritis, cancer,piles and locomotor disability are the chronic diseasessuffered by the elderly.(iv) GenderDuring the 17 th and 28 th Rounds, the reporting of nonhospitalisedillnesses was higher for males in rural and urbanareas. In the 42 nd Round, male reporting was higheronly in rural India while more females reported illnesses in10

Morbidity Profileurban India, but during the 52 nd Round the reporting isfound to be higher for females both in rural and urbanIndia. This could be due to increasing awareness via media,health programmes and education.During 1973-74, major acute health problems reportedby men and women from urban and rural areas were dysentery,malaria, influenza and small pox. Men had higherreporting of ailments due to accidents. In the 52 nd Round,fever, diarrhoea/dysentery/cholera, cough, bronchitis,whooping cough and diseases of the eye/mouth/gum aresome of the major acute ailments reported by men andwomen in rural and urban areas. Reporting of accidentalinjuries and acute respiratory infections are more amongmen in both the areas. This could be related to driving ofvehicles and smoking both of which are higher amongmen. Air pollution is an additional factor causing increasein respiratory illnesses.The three common chronic diseases that were prevalentamong men and women during 1973-74 were asthma,TB and rheumatism both in rural and urban areas. In urbanareas, in addition to these diseases, hypertension anddiabetes were observed among men and, hypertension wasobserved among women. The 52 nd Round survey resultsreveal that joint problems, hypertension, gastritis and TBare the common long-term diseases suffered by men andwomen in rural areas. In urban areas, there is more reportingof joint problems, hypertension, diabetes and heartproblems among men and women.As per the 52 nd survey results, hospitalised cases per 1000persons are more in urban and rural Maharashtra as alsorevealed in the 42 nd Round. The incidence of femalehospitalisation in rural areas (per 1000) varied from 11 inOrissa to 18 in Maharashtra and, incidence of malehospitalisation varied from 14 in Orissa to 20 in Maharashtra.In urban areas, female hospitalisation varied from 14 in Orissato 25 in Maharashtra and male hospitalisation varied from17 in Karnataka to 27 in Maharashtra (per 1000).(v) Social GroupsDuring the 42 nd Round, of the total hospitalised cases inrural areas, 4.75 percent were STs, 17 percent were SCsand 78 percent were others. In urban areas, STs constitutedless than two percent of hospitalised cases, SCs were18 percent and others were 80 percent.In the 52 nd Round, reporting of acute and any type ofailments is higher for SCs and STs in Orissa both in ruraland urban areas. In Karnataka, SCs have higher reportingof acute diseases in rural and urban areas. In MaharashtraSCs have higher reporting of ailments only in urban areas.Reporting of chronic ailments is also higher among STs inOrissa. Morbidity reporting (15 days) for chronic and anytype of ailments in the country is higher (except higherreporting of acute ailments for SCs) for other (general)groups. But, this is not uniformly found in all the states.In the 52 nd Round, the incidence of hospitalisation in ruralareas in all the three states and in the country is higher amongsocial groups other than SCs/STs, but this is not so in urbanareas where the incidence is higher among STs inKarnataka and Maharashtra and among SCs in Orissa. Thenumber of persons (per 1000) hospitalised is higher forSTs in urban India. The incidence of female hospitalisationis more among SCs/STs than males and females fromother social groups in rural and urban Maharashtra. Femalehospitalisation is lower than male hospitalisation inOrissa among all the social groups in both rural and urbanareas. In Karnataka, the incidence of female hospitalisationis higher in rural areas for STs and others.(vi) Fractile (MPCE) groupsThere is no particular pattern observed in the distributionof outpatients over the fractile groups in the 42 nd Round.Yet, the distribution in the 52 nd Round shows that there isincreased reporting of ailments among higher fractilegroups in the majority of states.In the 42 nd Round, the hospitalised cases were reported tobe more among lower middle-income groups and uppermiddle-income groups in the country, but in urban Orissa,hospitalisation was higher among the lower 20 percent offractile groups.In the 52 nd Round, the incidence of male and femalehospitalisation is highest for the top most fractile group11

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And Maharashtrai.e., the rich in all the three states and in the country. Thispattern is observed in rural as well as urban areas. Thispattern was not observed uniformly in the 42 nd Round.(vii) EducationThe 42 nd Round results showed that percentage distributionof hospitalised cases was higher among those with ahigher level of adult education. The proportion of personswith ailments being treated was positively associatedwith the level of adult education.6.2 Morbidity Reporting andSurrounding EnvironmentDuring the 52 nd Round survey, information was collectedon the use of insecticides in the premises of the houseand the reporting of fever (short duration incidence offever). The survey results indicate that sanitation and otheraspects have a marginal influence on health conditions. Inrural areas, incidence of fever (per 1000) from householdswith premises sprayed with insecticides was higher(by one episode of illness). It was higher by two illnessepisodes in urban areas. Reporting of fever cases is16 per 1000 in both rural and urban areas from householdswith cattle sheds, while it is one case more in ruralareas and one case less in urban areas in households, whichdid not have a cattle shed. Reporting of fever cases ishigher in urban households, which had a cattle shed,detached from the house (three cases more per 1000).Reporting is less in households having covered pucca drainsand in households with underground drains, both in ruraland urban areas. In houses without drainage, reportingof ailments is higher in both the areas. While the impactof the presence of a cattle shed in the house on healthconditions needs to be probed further, survey resultsindicate that clean air (free from insecticides spray) and agood drainage system do have a positive influence onhealth as a lower number of ailments are reported insuch households (see Annex, Table A-2).6.3 Tobacco Consumption andMorbidityWorldwide it is known that tobacco consumption leadsto the occurrence of diseases among its consumers, cancerbeing in the forefront. During the 52 nd Round, detailswere collected from tobacco consumers on their healthcondition.Prevalence of TB among persons aged 10 years and above,who do not have any bad habits, is 98 (per 1000) in ruralareas and 60 in urban areas. It is higher among those whosmoke with a prevalence rate of 120 (22% more than thosewho do not have any bad habits i.e., 98 per 1000 in rural)in rural areas and 124 (107% more than those who do nothave any bad habits i.e., 60 per 1000 in urban) in urbanareas. People who consume tobacco in ways other thansmoking have the highest prevalence rate of TB in rural(182) and in urban (202) areas. Prevalence of cancer is higheramong both rural and urban smokers and hypertension (inrural areas) is higher among rural smokers. Yet heart diseasesoccurred more frequently among those who do nothave any bad habits in rural areas and among those whohave other bad habits (tobacco use other than smoking) inurban areas. Hypertension is higher among those who donot have any bad habits in urban areas. We can thereforesay that in addition to tobacco consumption, other factorslike food, heredity, stress, life style, age etc., could influencemorbidity. Tobacco is one of the major factors causingmorbidity (see Annexure, Table A-3 and A-4).12

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And Maharashtrathat need to be attended, they are unable to do so, due toseveral other factors like non–availability of health carefacilities, higher cost of treatment, lack of faith, etc.The proportion of persons treated to total ailing personsis higher among higher income groups in all the three statesas well as in the country, except that it was higher for lowerfractile groups in urban Karnataka in the 42 nd Round andhigher for lower fractile groups in Maharashtra in the 52 ndRound. Bias towards the rich in medical treatment of illnessis higher in Orissa as revealed in both the 42 nd and52 nd Rounds.14

8Source ce of Treatment8.1 OutpatientsThe 42 nd survey results revealed that private doctors andhospitals treated 69 percent of the outpatients in rural andurban India and public facilities catered to 26 percent and28 percent of the outpatients in rural and urban areas respectively.In the north-eastern states, hilly states, union territoriesand in poor states like Orissa and Rajasthan, thepublic sector provided largely (>80%) for both outpatientand inpatient care during 1986-87. The topography andthe poverty in hilly and poor states could be the main reasonsfor the larger share of public hospitals as revealed inthe 42 nd Round. In Maharashtra, which is a well-devel-oped state only 21 percent and 24 percent of outpatientsin rural and urban areas had taken treatment in public facilities.In Karnataka, a medium developed state; the dependenceon public facilities was 35 percent and30 percent respectively for rural and urban areas. In Orissa,52 percent in rural areas and 46 percent in urban areasdepended on public facilities. The national average showedthat only five percent and one percent of outpatients inrural and urban areas visited PHCs during 1986-87. In1995-96, there was no major change in utilisation of PHCs.Table 4 shows that during 1995-96 there was a preferencefor the private sector.Table 4: Percentage distribution of non-hospitalized treatment by source of treatment in India from42 nd and 52 nd RoundsSource of treatment Rural Urban1986–87 1995–96 1986–87 1995–9642 nd Round 52 nd Round 42 nd Round 52 nd RoundPublic hospital 18 11 23 15PHC / CHC 5 6 1 1Public Dispensary 3 2 2 2ESI doctor 0 0 2 1All govt. sources 26 19 28 20Private hospital 15 12 16 16Nursing home 1 3 1 2Charitable institution 0 0 1 1Private doctor 53 55 52 55Others 5 10 3 7All non-govt. sources 74 81 72 80Total 100 100 100 100Note : The estimates of the 52nd round are based only on the treatments with reported source of treatment.Source: NSSO(1998), Morbidity and Treatment of Ailments, 52 nd round(1995-96), Report No.441, p.2215

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And MaharashtraTable 4 indicates that the coverage of PHCs in urban areasis limited. The utilisation of ESI hospitals, which providesubstantial hospital care particularly for industrial employees,is very low for outpatients. The utilisation of ESI doctorsfor outpatient care even in an industrial state likeMaharashtra is less than one percent (not shown inTable 4). The location of ESI hospitals in far off places,limited number of hospitals, etc., could be the reason forlower coverage. Data about ESI hospitals treating inpatientsis not available in NSS reports. ESI hospitals also providehospitalised care.Table 5 shows that there is a reduction in the dependenceon public facilities across the states. Yet, in Bihar, theutilisation of public facilities in urban areas increased from17 percent in the 42 nd Round to 33 percent in the 52 ndRound. This is not so in the rural areas of Bihar wherethere is a slight decline in dependency.The dependence on public facilities is very low in the highincomestates viz Punjab and Haryana and has declinedover the decade (1986-87 to 1995-96).8.2 InpatientsPeople use public facilities more frequently for ailmentsthat require hospitalisation. This is generally because treatmentis free or costs less in public hospitals as comparedto private hospitals and nursing homes. Table 6 shows thatduring the 42 nd Round, all India utilisation of public facilitiesfor hospitalised treatment was 60 percent for publichospitals and three to four percent for PHCs. Even in adeveloped state like Maharashtra (Table 7) 45 percent ofthe cases requiring hospitalisation were admitted to publichealth centres.Table 7 shows that in Orissa where more than 50 percentof the population live below poverty line (1986–87),16Table 5: State wise percentage of ailments receiving non-hospitalized treatment from governmentsources (public hospital, PHCs & public dispensary)State Rural Urban1986–87 1995–96 1986–87 1995–9642 nd Round 52 nd Round 42 nd Round 52 nd RoundAndhra Pradesh 12 22 16 19Assam 40 29 26 22Bihar 14 13 17 33Gujarat 28 25 18 22Haryana 15 13 19 11Karnataka 32 26 30 17Kerala 32 28 33 28Madhya Pradesh 24 23 28 19Maharashtra 21 16 15 17Orissa 37 38 43 34Punjab 12 7 11 6Rajasthan 46 36 52 41Tamil Nadu 28 25 31 28Uttar Pradesh * 8 14 9West Bengal 16 15 20 19India 21 19 24 20Note:1. The estimates of the 52nd round are based only on the treatments with reported source of treatment.2. * denotes that estimate is not available.Source: NSSO (1998),Morbidity and Treatment of Ailments, 52 nd round (1995-96), Report No.441, p.25

Source of TreatmentTable 6: Per 1000 distribution of hospitalized treatments by type of hospital in Indiaduring 1986–87 and 1995–96Type of hospital Rural Urban1986–87 1995–96 1986–87 1995–96(42 nd Round) (52 nd Round) (42 nd Round) (52 nd Round)Public Hospital 554 399 595 418PHC/CHC 43 48 8 9Public dispensary - 5 - 4All govt. sources 597 438 603 431Private hospital 320 419 296 410Nursing home 49 80 70 111Charitable institution 17 40 19 42Others 17 8 12 6All non-govt. sources 403 562 397 569All hospitals 1000 1000 1000 1000Source: NSSO (1998), Report No. 441(52 nd round), p.2888 percent and 81 percent of the inpatients respectively inrural and urban areas took treatment in public hospitals/PHCs.The 52 nd Round results show that the utilisation of publicfacilities for hospitalised care has declined to nearly 32percent in both, rural and urban areas, in Maharashtra. Thecurrent dependence on government hospitals is higher instates like Assam, Rajasthan, West Bengal, Orissa andMadhya Pradesh, both in rural and urban areas (1995-96).The use of public facilities for treatment requiringhospitalisation corresponds to the percentage share of bedsTable 7: Hospitalized treatments received from public providerState 42 nd Round 52 nd Round(percentage distribution) (percentage distribution)Rural Urban Rural UrbanAndhra Pradesh 29.91 37.98 22.5 36.2Assam 90.02 82.33 73.8 65.2Bihar 49.86 45.71 24.7 34.6Gujarat 48.96 59.21 32.1 36.9Haryana 50.96 55.31 30.5 37.3Karnataka 58.02 48.9 45.8 29.8Kerala 43.38 55.65 40.1 38.4Madhya Pradesh 79.23 76.98 53.3 56.0Maharashtra 43.57 46.23 31.2 31.8Orissa 88.06 81.48 90.6 81.0Punjab 47.49 48.77 39.4 27.6Rajasthan 80.01 85.62 64.9 73.1Tamil Nadu 56.15 58.04 41.1 35.7Uttar Pradesh 55.37 59.25 47.1 39.8West Bengal 91.62 73.9 82.0 72.1India 59.74 60.26 45.3 43.1Source: NSSO (1992), Sarvekshana (42 nd round, Vol. 15, No.4, p.53 and NSSO (1998),Report No. 441(52 nd round), p.29.17

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And Maharashtrain government hospitals in different states, which is higherin Madhya Pradesh, Orissa and Rajasthan (not shown inTable 7). The dependence on public facilities for hospitalisedtreatment is very low in Andhra Pradesh. The percentageof beds in government hospitals is also very low (10%) inAndhra Pradesh as compared to other states.Utilisation of Health Services byFractile Group of Monthly PerCapita Expenditure (MPCE) Class,Region, Gender, , Education andSocial Groups.Fractile Groups (MPCE): In the 52 nd Round, theutilisation of public health facilities for outpatient care, byall the fractile groups in rural areas, has declined over thedecade (1986-1987 to 1995-1996). The dependence of thepoor on primary health care centres has also declined inrural areas. This clearly indicates that people are seekingmore and more private services. The utilisation of publichealth facilities in urban India for outpatient treatment isonly 20 percent. In less developed states like Rajasthan,Madhya Pradesh, Bihar and Orissa also, 60 percent to 80percent of outpatients in urban areas depended on privateand other facilities.The results of the 42 nd Round revealed that the bottom20 percent of the fractile groups depended largely onpublic providers for inpatient services or hospitalisation.However, over the decade, dependence on public providershas declined. The percentage dependence on publicproviders varied from 32 percent to 63 percentamong different fractile groups in rural areas in the 52 ndRound while in urban areas, the dependence varied from26 percent to 68 percent. Except the lowest MPCE classin rural areas, there is a decline in dependence on publicproviders for hospitalised treatment with a rise in MPCEclass (NSS, Report No. 441, 1995-96). This indicates thatthere is need for continued supply of subsidised healthcare, particularly hospitalised treatment, for the poor.Social groups: In the 42 nd Round, of the total hospitalisedcases treated in public hospitals, STs constituted 5.48 percentand SCs constituted 20.19 percent in rural areas. Inurban areas, of those who sought treatment in governmenthospitals, STs were 1.73 percent and SCs were 17.85percent. Classification of hospitalised cases, as per socialgroups, under different sources of treatment in the 42 ndRound, revealed that SCs and STs depend more on publichospitals and PHCs as compared to other social groups(See Table 8).In the 52 nd Round, though the overall dependence on publichealth care institutions by all the social groups has comedown, tribal people and the SCs still depend more onpublic facilities as compared to private services.Table 8: Hospitalized cases as per social groups under different sourcesof treatment in IndiaSocial Groups Private hospitals PHCs Public hospitalsRural Urban Rural Urban Rural Urban42 nd RoundSC 3.38 1.75 10.17 3.11 5.48 1.73ST 12.29 10.18 20.56 29.83 20.19 17.85Others 84.12 87.78 69.26 66.76 74.09 80.1552 nd RoundSC 16.0 10.0 25.2 20.9 24.3 18.5ST 4.0 2.3 15.0 9.9 8.4 4.1Others 80.0 87.7 59.4 69.2 67.2 77.3Source: NSSO, Sarvekshana (1992-42 nd round) and Report No 441(1998-52 nd round, p.165-70)18

9Type ype of TreatmentThere is a general complaint by the public in both ruraland urban areas that government health services, whichare free and are mainly for the poor, are not free in reality(See Annex, Table A-6 & A-7). The survey results of the42 nd and 52 nd Rounds support this. In 1986-87, 91 percentand 92 percent of the hospitalised cases in the countryrespectively, in rural and urban areas, received free treatmentin government hospitals. In the 52 nd Round, free treatmentwas available only for 39 percent and 35 percent ofhospitalised cases in rural and urban areas respectively. InOrissa, while, 94 percent and 89 percent of the hospitalisedcases in rural and urban areas respectively had receivedfree treatment in 1986–87, only 83 percent (rural) and74 percent (urban) received free treatment according tothe 52 nd Round. In Maharashtra, free treatment is availableto only one-fourth of hospitalised cases. Earlier, i.e., in the42 nd Round, 91 percent of those in rural areas and89 percent in urban areas received free treatment in governmenthospitals. In Karnataka also, the proportion ofthose able to access free treatment has declined. It is availableto one-fourth of the urban patients and one-third ofrural patients. In 1985–86, in addition to government hospitalsand PHCs, hospitals run by public trusts also providedrelief to poor patients to a larger extent. This informationis not available for the 52 nd Round. Table 9 showsthat the percentage of free treatment has also declined inprivate sector hospitals.None of those hospitalised in the public sector in Orissa inthe 42 nd Round, paid for special treatment, either in ruralor in urban areas. In Maharashtra, those paying for specialtreatment were only from the bottom 10 percent and top10 percent of fractile groups in rural areas and from thetop 10 percent in urban areas. In the rural areas ofKarnataka, while higher income groups opted for specialtreatment, all the cases paying for special treatment in urbanareas were from the bottom 10 percent income group.During 1986-87, medicines, facilities of x-ray, electrocardiogram(ECG), electroencephalogram (EEG), other diagnostictests and physiotherapy and radiotherapy wereavailable to 83 percent of the outpatients in the country.Surgical operation facilities, for patients not treated asTable 9: Percentage distribution of hospitalized cases during last 365 days by type of ward ingovernment & private hospitalsStates Free Ward (42 nd Round) Free Ward (52 nd Round)Govt. Private Govt. OtherRural Urban Rural Urban Rural Urban Rural UrbanMaharashtra 91.32 88.95 8.68 11.06 27.30 25.10 1.40 3.50Karnataka 91.33 96.20 8.67 3.80 36.40 23.50 1.40 1.80Orissa 94.35 88.95 5.67 11.05 82.70 73.30 0.40 1.90All India 91.01 92.35 8.99 7.65 38.80 34.70 2.80 3.50Source: NSSO’s 42 nd round (1992) and 52 nd round(1998) A 66-67 & A 171-7219

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And Maharashtrainpatients, were available to only 53 percent of the outpatients.Details regarding these services are not available forthe 52 nd Round.In rural Orissa, where the majority of the inpatients dependon government hospitals, only 17 percent of the inpatientsin government hospitals had received free medicinesas indicated in the 42 nd Round survey results. InMaharashtra and Karnataka only 34 percent and 32 percentof the inpatients respectively, did not pay for medicines.For the other items of expenditure, the percentageof hospitalised cases receiving treatment on payment ingovernment hospitals is higher in Orissa. Though patientsin Orissa do not go for paid special treatment, the freeservices on which they largely depend are free on paperonly. Next to medicines, X–ray and ECG expenses are aburden on poor people, as most of the government hospitalsdo not have these facilities.In the urban areas of Orissa during 1986-87, there werefewer hospitalised cases that paid for treatment in governmenthospitals. In Karnataka, a higher percentage of inpatientsin government hospitals in urban areas incurred expenditureon all types of diagnostic tests, physiotherapyand radiotherapy and on surgical operations as comparedto the other two states. For all types of expenditure categories,payment for treatment cases were comparativelylower in Maharashtra in urban and rural government hospitals.In private urban hospitals, four percent of inpatientshad received free medicines and up to two percenthad received other facilities free of cost in the countryduring 1986–87.20

10How Much Do People Spendon Treatment?10.1 InpatientsThe World Development Report (1993) revealed that outof-pocketspending for drugs, traditional medicine and userfees usually accounts for more than half of the total spendingfor health in India. Based on this one can argue thatwhen people are currently spending more than half thetotal expenditure from their pocket for free (public), butpoor quality health service, then it would be better to payfor private, better quality services.Yet, the fact that the majority of the poor still use publicfacilities particularly for hospitalisation reflects the need forthe continued provision of public services. Even if theybear half of the expenditure themselves, the other halfthat is saved reduces the burden on the family.Table 10: Average total expenditure perhospitalization by type of hospitalin India from 52 nd Round (Rs.)Type of hospital Rural UrbanPublic hospital 2245 2191PHC / CHC 740 2461Public dispensary 1887 1977Public sector hospital 2080 2195Private hospital 4394 5524Nursing home 4185 5749Charitable institution 3808 3078Other 3015 1630Private sector hospital 4300 5344Any hospital 3202 3921Source: NSSO (1998) , Report No. 441( 52 nd round), p.28The cost of hospitalised treatment generally includes expenseson medicines, pathological and diagnostic tests likeX-rays, ECG, EEG, physiotherapy/radiotherapy, chargesfor an ambulance, bed charges, cost of oxygen and blood,surgery and consultation charges.As shown in Table 10, average total expenditure perhospitalised case varies from Rs. 2,080 in public hospitalsto Rs. 4,300 in private sector hospitals in rural areas. Inurban areas, the variation is from Rs. 2,195 to Rs. 5,344 forpublic and private sector hospitals, respectively. There isno wide difference between inpatient care for rural andurban patients in public hospitals, but urban patients pay ahigher price for hospitalisation in private hospitals.As shown in Chart 1, there has been no substantial changein the average cost of hospitalisation in rural Orissa overthe decade. In fact there is a slight decline in thehospitalisation cost, but, hospitalisation costs in urban Orissahave increased by 112 percent and the increase is higher inprivate hospitals. One possibility could be that in Orissa,99 percent of the patients who seek treatment in governmenthospitals go for free treatment. While they still payfor medicines and other expenses there are no service andrental charges. In the private sector the expenditure is higher.The quality of services in public hospitals is, however nocompetition for the private sector. Among the three specifiedstates, total expenditure was higher in Maharashtra andlower in Orissa (Table 11). This is not so if private andpublic hospital costs are considered separately. Of the21

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And MaharashtraChart 1: Cost of IP treatment - Average total expenditure per illness(in constant prices)1400.001200.001000.00800.00600.00400.00200.000.00Rural Urban Rural Urban42 nd Round 52 nd RoundMaharashtra Karnataka Orissa All IndiaTable 11: Average total expenditure per hospitalization by type of hospital for rural and urban areas(in constant prices with base year 1980-81)(Rs.)State 42 nd Round (1986-87) 52 nd Round (1995-96)Rural Urban Rural UrbanGovt. Other All Govt. Other Allhospitals hospitals hospitals hospitalsKarnataka 576.67 772.46 489.34 1120.00 818.85 427.00 1230.05 981.69(919) (1231) (1791) (4100) (2997) (1564) (4502) (3593)Maharashtra 634.65 1065.44 449.7 1128.23 908.52 423.23 1572.00 1175.58(951) (1597) (1529) (3836) (3089) (1439) (5345) (3997)Orissa 461.36 475.35 440.05 676.17 429.58 560.73 3096.59 1012.56(744) (767) (1681) (2583) (1641) (2142) (11829) (3868)India 536.62 743.99 571.43 1181.32 879.67 603.02 1398.95 1077.30(853) (1183) (2080) (4300) (3202) (2195) (5344) (3921)Source: (i) NSSO (1992 & 1998), Report No. 364 (42 nd round) and Report No. 441( 52 nd round), p.28(ii) Constant prices using deflator –Handbook of Statistics on Indian Economy, RBI, 1999Note: Figures in parenthesis are current prices.15 major states, the expenditure was lowest in Kerala andhighest in Punjab in the rural areas. In urban areas alsohospitalisation expenses were lower in Kerala and higherin Uttar Pradesh.Poor people in a backward state like Orissa are vulnerableto increased costs of treatment, which are higher in publichospitals in rural and urban areas and in private hospitals inrural areas as compared to the corresponding costs inKarnataka and Maharashtra, but the costs in urban privatehospitals are lower in Orissa in comparison with Karnatakaand Maharashtra.Among the three states, in the 42 nd Round, in rural areas,average expenditure (per day) per hospitalised case underthe free category of treatment in government hospitals washighest at Rs.40 in Orissa as compared to Rs.24 inMaharashtra and Karnataka. In urban government hospitals,inpatients in Orissa had to spend on an average Rs. 40for free category of treatment and Rs.115 in the generalcategory. In urban Maharashtra, patients from middle andupper middle-income groups used special category servicesin public hospitals and spent on an average Rs. 143per day per case. Per day expenditure in rural private22

How Much Do People Spend on Treatment?hospitals varied from Rs. 40 in the free category inKarnataka to Rs. 205 in free category services (wards) inOrissa. In a developed state like Maharashtra, per dayexpenses in the free category of treatment in private ruralhospitals was Rs. 86, which is less than that in Orissa (formore details see Tables 6.1-6.18 in NSSO 42 nd Round).Details of state wise expenditure for the 52 nd Round forthe three selected states reveal that hospitalisation is costlierin government and private hospitals in rural Karnataka.Treatment costs in government hospitals are lower in ruraland urban Maharashtra. In urban areas, hospitalisation iscostlier in Orissa, both in government and private hospitals.Average expenditure on hospitalised cases is lower ingovernment hospitals in urban Maharashtra. Expenditureis relatively lower in private hospitals in urban Karnatakaas compared to Maharashtra and Orissa. In rural areas,cost per hospitalisation in government hospitals is least inTamil Nadu (Rs. 751) and highest in Uttar Pradesh(Rs. 4,237). In other hospitals, the cost is highest in AndhraPradesh (Rs. 7,822) and least in Assam (Rs. 2,003). In urbanareas, the cost varies from Rs. 934 in Tamil Nadu toRs. 8,888 in Haryana for government hospitals and fromRs. 2,254 in Kerala to Rs. 11,829 in Orissa for private hospitals(See NSS Report No.441, pp. A-93-94 and A-198-199).Though the average expenditure is higher for higher incomegroups, it is not uniform and regular for all the states.There is variation in average expenditure when the bottomand top 10 percent fractile groups are taken into consideration.The 52 nd Round results revealed that average totalexpenditure per hospitalised case varied from Rs. 961 toRs. 5,126 (1:5) and from Rs. 1,176 to Rs. 7,619 (1:6) respectivelyfor public and private hospitals and for the bottom10 percent and top 10 percent of fractile incomegroups in rural areas. In urban areas, the average total expenditurevaried from Rs. 497 to Rs. 8,104 (1:16) andfrom Rs. 1,186 to Rs. 12,957 (1:11) respectively for publicand private hospitals and for the bottom 10 percent andtop 10 percent of fractile income groups. In rural areas,the poor spent more on treatment in public hospitals comparedto their counterparts in urban areas. For hospitalisedtreatment, the rich spent nearly five times more than thepoorest in rural areas and more than ten times in urbanareas. There is no major difference between rural and urbanareas in the average expenditure incurred by the pooreston hospitalised cases in private hospitals. The averageexpenditure on hospitalisation was found to be generallylower for STs as compared to SCs and others in publichospitals in urban areas and private hospitals in rural areas.10.2 OutpatientsAmong the three specified states (shown in Table 12-A),the cost of treatment for outpatients (OP) was lower inrural Karnataka and urban Orissa during the 52 nd Round.Average expenditure per ailment varied from Rs. 91 inKarnataka to Rs. 144 in Maharashtra in rural areas and fromRs. 117 in Orissa to Rs. 170 in Maharashtra in urban areas.Expenditure incurred on treating female outpatients wasless than that incurred on treating male patients in rural andurban areas in Karnataka and Maharashtra, while it washigher for females in Orissa.Table 12–A: Average medical and other related non-medical expenditure per treated ailment during15 days by source of treatment and per capita public expenditure onhealth - Outpatient (OP) from 52 nd Round (in current prices)(Rs.)State Medical expenditure by source Total expenditure by sourcePer capitaof treatmentof treatmentpublic exp.on health Rural Urban Rural UrbanGovt. Other All Govt. Other All Govt. Other All Govt. Other AllKarnataka 54 61 127 108 120 160 151 70 142 122 136 184 172Maharashtra 78 73 161 147 91 175 163 90 179 165 125 195 185Orissa 47 118 151 137 128 127 128 129 158 147 143 133 136India 70 110 168 157 146 185 178 129 186 176 166 200 194Source: NSSO (1998), Report No. 441(52 nd Round)23

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And MaharashtraTable 12-B: Cost of OP treatment - Average total expenditure per illness(in constant* prices with base year 1980-81)States 42 nd Round 52 nd RoundRural Urban Rural UrbanMaharashtra 60.12 76.66 42.32 49.97Karnataka 31.57 44.89 33.33 46.99Orissa 44.39 41.54 25.94 30.65All India 62.79 61.23 39.56 48.08Source: NSSO (1992 & 1998), Report No. 364 (42 nd round) and Report No. 441( 52 nd round)Note: * Using deflator- Handbook of Statistics on Indian Economy, RBI, 1999.(Rs.)Chart 2: Cost of OP treatment - Average total expenditure per illness(in constant prices)(Rs.)90.0080.0070.0060.0050.0040.0030.0020.0010.000.00RuralUrban Rural Urban42 nd Round 52 nd RoundMaharashtra Karnataka Orissa All IndiaTotal average expenditure on outpatient treatment (1995-96) was Rs. 176 (Rs. 40 in constant prices) in rural areasand Rs. 194 (Rs. 48 in constant prices) in urban areas.Average outpatient expenditure was least for Tamil Naduin rural areas and for Kerala in urban areas and highest inUttar Pradesh and in Madhya Pradesh in urban areas (seeTables 13-A and 13-B). The cost of treatment was higherfor the middle aged in rural and in urban areas. On thewhole, there was an increase in average expenditure correspondingto an increase in age. The comparison ofexpenditure between the two rounds of the NSS revealedthat the outpatient cost had not risen in real terms (seeTable12-B and Chart 2). The reforms process had nomajor effect on the cost of non-hospitalised treatmenti.e., primary health care. Increase in the number of doctors,transport facilities, services of doctors trained inayurveda and homoeopathy at lower costs, availability ofcheaper medicines, etc., may be the reasons for the stabilityin the cost of outpatient treatment.World Bank estimates of total health expenditure in India(1990-91) reveal that per capita expenditure on health bythe public sector was Rs. 68.8 (21.5%) and that by the privatesector was Rs. 250.5 (78.5%). Of the total privateexpenditure, 75 percent is reported to be out-of-pocketexpenditure incurred by households (Berman Peter, 1998).24

How Much Do People Spend on Treatment?Table 13- A: Average total expenditure* for hospitalized and non-hospitalized treatment for eachState/U.T. in India (in constant prices** with base year 1980-81)(in Rs.)State / U.T Hospitalized Treatment Non-hospitalized TreatmentRural Urban Rural Urban42 nd 52 nd 42 nd 52 nd 42 nd 52 nd 42 nd 52 ndRound Round Round Round Round Round Round Round1986-87 1995-96 1986-87 1995-96 1986-87 1995-96 1986-87 1995-96Andhra Pradesh 460.11 1668.32 549.79 1268.11 45.99 30.11 39.14 37.11Arunachal Pradesh. - - - - - 159.15 - 71.13Assam 287.05 480.52 586.33 936.34 105.24 20.51 89.86 27.18Bihar 720.61 1074.34 713.37 1036.49 123.90 61.23 61.13 48.99Goa*** 343.26 - 937.97 - 104.45 63.50 68.67 39.65Gujarat 503.19 725.20 706.17 906.03 52.47 39.21 57.66 57.46Haryana 919.26 873.88 548.36 1771.87 46.67 49.60 49.13 108.96Himachal Pradesh 601.62 - 661.81 - 90.54 27.91 81.35 41.15Jammu & Kashmir 397.46 - 384.30 - 61.72 67.14 59.07 51.46Karnataka 576.67 819.22 772.46 982.14 31.57 24.87 44.89 42.37Kerala 251.89 560.25 264.43 470.82 21.52 29.08 28.53 26.39Madhya Pradesh 452.10 599.47 429.39 758.98 103.82 35.30 67.16 96.04Maharashtra 634.65 907.92 1065.44 1174.80 60.12 42.32 76.66 49.97Manipur 421.73 - 693.42 - 80.23 101.17 122.09 55.92Meghalaya 316.22 - 337.59 - 29.19 7.35 61.48 19.05Mizoram - - - - - - - -Nagaland - - 383.31 - - - 123.61 -Orissa 461.36 429.92 475.35 1013.36 44.39 25.94 41.54 30.65Punjab 936.96 1297.58 1069.17 1485.92 61.03 45.00 56.65 40.32Rajasthan 698.53 871.26 501.72 903.09 73.27 49.33 83.21 50.47Sikkim 294.90 - 469.17 - 336.30 - 242.45 -Tamil Nadu 416.30 783.45 628.22 1085.25 31.05 21.79 33.97 32.28Tripura 206.82 - 143.11 - 25.92 22.82 40.70 53.52Uttar Pradesh 803.56 1225.33 1184.03 1661.20 93.53 56.91 103.21 59.73West Bengal 310.92 603.81 804.90 992.57 37.95 32.40 57.20 38.26A. & N. Islands 79.12 - 976.44 0.00 26.53 7.55 21.91 15.11Chandigarh - - - - - - - -Dadra & N. Haveli - - - - - - - -Daman & Diu - - - - - - - -Delhi 1364.60 0.00 1055.74 0.00 251.55 41.91 86.32 51.93Lakshadweep - - - - - - - -Pondicherry 211.41 0.00 272.96 0.00 17.87 2.83 165.63 11.56All India 536.62 879.67 743.99 1077.20 62.79 39.56 61.23 48.08Source: NSSO (1992 &1998), Sarvekshana-42 nd round (1986-87), 51st issue, Vol. .XII, No. 4; Morbidity and Treatment of Ailments, 52 nd round (1995-96).ReportNo.441.Note: * Average total expenditure= medical expd plus other expd= (medicines, bandages, plaster, fees, diagnostic tests, ambulance, oxygen, blood) ( transport, lodging,attendant charges)** Using deflator –Handbook of Statistics on Indian Economy, RBI, 1999*** Includes Daman and Diu25

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And Maharashtra26Table 13-B: Average total expenditure* for hospitalized and non-hospitalized treatment for eachState/U.T. (in current prices)(in Rs.)State / U.T Hospitalized Treatment Non-hospitalized TreatmentRural Urban Rural Urban42 nd 52 nd 42 nd 52 nd 42 nd 52 nd*** 42 nd 52 nd***Round Round Round Round Round Round Round Round1986-87 1995-96 1986-87 1995-96 1986-87 1995-96 1986-87 1995-96Andhra Pradesh 753.81 6428 900.73 4886 75.34 116 -165 64.12 143-172Arunachal Pradesh. - - - - - 490 - 219Assam 499.75 1945 1020.79 3790 183.22 83-151 156.45 110-180Bihar 1141.87 3860 1130.4 3724 196.33 220-213 96.86 176-212Goa** 589.56 - 1610.98 - 179.39 197 117.94 123Gujarat 809.14 2663 1135.54 3327 84.38 144-157 92.72 211-218Haryana 1336.05 3224 796.98 6537 67.83 183-189 71.41 402-414Himachal Pradesh 919.29 - 1011.26 - 138.35 97 124.31 143Jammu & Kashmir 681.27 - 658.71 - 105.79 214 101.25 164Karnataka 918.68 2997 1230.59 3593 50.29 91-122 71.52 155-172Kerala 463.91 2293 487.02 1927 39.63 119-136 52.55 108-120Madhya Pradesh 723.16 2191 686.84 2774 166.07 129-155 107.43 351-376Maharashtra 951.23 3089 1596.9 3997 90.11 144-165 114.90 170-185Manipur 688.35 - 1131.8 - 130.95 351 199.27 194Meghalaya 559.91 - 597.76 - 51.69 32 108.86 83Mizoram 144.5 - 191.2 - 48.01 37 196.30 86Nagaland - - 600.75 - - 270 193.73 790Orissa 744.09 1641 766.65 3868 71.60 99-147 66.99 117-136Punjab 1402.01 4988 1599.84 5712 91.32 173-175 84.76 155-162Rajasthan 1024.88 3038 736.12 3149 107.50 172-192 122.09 176-198Sikkim 450.64 - 716.94 - 513.90 63 370.49 252Tamil Nadu 684.37 2840 1032.76 3934 51.05 79-102 55.84 117-129Tripura 351.67 - 243.34 - 44.07 55 69.21 129Uttar Pradesh 1236.11 4349 1821.39 5896 143.88 202-224 158.77 212-227West Bengal 488.02 1957 1263.35 3217 59.57 105-131 89.78 124-137A. & N.Islands 131.86 - 1627.41 44.21 25 36.51 50Chandigarh 282.44 1309.06 33.88 36 89.02 200Dadra & Nagar Haveli 404.06 - 44.70 85 - 112Daman & Diu - - - 73 - 114Delhi 2053.46 1588.68 378.53 138 129.90 171Lakshadweep 1973.01 1055.33 114.60 56 102.20 5Pondicherry 340.55 439.7 28.78 11 266.81 45All India 853.23 3202 1182.95 3921 99.84 144-176 97.35 175-194Source: NSSO (1992 &1998), Sarvekshana-42nd round (1986-87), 51st issue, Vol.XII, No. 4; Morbidity and Treatment of Ailments, 52 nd round (1995-96).ReportNo.441.Note: * Average total expenditure- medical expd plus other expd = (medicines, bandages, plaster, fees, diagnostic tests, ambulance, oxygen, blood) ( transport, lodging,attendant charges)** Includes Daman and Diu*** The variation in average expenditure (i.e. the ranges shown for non-hospitalized treatment in 52 nd round is due to separate estimates presented in the report(Table 4.19 and Table 22.1) gender wise and state wise.

11Loss of Household Income Due to Illness(Outpatient)As per the 52 nd Round survey results, due to illness, householdshad to forego, an average amount of Rs. 55 in ruralareas and Rs. 44 in urban areas per non-hospitalised illnessepisode. This almost amounts to a loss of one day’s wageon account of occurrence of an illness. In rural areas, theburden of illness in terms of loss of household incomewas higher in Arunachal Pradesh, Haryana and Manipurand lower in Assam, Goa, Mizoram, Delhi, Pondicherryand Daman and Diu.The loss of income in rural areas varied from Rs. 2 inDaman and Diu to Rs. 185 in Arunachal Pradesh.In urban areas, the average loss of income was higher inArunachal Pradesh, Haryana, Nagaland, Rajasthan andChandigarh and lower in Delhi, Tripura, Goa andMeghalaya. The loss of income in urban areas varied fromRs. 2 in Mizoram to Rs. 191 in Arunachal Pradesh. Of thethree specified states, the burden of outpatient treatmentwas higher in Karnataka both in rural (Rs. 72) and urban(Rs. 54) areas (See Table 14).Average loss of household income per hospitalised casewas roughly Rs. 270 (Rs. 273-urban) for the bottom 10percent mpce class and Rs. 937 for the top 10 percentmpce class in rural and urban areas. The average loss for allthe mpce groups was Rs. 563 in rural areas and Rs. 521 inurban areas. The loss of income due to hospitalisation forthe bottom 10 percent group is higher in urban Orissa ascompared to Maharashtra and Karnataka and higher inrural Karnataka as compared to Orissa and Karnataka. Onan average the burden of hospitalisation was higher in ruralKarnataka and urban Maharashtra.Table 14: Loss of Household income per ailment (52 nd Round)(in Rs.)States Outpatient InpatientRural Urban Bottom 10% mpce Top 10% mpce AllRural Urban Rural Urban Rural UrbanMaharashtra 55 35 188 383 1113 706 587 534Karnataka 72 54 260 203 1326 741 798 518Orissa 70 35 101 418 811 680 402 450All India 55 44 270 273 937 923 563 521Source: NSSO (1998), Morbidity and Treatment of Ailments, 52 nd round (1995-96).Report No.441.27

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And Maharashtra12Messages from NSS in the Light ofOngoing Economic ReformsIt is difficult to determine whether development leads togrowth or growth facilitates development. Both arecomplementary. Similarly, there are many developments inthe economy over the last decade, which have had both apositive and negative impact on different sectors independentof economic reforms. The technological developmentin the health sector has facilitated detection of diseases,conducting of complicated surgeries, increased comfortsin the post-surgery period, introduced new drugs andenabled dissemination of latest health information. On theother hand it has led to over use of diagnostic tests, increasein hospital waste, female foeticide and increase inthe cost of hospitalised health care. Technological developmentis an outcome of the growth process and,liberalisation or economic policies act as facilitators foravailing it.Yet, changes like increasing privatisation, the changing roleof the public sector in the provision of health care, drugproduction and sale due to WTO / TRIPS are some ofthe developments which are induced by liberalisation.12.1 Private v/s PublicThe private sector has been playing a predominant role inthe provision of health care for many years, but there is anincrease in the share of the private sector in many fieldsincluding health. The liberalisation policies under the eco-nomic reforms favour the operation of market forces inall the fields including the social sector. Yet, it is doubtfulwhether the model premised upon competitive chargesand cost containment would operate effectively in the distributionof social goods such as health (Sen, 2001).Private health services are urban biased, cater to the betteroff and provide costlier services (Baru, 1999; IIM, 1987;Bhat, 1999) whereas, public health facilities cater to the poor,rural and disadvantaged sections and are cheaper (Prabhu,1999; IIM, 1987). The growth of the private sector hasbeen linked to the new economic policy, influx of medicaltechnology, growing deficits of the public sector hospitalsand the rising middle class. In a study undertaken inAhmedabad, 91 percent of the providers surveyed believedthat the cost and use of diagnosis have increaseddue to the Consumers Protection Act (Bhat, 1999). Whilegovernment initiatives in health care partnership have failedin large-scale ventures in Delhi, Punjab and Rajasthan, smallerventures involving NGOs in running PHCs in Gujarat (SelfEmployed Women’s Association) and Tamil Nadu (Bhat,1999) have proved to be successful. The Karnataka governmenthas also initiated the involvement of NGOs inrunning PHCs.Studies have shown that there is a strong positive relationshipbetween per capita health spending and per capitaGDP (New house, 1977) 1 . A few others like Lew (1986) 21As cited in Hitiris Theo and John Posnett (1992), Journal of Health Economics, Vol. II, pp.173-181, 19922Ibid28

Messages from NSS in the Light of Ongoing Economic Reformshave reported that the share of public expenditure in totalhealth spending and the presence of a centralised nationalhealth system influence health care spending. Both the studiesquoted above support the argument that health care expendituredepends on the resource position of the statesand the quantum of government share in total health expenditure.Poor states need continued financial support toinvest in merit goods like health. In such a situation, if thestates get central assistance for health on matching grantbasis then poor states, which are unable to spend more,would suffer.NSS results and other studies (IIM, 1987; NCAER, 1992;Baru, 1999) reveal that a substantial section of the population,particularly the poor and the underprivileged, dependon public hospitals for hospitalised care. An IIM studyrevealed that government hospitals served the poor andprivate hospitals served the better off. Middle class peopleused government hospitals mainly to avail of diagnosticand surgical facilities, which they could not avail privately.Medical college hospitals had multiple roles of super-specialtyand emergency care for serious patients, legal casesand the poor.12.2 Drugs and the PoorDrug prices were said to be high in India at the time ofIndependence. The establishment of two public sector unitsin the early 1970s led to a 60 to 70 percent decline in theprices of antibiotics (Sen, 1999) during that period. Evenafter that, the dependence on foreign drug industries andimports to meet the domestic demand continued. The IndianPatent Act 1970, which recognises process patents,stimulated domestic production of bulk drugs and formulations.Process patent has enabled domestic industriesto make process modifications to develop bulk drugs andtheir formulations, but there is need for regulation of thedrug industry and drug prices in India. A large number ofsmall-scale units have been set up and a large number ofbrands reported to be irrational and unnecessary are producedon a wide scale. Though, in general, the drug pricesare cheaper in India, some of the drug prices, particularlythe prices of antibiotics, are higher and are reported to bebeyond the reach of the common man. It is reported thatthe amount spent annually by the drug industry inindustrialised countries on each doctor, for the sale of theirproducts varies from US $ 2,665 in Canada to $ 8,000 inUK and USA (Chauhan et al, 1997). With the entry ofmultinationals, advertising costs have also increasedin India.WDR (1993) reports that developing countries should reducethe waste and inefficiency in drug management. Bulkpurchase, selection and quantification of drug requirements,in part through the use of essential drug lists, are some ofthe measures advocated as 10 to 30 percent of publicspending for health, comprises of pharmaceuticals in mostof these countries.Under the liberalisation policy of the government, it is arguedthat prices should be left to self-regulation by marketforces. The reduction in the number of drugs under pricecontrol in the New Drug Policy, 2002 is one measure, whichsupports this argument. Our earlier experience with theDPCO reveals that if more drugs are out of the DPCO,then generally there is an increase in the price of these drugsand also increased production of non-essential drugs. TheDPCO helps in putting a ceiling on prices of certain massusage bulk drugs and their formulations and prevents undueprofit earning. The availability, accessibility and the costof essential drugs depends upon the drug policy that isadopted by the country. The criteria of categorisation ofdrugs by the DPCO in India are generally based on monopolyand turnover rather than on what is essential. Thenumber of drugs under the DPCO declined from 450 to347 in 1975, from 347 to 142 in 1986, from 142 to 73 in1994 and, from 73 to 39 in 2002. The coverage of controlhas come down to 20 percent to 25 percent from 50 percentto 60 percent. The earlier developments in the pharmaceuticalindustry encouraged the growth of the industry.Exports went up and a large number of small-scaleunits were set up, but due to a hike in the Maximum AllowablePost Manufacturing Expenses (MAPE) in 1986,consumers were affected.At present drugs prices in India are said to be comparativelylow. With product patent, prices would definitely29

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And Maharashtrago up. NSS results indicate that free medicines at publichospitals are available to a limited percentage of the sickpopulation. Patients are spending more money on medicinesand will have to spend even more in the future, asnew drugs would be available at higher prices.12.3 Primary vs. Secondary/Terertiartiary careMany studies and reports emphasise the importance ofthe provision of primary health care as the basis for improvinghealth status. Countries like Sri Lanka, China andthe state of Kerala in India have achieved low morbidityand mortality rates in spite of their relatively low per capitaincomes, due to the expansion of primary health care services.Shariff and others (1999) argue that the majority ofthe health problems faced by people in India can be avoidedthrough essential public health investments, cost-effectiveintervention, and improvement in the efficiency of publichealth services focusing on primary health care.The IIM (1987) study revealed that there is underutilisationof public facilities in rural areas whereas the load of patientsat the district level and specialised hospitals is high.This indicates that services available in rural areas are ofpoor quality, inadequate, inefficient and people depend onpublic tertiary care. Therefore, the government should firstimprove primary health care facilities before involving theprivate sector in tertiary care.The WDR (1993) has aroused much debate over the issuesof primary and tertiary care. World Bank advocatesa cut in government expenditure for tertiary care, encouragementto the private sector for clinical services, investmentin cost effective public health activities and communitycontrol and financing of essential health care. NationalHealth Policy-2002 incorporates many of these recommendations.But, in the light of NSS results on the utilisation of healthcare services and treatment seeking behaviour, there is needto address the issues of equity, affordability and sustenancein designing and formulating policies on health careprovisioning.12.4 Availability and AccessibilityUtilisation of health care services is determined to a largeextent not just by their availability, but also by their accessibility.Mere provision of health institutions may not leadto improvement in public health. People need to utilisethem when there is need so as to improve their healthstatus. NCAER (1992) reveals that in rural areas, peoplehave to travel a long distance to avail medical facilities ascompared to urban households. States like Maharashtraand Punjab have a good record on health status and awell-distributed public health system. West Bengal, Gujarat,Karnataka and Tamil Nadu are below these states, butbetter than Andhra Pradesh, Madhya Pradesh, UttarPradesh, Bihar, Rajasthan and Orissa. This indicates thatgenerally economic development of a state is linked toits health status (except for Kerala) and availability ofpublic facilities.Tamil Nadu has a higher number of PHCs per 100 sqkilometres as compared to Maharashtra. Yet, according toa study in Tamil Nadu, 36 percent of the patients had totravel three to five kilometres and 30 percent had to travelsix to ten kilometres to get treatment. In Tamil Nadu thereis higher reliance on private facilities (>50%). In Maharashtraless than 50 percent illness episodes were referred to privatedoctors (Prabhu, 1999).The 42 nd and 52 nd Rounds reveal that public primary healthcare facilities (i.e., PHCs/SCs) are not utilised properly bythe people. Longer waiting periods, arrogant behaviour,non-availability of medicines, irregular visits by doctor, notresponding to community health needs, are the reasonsstated for non-utilisation of PHCs/SCs (Chirumule andAnuradha, 1997; Prabhu, 1999; NIHFW, 1983; NIHFW,1989; IIM, 1987). People opt for home remedies only whenthere is non-availability of either private or public servicesand also due to poverty, which restricts the use of paidservices (Chirumule and Anuradha, 1997 - Rajasthan Study).The NIHFW (1983) study on utilisation of health servicesin Madhya Pradesh revealed that as many as50 percent of the people who died of various causes didnot get medical attention on time. The incidence would be30

Messages from NSS in the light of Ongoing Economic Reformsmore in rural areas, where emergency treatment or timelytransport is not available.NSS results indicate that primary health care services arenot available regularly and uniformly. The percentage ofpeople not seeking treatment due to non-availability ofservices has increased during the 42 nd to 52 nd Round.12.5 Decentralisation/CommunityInvolvement in Health CareDeliveryThe empowerment of the Panchayat Raj bodies under the73 rd Amendment to the Constitution has strengthenedpanchayats with greater devolution of power, finances andfunctions. Health and education are functions listed underpanchayats, but the involvement of panchayats in healthand education is nominal and it is only at the district level.Village panchayats till today do not perform any majorprogramme under health and education. Provision ofhealth services is limited to water supply and sanitation.Kerala is an exception to this wherein, panchayats are involvedin the planning of services at the local level and40 percent of the district funds are allocated to panchayatprogrammes.Due to resource constraints, technological development,emergence of new communicable and non-communicablediseases and the growth of population, government isunable to allocate sufficient resources to the health sector.Economic reforms leading to liberalisation have openedthe way for privatisation, but, complete privatisation ofbasic services like health and education is not feasible, as itwill not assure equitable distribution of primary health servicesand it may also prevent the poor from gettingsubsidised inpatient care in hospitals.12.6 National Health Policy (NHP),2002: Are We Moving in the RightDirection?Before discussing the NHP-2002, it would be worthwhileto see what happened after NHP-1983. The main focusof NHP-1983 was on achieving health for all by 2000AD, but targets could not be achieved due to the lack ofresources, co-ordination and fulfilment of equity aspects.The poor states viz. Rajasthan, Madhya Pradesh, Bihar,Orissa and Uttar Pradesh are rated to be low performingstates in terms of health status (2000). IMR, MMR, percentageof under-weight children, leprosy and malaria casescontinue to be high in these states. Nutrition was one ofthe priority areas in NHP-1983. However, undernourishmentcontinues to be high in the poor states indicating thatthe provisions of the policy were not seriously adhered to.These states are largely depending on public facilities. Thisindicates that health services are inadequate in poor states.And, the focus on the creation of sub-centres (SCs) andPHCs as a part of NHP-1983, without ensuring the qualityof the infrastructure and availability of staff has resultedin non-utilisation of PHCs to a large extent as revealedin 52 nd Round results.NHP-2002 refers to the use of the services of practitionersin Indian systems of medicine who have undergoneformal training in implementation of public health policy.NSS 52 nd Round results indicate that dependence on ayurvedaand homoeopathy is negligible. This is because these graduateswho have training in other systems, practice allopathyand meet the emergency requirement of people in ruralareas. This has not reduced the demand for trained medicalgraduates in allopathy in rural areas. Ayurveda andhomoeopathy, which are gaining importance in urban areas,are not popular in rural areas.The present policy of promoting indigenous/alternatemedicines would benefit only the rich and urban areas,unless awareness and a suitable atmosphere for cheaperproduction of ayurvedic drugs and legal framework for itspractice on a large scale are created.Since health is a state subject, the responsibility for provisionof health care services falls on state governments, butdue to resource constraints, the share of the health sectorin the state budget is declining. Resource constraints andincreasing population call for alternative arrangements forhealth care provision.31

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And MaharashtraThe emphasis in NHP-2002 is on the implementation ofpublic health programmes through local self-governmentand autonomous institutions. Without control over primaryhealth care and the concerned staff it may be difficult forthese institutes to monitor and implement only the publichealth programmes in isolation.NHP-2002 refers to the setting up of urban primary healthcentres for every one lakh population with local, state andcentral assistance. The existing municipal hospitals, whichare already in the worst condition due to lack of funds,need to be strengthened and activated rather than establishingnew primary health centres in urban areas. Secondaryand tertiary care may be transferred to taluk and districthospitals respectively, to avoid duplication and loss ofresources. Moreover, the private sector is effectively cateringto primary health care in urban areas.Considering the increase in accident cases, NHP-2002emphasises the establishment of trauma centres at differentplaces. It should be noted that the existing accidentunits at civil hospitals are not well equipped to handleserious cases and refer them to medical college hospitals.By the time the patient is shifted, he is dead . Therefore, itis necessary that government plans to strengthen the unitsat civil/district hospitals.The strategy to focus on new therapeutic drugs and vaccinesfor tropical diseases is a welcome feature in the lightof emergence of malaria and the continued prevalence ofTB, which is resistant to the existing drugs and vaccines.Equity is treated as a major goal in NHP-2002, but thepolicy’s emphasis is on shifting the secondary and tertiarycare to the private sector. NSS results indicate that the poorand SCs/STs depend largely on public facilities as comparedto others. IMR and MMR are high in the poor states.IMR, under five (age) mortality and percentage of underweightchildren is higher among SCs and STs. Health insuranceschemes like ‘Janarogya Policy’ and ‘JanarakshaPolicy’ are heard only during the presentation of the budget.The common man or the poor, whom these subsidisedhealth insurance programmes target (but who are rarelycovered) are unaware of these policies.32

13Summary y and Insights forPolicy InitiativesA summary of the findings from a comparative study ofthree Rounds of NSS (28 th , 42 nd and 52 nd ) on morbidityand utilisation across states is presented below.• Overall morbidity, which had declined during twodecades i.e., 28 th Round–42 nd Round (1961-62 to1986-87), has increased during 1986-87 to 1995-96.• Morbidity reporting is slightly higher in rural areas (allthe Rounds).• Joint pain and hypertension are common ailments inrural and urban areas. While, the incidence of gastritisand TB is higher in rural areas, diabetes and heart problemsare found largely in urban areas. Stress, sedentarywork, change in life styles and food habits could bethe reasons for increasing problems of heart, hypertensionand diabetes.• Over the last decade, there has been a substantial increasein the dependence on the private sector for outpatientand inpatient care in the country.• In urban areas private provisioning of health servicesis growing faster.• Though there is reduction in the use of governmentfacilities during the past decade, the poor and hilly statesstill depend largely on government facilities for outpatientand inpatient care.• For inpatient care, 45 percent of the poor continue todepend upon public sector hospitals.• There is urban bias in the treatment of reportedailments.• The poor have the highest proportion of untreatedillness. In the backward state of Orissa, the percentageof ailing patients treated as inpatients from total ailingpersons was lower for all the fractile groups in ruralareas and for lower income groups in urban areas(42 nd Round).• Child morbidity due to acute diseases is more in urbanareas and more so in Orissa. The incidence ofmorbidity for acute and other diseases in all the agegroups and for both the areas is higher in Orissa(52 nd Round).• Hospitalised cases have declined during 1986-87 to1995-96 in rural areas and increased in urban areas.Still, the absolute number of people hospitalised (per1000) is higher in rural areas.• The percentage of hospitalisation cases is higher in ruralareas as compared to urban areas in poor states likeOrissa, Bihar, Madhya Pradesh, Uttar Pradesh andRajasthan.• The percentage of hospitalisation cases is higher inMaharashtra in rural and urban areas in both the42 nd and 52 nd Rounds as compared to Orissa andKarnataka.• The cost of subsidised (free) treatment (average expenditureper day for hospitalised care) in government33

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And Maharashtra34hospitals is higher in the poor state of Orissa as comparedto Karnataka and Maharashtra (42 nd Round).• There is a reduction in the level of subsidised healthcare. There is a scarcity of medicines and other facilitiesin public hospitals.• The burden of hospitalisation due to loss of householdincome is higher in urban Orissa and ruralKarnataka for the bottom 10 percent mpce. It shouldbe noted here that this corresponds with the cost ofhospitalisation (average expenditure), which is higherin urban Orissa and rural Karnataka.• Though the percentage of people perceiving illness asnot serious has come down, there is no correspondingincrease in the number of people treated over thedecade (42 nd to 52 nd Round).• Tobacco consumption and unhygienic surroundings(marginally) have a negative impact on health.Insights from the Study for PolicyInitiatives• The results of the NSS Rounds reveal that morbidityamong children and the elderly is high and increasing.Malnutrition/under-nutrition could be one of the reasonsfor child morbidity. The National Human DevelopmentReport 2001 indicated that over half ofthe children under the age of five in India are moderatelyor severely malnourished and 30 percent of newbornchildren are significantly under weight. Postnatalcare, nutritional supplements programme and a propersupply of drinking water and the provision of sanitationare the most essential services that are required.Continued public provision of these services is necessary.• The higher incidence of water-borne diseases andprevalence of communicable diseases calls for publicaction in the provision of safe drinking water and sanitationservices. Rural and urban sanitation and solidwaste management are essential for safe health andthis needs coordinated efforts from the government,local bodies and community. Public/private mixincluding community participation is inevitable in watersupply and sanitation services.• The study highlights the need for reorienting the healthcare system considering the higher prevalence of waterborne and chronic non-communicable diseases andthe continued existence of TB both in rural and urbanareas. AIDS is a specific disease, which needs integrationof health education with primary health care.Programmes related to prevention and treatment ofspecific diseases like TB, malaria, AIDS and leprosyshould be under the purview of the government. Thesediseases require new drugs, which are likely to be inthe patent list. The prices of drugs will increase due tothe impact of patents. As such government efforts foradvanced research on drugs, monitoring for continuedtreatment of a disease, encouraging research fordetecting the main factors causing the disease and procurementof new drugs is essential.• Community participation in health care planning, managementand provision is suggested as an alternativefor improvement in health care. Rogi Kalyan Samiti inMadhya Pradesh is an example of successful communityparticipation in health care. Individual efforts byDr. Sudarshan in Biligiri hills, Vivekananda YouthMovement in Mysore (both from Karnataka), Dr. Antiaand Dr. Arole (from Maharashtra) are noteworthyexamples of initiating community awareness in healthcare. People are willing to pay for medicines and otherservices provided the quality of services improves andpeople have a stake in the health care system. The WorldBank emphasises that user charges and a pre paidmechanism are a practical necessity for improving qualityand reliability. The user charge concept, its applicationand implications of its introduction on the poorneeds to be examined.• The utilisation pattern observed across the states, showsthat government spending on the provision of healthcare services, particularly inpatient care, is essential. Poorand weaker sections largely depend on public hospitalsfor cases requiring hospitalisation. NSS results indicatethat while there is no major change in the cost ofoutpatient care in real terms, the cost of hospitalisation

Summary and Insights for Policy Initiativeshas increased substantially. The study also indicates thatfinance is one of the major reasons for not seekingtreatment. In the light of this, the focus should be onsecondary care with tie-up arrangements and statesupported insurance coverage for tertiary care in privatehospitals for the poor and middle class patients. Thegovernment’s involvement in primary health services(particularly PHCs) needs to be redefined in the lightof low utilisation of PHCs for both outpatient andinpatient care. Regulation of staff, providing adequateand quality infrastructure for the staff as well as patientsand essential drugs at no profit prices is a must for theutilisation of PHCs.• It is the gram panchayat, which is accountable to thevillage community for the functioning of PHCs in thevillage. The questions related to health care are raisedin the gram sabha. Night services are not available inmost of the PHCs. Doctors do not stay in villagesbecause of un-repaired quarters and lack of other facilities.The maintenance of PHCs vests with the zillapanchayat (district level) in the existing framework.There is a need to shift this responsibility to the grampanchayats with the required amount of funds, so thatthey can take necessary steps to provide facilities forthe PHC staff.• Health policies should address the problems of theelderly. NSS results indicate that health problems areincreasing among the elderly and more than 50 percentof the aged population is suffering from one orthe other illness. The aged are vulnerable due to changingfamily relations (joint family to nuclear family),migration of children to urban areas and increasingfinancial problems among the poor and middle-incomegroups.• The school health programme was a priority issue inNHP-1983, but no major efforts were made to streamlineit. The programme should not be limited only tomedical check-up camps. Creation of awareness aboutdiseases, first–aid, personal hygiene, healthy practicesand sanitation should be a part of the school curriculum.‘Health Clubs’ on the lines of ‘Eco Clubs’programme initiated by the central government maybe introduced in schools.• The formation of Citizens’ Health Care VigilanceCommittee may be encouraged on formal lines toavoid unhealthy practices at civil/district hospitals.• NHP-2002 emphasises the use of practitioners, whohave formal training in the Indian systems of medicineand homoeopathy, in central and state governmenthealth programmes, but there may be drawbacksin such an integrated effort. Firstly, the expertise maynot be useful as programmes for control of TB, leprosyand malaria focus on allopathic drugs. Secondly,preventive care also depends on allopathic drugs, whichare tested, approved and widely accepted, particularlyfor family planning programmes. Thirdly, the use oftraditional drugs for curing any of these diseases isneither formalised nor popularised. Fourthly, it is wellknown that the majority of those who have formaltraining in the traditional systems, practice allopathy.Moreover, the NSS 52 nd Round results indicate thatdependence on ayurveda and homoeopathy is negligible.The policy has not elaborated on the nature andextent of utilising their expertise. Without creating aplatform for wider use and recognition of traditionalsystems in primary and promotional care, especially inrural areas, integration may be a wasteful exercise.• Registration of all medical practitioners, with the respectivelocal governments in rural and urban areas, isessential for health care planning.• Measures must be taken to tackle sale of outdateddrugs particularly in rural areas. Licenses of shops sellingsuch drugs should be cancelled on the spot.• NSS results indicate that the utilisation of PHCs is verylow. As a result there is rush at the district hospitals. Asenvisaged in NHP-2002, state governments mustenforce compulsory rural posting for all the medicalstudents who have completed their internship beforeawarding the degrees/certificates to them. It shouldbe a resident rural posting, so that people get servicesat night and in an emergency.35

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And MaharashtraAnnexure-IReview of NSS-based StudiesKrishnan (42 ndnd )• Cost of treatment highest for states where facilitiesare least developed.• Poor paid more for health care.• Cost of outpatient treatment could be reduced if primaryhealth care is readily accessible to the ruralpopulation.Baru (42 ndnd )• More than 50 percent of the bottom 20 percent andtop 20 percent income groups in rural areas in a majorityof the states used public services.• Cuts on secondary and tertiary sectors are notwelcome, both under the welfare and politicalconsiderations.• Private and voluntary sector are skewed in favour ofurban and better developed states.Gumber (42 ndnd )• Poor and disadvantaged sections spend a higher proportionof their income on health care.Shariff et al (42 ndnd )• Reporting of illness and hospitalisation cases haveshown increase with increase in income.• Need for regulating private sector.• Introduction of user fees in public health centres.• Encourage involvement of public –private mix andNGOs in delivery of health services to insulate costescalations.Sen Gita et al. (42 nd and 52 ndnd )• Higher untreated illness among women and poor• Underestimation of illness among women.• There exists positive class gradient for morbidity rates.Alam Moneer (42 nd and 52 ndnd )• Increase in the over all proportion of sick elderly during1986-87 to 1995-96 (more than half of the elderlyare suffering from one or the other illness).CMDR (28 th , 42 nd and 52 ndnd )• There is urban bias in treatment of reported ailments.• Poor have highest proportion of untreated illness.• Percentage of hospitalisation higher in rural areas ascompared to urban areas in poor states like Orissa,Bihar, MP, UP and Rajasthan indicating non availabilityof services in the initial stages or for minorailments.• Per day hospitalisation cost in free category of treatmentin public hospitals is higher in poor states (Orissa)both in rural and urban areas.36

Annexure-I: Review of NSS-based Studies• There is no change in outpatient treatment cost inreal terms, but hospitalisation cost has increased overthe decade.• The cost of subsidised (free) treatment (average expenditureper day for hospitalised care) in governmenthospitals is higher in the poor state of Orissaas compared to Karnataka and Maharashtra (42 ndRound).• There is a reduction in the level of subsidised healthcare. There is a scarcity of medicines and other facilitiesin public hospitals.• The reform process has had no major effect on thecost of non-hospitalised treatment i.e., primaryhealth care.• The burden of hospitalisation due to loss of householdincome is higher in urban Orissa and ruralKarnataka for the bottom 10 percent mpce.• Though the percentage of people perceiving illness asnot serious has come down, there is no correspondingincrease in the number of people treated over thedecade.• Tobacco consumption and bad surroundings (marginally)have a negative impact on health.37

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And MaharashtraAnnexure-IIRounds of NSS – A Comparative Picture28 th Round (1973–74) 42 nd Round(1986–87) 52 nd Round(1995–96) CommentsI. Morbidity(i) Major Chronic Illnesses:Asthma,TB, rheumatismand peptic ulcer in ruralareas;Asthma, TB, Rheumatismand hypertension in urbanareas————*————Joints pain, hypertension,gastritis and TB in ruralareas;Joints pain, hypertension,diabetes and heart problemsin urban areasStress, sedentary work,change in life style and foodhabits could be the reasonsfor increasing problems ofheart, blood pressure anddiabetes.TB and asthma were themost common chronic diseasesfound in rural and urbanareas————*————Though the prevalence rateof TB has come down it isstill a cause of concern and isone among the four majorcauses of morbidity in ruralareasIntroduction of new medicines,monitoring for continuedtreatment of diseaseand encouraging researchfor detecting the main factorscausing the disease isessential.Diabetes and hypertensioncases were more prevalent inurban areas as compared tothe cases in rural areas.————*————Prevalence of diabetes andhypertension in urban areashas increased and hypertensionhas emerged as one ofthe four major diseases inrural areas————*————Lower prevalence of epilepsyand significant cases ofpiles in rural and urbanareas.————*————Prevalence of epilepsy andpiles has reduced in rural areas.In urban areas only theprevalence of piles has reducedwhile more number ofepilepsy cases are reported.————*————38

Annexure-II : Rounds of NSS - A Comparative Picture28 th Round (1973–74) 42 nd Round(1986–87) 52 nd Round(1995–96) CommentsRheumatism and peptic ulcerwere major health problemsin R & U areas.Incidence of measles (per 1lakh persons) was 17 in ruralareas and 14 in urban areasOther Types————*————————*————————*————There is no change in the incidenceof measles cases inurban areas, while it hascome down in rural areas.Rheumatism seems to be amajor illness even now.Though 52 nd Round doesnot give separately details underrheumatism, high prevalenceof pain in the joints doindicate that rheumatism is amajor problem both inR & U areas.Measles immunisationprogramme needs to bestrengthened further. Thereis l loss of school days dueto measles.Dysentery, influenza, malariaand whooping cough werethe temporary/acute illnessesin rural and urban areas.Injuries due to accidentswere 39 in rural areas and 54in urban areas.————*————————*————Incidence of dysentery, diarrhoeaand cholera is higherboth in rural and urbanareas.Incidence of injuries due toaccidents have increasedboth in rural and urbanareas. (63 in rural and 83 inurban).The higher incidence of waterborne diseases calls forpublic action in the provisionof safe drinking water andsanitation servicesDue to overall developmentof the economy and increasein the purchasing power ofthe people, there is increasinguse of vehicles leadingto more accidents.(iii) Gender(a) Reporting of illnessFor all types of acuteailments and chronicillnesses female reportingwas less in most of thestates and in the countryboth in R & U areas.R : M – 47, F – 40.U : M – 43, F – 41.While female reporting waslower in rural India, morefemales reported sickness inurban India. But, in ruralareas, female reportingwas higher in the higherexpenditure group.R : M – 64, F –63.U : M – 30, F – 33.Reporting is found to behigher for females both inrural and urban India.R : M – 84, F – 89.U : M – 81, F – 89.Gender bias in reporting hasreduced. Women are gettingover their shyness and hesitation.It shows that there isincreasing awareness amongwomen, which could be dueto education, media, empowerment,health programmesand large numberof health and other surveysundertaken in the country.39

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And Maharashtra28 th Round (1973–74) 42 nd Round(1986–87) 52 nd Round(1995–96) Comments(b) Untreated cases(iv) Age wiseProportion of untreatedcases was higher in ruralareas and higher amongfemales.Rural: M–17, F– 20Urban: M–10, F–12Percentage of untreated caseshas reduced over the years.Rural: M–16, F – 18Urban: M – 9, F – 10Untreated ailments by fractilegroup is higher among bottom10% of fractile groupand is higher in states likeOrissa, Bihar, Assam andAndhra Pradesh.But, there is no reporting ofproblems related to reproductivehealth and STDs.Health surveys should involvetrained female investigatorsand more time shouldbe given for collecting qualitativeinformation fromhouseholds.Among the untreated cases,non-availability of medicalfacility and financial problemswere the two reasonsquoted largely by illiterates.Prevalence rate of morbiditywas higher among infantsand aged.————*————Reporting of illness is higherfor aged, middle aged andchildren.Incidence of morbiditydue to chronic diseasesis lower among the children(0 – 14)Health policies should addressto the problems ofaged. Aged are a vulnerablesection due to changing familyrelations (joint family tonuclear family), migration ofchildren to urban areas andincreasing financial problemsamong poor and middle incomegroups.(v) State-wiseThe prevalence rate of morbidity(all types) and prevalenceof morbidity (all ages)was higher in Kerala andlower in Bihar both in R&Uareas. The number of per-————*————The incidence of morbidityfor acute and other diseasesin all the age groups and forboth the areas is higher inTripura and Chandigarh andlower in Manipur andEducation and awarenessprobably lead to higher reportingof illness.40

Annexure-II: Rounds of NSS - A Comparative Picture28 th Round (1973–74) 42 nd Round(1986–87) 52 nd Round(1995–96) Commentssons suffering from chronicdiseases was also higher inKerala but lower in Gujarat.(vi) Inpatients————*————(vii) OutpatientsPrevalence rate of ailingpersons was 43 and 42 per1000 in rural and urban areasrespectively.(viii) Ailments treated————*————Hospitalised cases (per 1000)were 28 and 17 in rural andurban areas.The number of hospitalisedcases was highest for Keralaboth in rural and urbanareas.OPs increased to 64 (per1000) in rural areas, but decreasedto 31 per 1000 inurban areas.82% and 89% of the ailingpersons treated in rural andurban areas.R : M – 83, F – 80.U : M – 90, F – 88.Mizoram. Number ofpeople reporting chronic ailmentsis higher in Kerala andChandigarh and lower innorth-eastern states. Amongthe major states reporting(PAP- per 1000) is higher inAssam and Punjab andlower in Rajasthan, MP, Biharand Gujarat.Hospitalised cases (per 1000)reduced to 13 in rural areas,but increased to 20 in urbanareas.Hospitalised cases (per 1000)higher in Kerala.The proportion of ailingpersons has increased to86(per 1000) in rural areasand 84(per 1000) in urbanareas.83% and 91% of the ailingpersons treated in rural andurban areas.R : M – 84, F – 82.U : M –91, F – 90.Proportion of personshospitalised is higher wherebed to population ratio islower (Kerala) andhospitalised cases are lowerin States where bed strengthis less (Orissa, Bihar, MP,Rajasthan and UP) Proportionof hospitalisation increaseswith the increase inmpce fractile group.There is increase in the prevalenceof morbidity or increasein proportion ofpeople suffering. Unlikehospitalised cases, the distributionof PAP (per 1000)over fractile groups does notshow any particular pattern.Gender bias in treatment ofailments has reduced over theyears and there is no significantdifference between malesand females in treating illnesses.But, there is urban biasin treatment of ailments,41

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And Maharashtra28 th Round (1973–74) 42 nd Round(1986–87) 52 nd Round(1995–96) CommentsII. Reasons for not taking treatmentwhich has remainedunchanged over the years.————*————Not serious R – 75%,U – 81%Financial problems R – 5%,U – 10%Non availability of health carefacility R–3%, U – 0%Non-availability and financialproblems were the reasonslargely quoted in poor statesviz. Bihar, Orissa andRajasthan. Finances were alsoa major problem in J&K.Not seriousR – 52%, U – 60%.Financial ProblemR – 24%, U – 21%.Non availabilityR – 9% (increased)U – 1%.Financial problems and nonavailabilityare major problemsin poor states. In Orissathese two were the reasonsquoted largely as comparedto Maharashtra andKarnataka.III Type of treatment————*————61% in rural and 55% in urbanhospitalised cases ingovt. hospitals received freetreatment.In Orissa, where dependenceon govt. hospitals, forIP care is very high in thecountry, only 26% of IPsreceived free medicines inspite of 98% of the casesadmitted to govt. hospitalbeing treated in free ward.42% in rural areas and 38%in urban areas received freetreatment.There is reduction in the levelof subsidised health care.There is scarcity of medicinesand other facilities.IV Average expenditure (Per hospitalised case)————*————Outpatient:RuralGovt. - Rs. 73Pvt. - Rs. 77UrbanGovt . - Rs. 74Pvt . - Rs. 80RuralGovt . - Rs. 129.Pvt. - Rs. 186.UrbanGovt . - Rs. 166.Pvt . - Rs. 200NSSO data on private Expenditurepattern on medicalcare also reveal that rich(top 10%) spend 9% to 12%of their total expenditure. onhealth care while, poor (BPL)spend 2% to 3% of their totalexpenditure on health care.42

Annexure-II: Rounds of NSS - A Comparative Picture28 th Round (1973–74) 42 nd Round(1986–87) 52 nd Round(1995–96) CommentsInpatients:Rural – Rs. 853Per day per hospitalised caseGovt.Free: R – 33 U – 36Pay gen: 83 U – 54Pay spl.: R – 74 U – 65Pvt.Free: R – 59 U – 60Pay gen: R – 134 U – 82Pay spl.: R – 210 U – 126Urban – Rs. 1183Rural (Public+Private)M – Rs. 151,F – Rs. 137P – Rs. 144Urban (Public+Private)M – Rs. 187, F – Rs. 164P – Rs. 175Rural (Public+Private)M – Rs. 3778,F – Rs.2510P – Rs. 3202Urban (Public+Private)M – Rs. 4185, F – Rs. 3625P – Rs. 3921RuralPublic sector hosp – Rs. 2080Private sector hosp – Rs. 4300UrbanPublic sector hosp. – Rs. 2195Private sector hosp –Rs. 5344RuralBottom 10% fractile group:Govt. – Rs. 961Pvt. – Rs. 1176Top 10% fractile group:Govt. – Rs. 5126Pvt. – Rs. 7619UrbanBottom 10% fractile group:Govt. – Rs. 497Pvt – Rs.1186Top 10% fractile group:Govt – Rs.8104Pvt. – Rs. 12957Average per capita monthlyhealth expenditure was3(1992) and 7(1998) forBPL families and 53(1992)104(1998) for top 10% expenditureclass. Share ofmedical expenditure. in totalexpenditure has increasedfor both poor and top 10%class.43

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And Maharashtra28 th Round (1973–74) 42 nd Round(1986–87) 52 nd Round(1995–96) CommentsV Costliness————*————Inpatients:In rural areas, hospitalisationcost per day was lower inMizoram, Sikkim &Lakshdweep (Rs. 10 toRs. 25) and higher in Haryana& Punjab (Rs. 90 to Rs. 125)In urban areas, per day costhigher in Andaman &Nicobar islands, Lakshdweep,Maharashtra, UP,Punjab (Rs.108 to Rs.193)and lower in Mizoram,Sikkim & Pondicherry (Rs.20to Rs.25). In poor states costvaried between Rs. 40 toRs.70 per dayCost per hospitalised case:RuralKerala – Rs. 464Punjab – Rs. 1402UrbanKerala – Rs. 464UP – Rs. 1802Karnataka: R – Rs. 919U – Rs. 1230Maharashtra: R – Rs. 951U – Rs. 1597Orissa: R – Rs. 744U – Rs. 767Hospitalisation in rural areasis costlier inUP : Govt- Rs.4237An. Pr-Pvt.-Rs. 7822Hospitalisation in urban areasis costlier inHaryana: Govt- Rs. 8888Orissa: Pvt-11829Cheaper inRuralTamil Nadu: Govt – Rs. 751Assam: Pvt – Rs. 2003UrbanTamil Nadu: Govt – Rs.934Kerala – Pvt. Rs. 2254For the rural poorhospitalisation in govt.hospitals is costlier(Rs. 961) than that for urbanpoor (Rs. 497).VI Surroundings and morbidity————*————————*————Unhealthy surroundingshave a marginal negativeeffect on health.Further studies and researchis essential to probe into thelinkage of morbidity withsurroundings44

Annexure-II: Rounds of NSS - A Comparative Picture28 th Round (1973–74) 42 nd Round(1986–87) 52 nd Round(1995–96) CommentsVII Tobacco consumption and morbidity————*————————*————Affects health status. Prevalenceof cancer is moreamong smokers.Information on other habitsshould be presented as prevalenceof TB is higher amongthose who have other habits.VIII UtilisationInpatients :60% of the IPs in rural areasand % of the IPs in urbanareas were treated in govt.hospitals.In poor and hilly areas governmenthospitals/ PHCsprovided for IP as well asOP care.Public sector provides IPcare for 44% in rural areasand 43% in urban areasIn poor and hilly areas dependenceon govt. forhospitalised care is stillhigher (viz. Orissa, Rajasthan& Assam).There is reduction in use ofpublic sector for hospitalisedtreatment also.Percentage of beds in govt.hospitals is more than 80%in these states.————*————Outpatients :25% of OPs in rural areasand 26% of OPs in urbanareas are treated in publichealth centres/hospitals.Public sector provides for19% in rural areas and 20%in urban areas for OP care.Dependence of poor onPHCs has reduced.There is reduction in use ofpublic sector for out-patientalso.For OP care, there isgreater dependence on governmentsources (>30%) inOrissa, Rajasthan in rural andurban areas, in urban areas inBihar and this dependencesupports the argument forcontinued governmentspending and provision ofhealth care particularly the inpatientcare.IX Average of loss of household income (in Rs.) per ailment (15 days)————*————————*————R – Rs. 55, U – Rs. 44. Variesfrom Rs. 2 (in Daman & Diu)to Rs. 185 (in AndhraPradesh).Burden of OP and in patientillness is higher in rural areas.45

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And Maharashtra28 th Round (1973–74) 42 nd Round(1986–87) 52 nd Round(1995–96) Comments————*————R – Rs. 563, U – Rs. 521Varies from Rs. 270 toRs. 937 for bottom 10%to top 10 % mpce classrespectively.* = Information not available in NSSO published sources. Note: BP=Blood Pressure, R=Rural, U=Urban, IP=Inpatient, OP=Outpatient, M=Male,F=Female, govt.=government, pvt=private, mpce=monthly per capita expenditure.Source: NSSO (1980, 1992 & 1998), Notes on Morbidity, 28 th (1973-74), Sarvekshana, Report No. 364 (42 nd )46

Annexure-IIITablesTable A-1: Expenditure on Medical CareYear 1992 1998% of People Below Poverty Line 30.87 27.09Average Per Capita Monthly Medical Expenditure 2.83 7.05Average Per Capita Monthly Consumer Expenditure 123.8 249.99% share of Medical to Total Expenditure 2.29 2.821992 1998Top 10% of the Expenditure Class 10 10Average Per Capita Monthly Medical Expenditure 53.1 103.91Average Per Capita Monthly Consumer Expenditure 588.19 895.19% Share of Medical to Total Expenditure 9.03 11.61Source: NSSO “Sarvekshana” series47

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And MaharashtraTable A-2: Incidence of fevers of short duration for population livingin different environments (52 nd Round)EnvironmentNumber of ailments per 1000 personsMale Female PersonRuralUse of insecticidePremises sprayed with insecticide 20 17 18Premises not sprayed with insecticide 16 17 17Animal shed in the neighbourhoodWith animal shed attached to residence 17 16 16With animal shed detached from residence 16 17 17With no animal shed 17 17 17Drainage systemNo drainage 17 18 18Open kutcha 15 15 15Open pucca 18 17 17Covered pucca 16 12 14Underground 14 20 17All households 17 17 17UrbanUse of insecticidePremises sprayed with insecticide 17 16 17Premises not sprayed with insecticide 15 15 15Animal shed in the neighborhoodWith animal shed attached to residence 16 16 16With animal shed detached from residence 19 19 19With no animal shed 15 15 15Drainage systemNo drainage 19 21 20Open kutcha 16 14 15Open pucca 14 15 15Covered pucca 12 13 12Underground 15 14 14All households 15 16 15Source: NSSO(1998), Morbidity and Treatment of Ailments, 52 nd Round(1995-96),Report No.44148

TablesTable A-3: Prevalence of tuberculosis among tobacco consumers and non-consumersaged 10 Years and above (52 nd Round)Tobacco consumption habitNumber of ailment per 1000personsMale Female PersonRuralOnly smoking 108 243 120Other habits only 207 134 182Smoking and others 52 50None 144 70 98All 136 79 108UrbanOnly smoking 127 30 124Other habits only 181 257 202Smoking and others 87 - 86None 60 60 60All 84 68 77Source: NSSO(1998), Morbidity and Treatment of Ailments, 52 nd Round(1995-96), Report No.441Table A- 4: Prevalence of different chronic (long duration) diseases among consumers andnon-consumers of tobacco aged 10 years and above (52 nd Round)TobaccoNumber of ailment per 1000 reporting personsconsumption habit Cancer Heart disease High / Low blood pressureMale Female Person Male Female Person Male Female PersonRuralOnly smoking 30 234 49 54 135 61 170 205 173Other habits only 14 18 15 75 34 61 98 196 131Smoking and others 6 6 60 58 71 83 71None 16 23 20 96 82 87 74 139 114All 17 27 22 80 78 79 97 145 121UrbanOnly smoking 26 25 81 767 108 203 643 220Other habits only 3 34 12 206 183 200 166 424 239Smoking and others 108 107 287 282None 8 24 17 141 107 122 134 336 248All 10 24 17 135 115 126 159 341 246Source: NSSO (1998), Morbidity and Treatment of Ailments, 52 nd Round (1995-96), Report No.44149

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And MaharashtraTable A-5: Incidence of difference acute (short - duration) diseases among consumers andnon - consumers of tobacco aged 10 years and above (52 nd Round)TobaccoNumber of ailment per 1000 reporting personsconsumption habit Acute respiratory Cerebral stroke Heart failureMale Female Person Male Female Person Male Female PersonRuralOnly smoking 52 89 55 0 0Other habits only 27 6 20 6 2Smoking and others 26 23 26 0 0 17 16None 6 22 16 3 2 2 8 3 5All 21 22 21 2 1 1 6 3 5UrbanOnly smoking 66 63 14 13Other habits only 32 109 54 7 5 5 13 7Smoking and others 4 4None 30 25 27 0 0 0 0 10 6All 34 28 31 1 0 1 3 10 6Source: NSSO (1998), Morbidity and Treatment of Ailments, 52 nd Round (1995-96), Report No.441Table A-6: Per 1000 distribution of hospitalised cases during last 365 days by typeof ward of Government and other hospitals (52 nd Round)State Government OtherFree Paying gen Paying spl All Free Paying gen Paying spl AllRuralKarnataka 364 76 11 450 14 424 95 533Maharashtra 273 34 1 309 14 542 124 680Orissa 827 15 0 842 4 53 29 87All India 388 41 8 438 28 411 91 529UrbanKarnataka 235 33 24 293 18 430 243 691Maharashtra 251 50 5 307 35 435 188 657Orissa 733 39 7 779 19 115 49 183All India 347 55 16 419 35 372 146 553Source: NSSO (1998), Morbidity and Treatment of Ailments, 52 nd Round (1995-96), Report No.44150

TablesTable A- 7: Average total expenditure per hospitalised case during last 365 days by type ofhospital for each type of ward (52 nd Round)(In Rs.)States Government Hospital Other HospitalsFree Paying gen Paying spl All Free Paying gen Paying spl AllRuralKarnataka 1510 1805 11199 1791 2038 3650 6402 4100Maharashtra 1217 3984 5922 1529 808 2726 9011 3836Orissa 1662 2364 12100 1681 445 2331 3329 2583All India 1781 3241 10540 2080 1463 3393 9281 4300UrbanKarnataka 1176 3935 2104 1564 948 3284 6919 4502Maharashtra 1164 1982 10082 1439 2507 4787 7157 5345Orissa 1886 3234 21956 2142 157 9223 22320 11829All India 1521 3350 12474 2195 1752 4295 8893 5344Source: Source: NSSO (1998), Morbidity and Treatment of Ailments, 52 nd Round (1995-96), Report No.44151

Economic Reforms and Health Sector in India with Special Reference toOrissa, Karnataka And MaharashtraReferencesAlam, Moneer 2001. ‘Looking Beyond the Current DemographicScenario: Changing age Composition, Ageing and growinghealth issues in India and South Asia’, Discussion Paper Series34, Institute of Economic Growth, Delhi.Assogba, L., Campbell, Oona and Allan, G.1989. ‘Advantages andlimitations of large scale health interview survey for the studyof health and its determinants’, in John Cleland and Allan Hill(ed.), The Health Transition Series, 3, 269-288. Health TransitionCentre, The Australian National University.Baru, Rama V. 1999. ‘The Structure and Utilisation of health Services:An Inter-State Analysis’ in Mohan Rao (ed.), Disinvesting inhealth – The World Bank’s prescriptions for health, 129-144. NewDelhi: Sage Publication.Peter, Berman 1996. ‘Health Care Expenditure in India’, in MonicaDas Gupta et. al. (ed.), Health, Poverty and Development in India,331-338. Oxford University Press.Bhat, Ramesh 1996. ‘Regulating the private care sector: The case ofthe Indian consumer protection Act’, Health Policy and Planning,2(3), 265-279.Chauhan, Devaraj; Antia, N.H. and Kamdar, Sangita 1997. HealthCare in India – A profile, The Foundation for Research inCommunity Health, Mumbai/Pune.Evlo, K. 1993. ‘Macroeconomic Changes in the Health Sector inGuinea - Bissau’, Country Paper Macroeconomics, Health andDevelopment Series 8, WHO, Geneva.Gerdtham, Ulf. G., Sigaar, Jer; Andersson, Fredrich and Jonsson,Bengt 1992. ‘An econometric analysis of health care expenditure:A cross-section study of OECD countries’, Journal of HealthEconomics, 11(1), 63-84.Hitiris, Theo and Posnett, John 1992. ‘The determinants and effectsof health expenditure in developed countries’, Journal of HealthEconomics, 11(2), 173-181.IIM 1987. ‘Health Care Financing in India- Based on Case Studiesin Maharashtra and West Bengal’, Ahmedabad.Janathan, Gruber 1994. ‘The effect of competitive pressure oncharity: Hospital responses to price shopping in California’,Journal of Health Economics, 13(2), 183-211.Kashyap, Subhash (ed.) 1990. National Policy Studies, Tata Mc Grow-Hill Publishing Company Ltd., New DelhiKrishnan, T.N. 1996. ‘Hospitalization Insurance – A proposal’,Economic and Political Weekly, 31(15), 944–946.Krishnan, T.N. 1999. ‘Access to health and the Burden of Treatmentin India: An Inter – State Comparison, in Mohan Rao (ed.),Disinvesting in health – The World Bank’s prescriptions for health,208–230. Sage Publications.Labelle, Roberta; Stoddart, Greg and Rice, Thomas 1994. A reexaminationof the meaning and importance of supplierinduced demand, Journal of Health Economics, 13, 347–368.Murray, Christopher and Lincoln, C. Chen 1992. ‘UnderstandingMorbidity Changes’, Population and Development Review, 18(3),481-503.Murray, Christopher; Fishermen, Richard; Phillips, Margaret andWillis, Carla 1992. Adult Morbidity: Limited Data andMethodological Uncertainty, World Bank. New York: OxfordUniversity Press.National Family Health Survey (NFHS – 2) – Key Findings (1998 –99), IIPS, Mumbai, India.National Health Policy 2001. Government of India. (availableonline http:// mohfw.nic.in/np2002.htm).52

ReferencesNational Sample Survey Organisation 1998. Morbidity and Treatmentof Ailments, 52 nd round(1995-96), Report 441.National Sample Survey Organisation 1992. ‘Morbidity andUtilisation of Medical Services’, Sarvekshana, 42 nd round (1986– 87), 51 st Issue, 12(4), Issue 39, April – June.National Sample Survey Organisation 1980. ‘Notes on Morbidity’,Sarvekshana, 28 th Round (1973-74), 4(1 & 2).Panchamukhi P.R. 2001. ‘Economic Reforms and the health Sector:Analysis of the Nexus in the context of Karnataka’, in ArunaP. Bali (ed.), Refashioning the new Economic Order in TransitionKarnataka, 302-349. Rawat Publications.Planning Commission 2001. National Human Development Report,Government of India.Prabhu, K . Seeta 2001. ‘Health Sector and Economic Reforms - Astudy of Maharashtra and Tamil Nadu’, in Imrana Qadeer,Kasturi Sen and K.R.N. Nayar (ed.), Public health and Poverty ofReforms – The South Asian Predicament, 253 – 275. SagePublications.Qadeer, Imrana 2001. ‘Impact of Structural Adjustment Programsin concepts in Public Health’, in Imrana Qadeer, Kasturi Senand K.R.N. Nayar (ed.), Public health and Poverty of Reforms –The South Asian Predicament, 117-136. Sage Publications.Sawhney, Maneeta 2001. ‘The category of the chronic – Someconceptual issues in the context of India’, IEG DiscussionPaper Series 36, IEG, Delhi.Sen, Gita; Iyer, Aditi and George, Asha 2002. ‘Structural Reformsand Health Equity – A Comparison of NSS Surveys, 1986-87and 1995-96’, Economic and Political Weekly, 37(14), April 6,1342-1352.Sen, Kasturi 2001. ‘Health Reforms and Developing Countries –A Critique’, in Imrana Qadeer, Kasturi Sen and K.R.N. Nayar(ed.), Public health and Poverty of Reforms – The South AsianPredicament, 137–153. Sage Publications.Shariff, Abusaleh; Gumber, Anil; Duggal, Ravi and Alam, Moneer1999. ‘Health Care Financing and Insurance: Perspective for theNinth plan (1997 – 2002)’, Margin, 31(2), 38–67.WHO 1990. Diet, Nutrition and the Prevention of Chronic Diseases,WHO, Geneva.Wood, P.H.N. and Foster G.M. 1986. Scientific Approaches to healthand health care, WHO, Geneva.World Bank 1993. World Development Report - Investing in Health,Oxford University Press.53

About the Series EditorsAasha Kapur Mehta is Professor of Economics at the Indian Institute of Public Administration, New Delhi and leadsthe Chronic Poverty Research Centre’s work in India. She has a Masters from Delhi School of Economics, an M.Philfrom Jawaharlal Nehru University and a PhD from Iowa State University, USA. She has been teaching since 1975,initially at a college of Delhi University and then at IIPA since 1986. She is a Fulbright scholar and a McNamara fellow.Her area of research is now entirely focused on poverty reduction and equity related issues.Pradeep Sharma is an Assistant Resident Representative and heads the Public Policy and Local Governance Unit inthe India Country Office of United Nations Development Programme (UNDP). A post-graduate from University of EastAnglia (UK) and Doctorate from Jawaharlal Nehru University, he has held several advisory positions in the Governmentof India and has taught economic policy at LBS National Academy of Administration, Mussoorie. He has severalpublications to his credit.Sujata Singh is an Associate Professor at the Indian Institute of Public Administration. She completed her doctoralstudies in Public Administration and Public Policy at Auburn University, USA. Her primary research interests are in thearea of Comparative and Development Administration, Public Policy Analysis, Organizational Theory and Evaluation ofRural Development Programmes.R.K. Tiwari is Senior Consultant, Centre for Public Policy and Governance, Institute of Applied Manpower Research,Delhi. He was formerly Professor of Public Administration at the Indian Institute of Public Administration (IIPA), NewDelhi. He received his education at Gwalior, Allahabad and Delhi. He has undertaken a number of research studiesin Development Administration, Rural Development, Personnel Administration, Tribal Development, Human Rightsand Public Policy. He has conducted consultancy assignments for the Department of Posts and in the Ministry of RuralDevelopment, Government of India; and for the Government of Orissa and the Narmada Planning Agency, Governmentof Madhya Pradesh. He has published several books.P.R. Panchamukhi, is Professor Emeritus, Centre for Multi-disciplinary Development Research (CMDR), Dharwad,where he was Founder-Director. He has a doctorate in Pubic Finance from Bombay University. He has beenawarded a number of coveted scholarships and prizes including Seth Mangaldas Jeshingbhai Economics prize forstanding first in the Bombay University and V.K.R.V.Rao Award for significant original research contribution. He hasheld the CN Vakil Chair in General Economics of Bombay University and has worked as Director, Indian Institute ofEducation, Pune. He been Advisor to the Planning Commission and has served on a number of committees of Govt.of India, Govt. of Karnataka, and Maharashtra, and been a consultant/adviser to international agencies like TheWorld Bank, UNICEF, UNESCO, Columbia University, WHO-Geneva, ESCAP-Bangkok, Indo-French Round Table.He has been Chief Editor /Editor of different national level journals. He has authored 15 major research works andhas more than 89 research papers in national and international publications in the areas of Education, Health,Public Finance and Developmental Economics.