Health system function, Health seeking behaviour and Health Impoverishment in India

Abstract: The Indian health system is characterized by low levels of public expenditure, significant public system dysfunction, high levels of out-of-pocket, catastrophic and ‘impoverishing’ health expenditure and a highly plural public-private mix. However, characteristics differ greatly by State with some States spending more, investing more extensively in public provision, and their systems having better reputations.

Much of the data that allows analysis of these issues comes from household surveys, cannot be disaggregated by condition and gives detailed accounts only of the ‘last visit’ to a health facility. Data are also used from Demographic and Health Surveys and related Facility
surveys that focus on communicable diseases and maternal and reproductive health, and a supply side concept of health system function and quality.

This presentation reports from a mixed methods study that re-analysed household survey data, undertook a primary survey exercise aimed at addressing the shortcomings of the existing data, and conducted qualitative work to explain and enrich the resulting analysis.

Reanalysis of secondary data suggests that public health expenditure has a large and probably causal impact on use of the public sector particularly by the poorest groups, consistent with a ‘regulation by competition’ mechanism operating.

The primary survey considered three specific conditions (chronic respiratory disease in adults; acute respiratory infection in children and common gynaecological conditions in adults) and focused on the full treatment seeking journey for an episode of care. It confirmed that key data are highly contingent on condition, and that health seeking journeys are frequently quite long and not adequately represented by a snapshot of the ‘last visit’. Alternative (demand side) indicators of health system function suggest a different ranking of States compared to those derived from supply side indicators.

Qualitative data underline the ‘moral economy’ of health seeking behaviour decisions that underpins decisions to make impoverishing health expenditures, and common patterns of poor value for expenditures made premised on limited sources of reliable and  trustworthy advice.

Overall, the study clarifies the value of investment in a public health system and challenges the view of inefficiency of public investment which is quite prevalent in India. It supports aspects of the Ayushman Bharat health system reforms with respect to their plans for large
scale investment in public primary health centres but questions elements of the same program that insures the poorest against costs of private hospital attendance.