The principal objective of the study is to examine the trends of morbidity, inter-state variation in treatment seeking behaviour and associated health care expenditure incurred by households in larger states of India across three rounds of NSS surveys. 

The unit level data from three rounds of ( 60th (2004), 71st (2014) and 75th (2017-18)) the National Sample Survey (NSS) has been used for morbidity rates, share of public and private sector on healthcare services, cost of hospitalized care (mean OOPE) between public and private sector among 21 larger states in India. 

In order to compare the OOPE of previous rounds (60th and 71st rounds) with 75th round OOPE, Consumer Price Index (CPI) has been used.  OOPE are defined as direct payments made by individuals to health care providers at the time of service use. 

Out of every 1,000 persons in rural areas, 72 reported an ailment.  The corresponding figure in urban areas is 98 during 2017-18.  The results show a positive trend from 71st to 75th round as the number of ailing persons fairly has come down (Rural:89 to 72 and Urban 118 to 98) in 75th round as compared to the previous round. 

Among the states, Kerala has highest proportion of ailing persons (24.5).  Hospitalization rates also show a similar trend across the three rounds.  The interstate comparison shows higher rates of hospitalization in Kerala (114 in rural and 95 in urban). 

The survey results show the following causes for hospitalization: 31.4 percent infections; 6 percent Genito-urinary; 4 percent Obstetric and neo-natal problems, 11.2 percent due to injuries remaining 47.4 percent coming largely from non-communicable diseases. 

The data reveals that significant percent respondents in both rural and urban areas (95 percent each) sought allopathic care and only 5 percent of the respondents (both rural and urban) sought care from other systems of medicine.  Over the three rounds more than two-thirds of the respondents (79.3%, 75% 70%) availed outpatient care in private sector.  People from Jammu and Kashmir has availed maximum services (69 percent) from Public sector, whereas, 86 percent of the population in Uttar Pradesh availed services from private sector. 

The analysis of findings reveals that there is a very significant improvement observed in home deliveries from 60th round to 75th round especially in rural areas. Home deliveries accounted for only 9.5 percent of all deliveries in rural areas in 75th round whereas the figures were 65% in 60th round. 

In the 75th round data, it is seen that nearly three-fifths of the hospitalized cases (58 percent) were treated in the private sector.  There has been a consistent increase in the expenditure by the individuals in private sector from 60th to 75th round (Rs.25,408/- to Rs.34,552/-).  In contrast, a consistent decrease in the expenditure in public sector was observed from 60th to 75th round (Rs.10,838/- to Rs.6,050/-).  Among 21 states, Jharkhand is the only state where expenditure has increased from Rs.8,863/- to Rs.10,191/- between 60th and 75th round.  

In 75th round, the highest cost of care for hospitalization by any disease category is for cancer (Rs.93,305/- in private hospitals and Rs.22,520/- in public hospitals), The lowest is for infections (Rs.15,208/- in private hospitals and Rs.2,054/- in public hospitals). 

The present study had also reviewed the reports published by National Health Accounts from 2004-05 to 2015-16 to understand trends of healthcare expenditure borne by different bodies in India.  There has been a consistent decrease in household OOPE observed from 2004-05 to 2015-16 (71% to 65%) due to increase of insurance coverage (1% to 9%) either provided by the employers or private individual insurance.

The high reliance on private health sector mainly because of doctors spend a longer duration with their patients and conduct physical exams as a part of the visit compared to those working in public healthcare.  As a result of high reliance on private sector, the mean OOPE is much higher in the private sector as compared to public sector.   

There has been a consistent increase in the expenditure by the individuals in private sector from 60th to 75th round.  In contrast, a consistent decrease observed in the expenditure in public sector from 60th to 75th round due to effective implementation of state specific health programmes in various states.

As one of the key objectives of National Health Policy (NHP) – 2017 is to “strengthen the trust of the common man in public health care system it is very important for the Government to take necessary measures to strengthen the public health system in terms of increasing the human resources, infrastructure, reaching out to the needy population in difficult terrains, quality of care and treatment. 

With a view to achieve the vision of Universal Health Coverage (UHC), the NHP has recommended a comprehensive health coverage called Ayushman Bharat , a flagship scheme of Government of India was launched in 2018 aimed at making necessary interventions in primary, secondary and tertiary health-care systems, in a holistic fashion.  In future, the scheme may expect to cover large number of people and further reduce household OOPE. 

*Ranganadham Srinadh is Research Assistant, NITI Aayog. Views expressed are personal.