1. Key Indicators of Health and Morbidity: Tamilnadu
Based on National Sample Survey (NSS), 71st Round (January-June, 2014)
Presented by
Prof. Anup Karan & Prof. Umakant Dash
Bonne Sante 16.   26th August 2016

2. Outline of the Presentation..
Introduction
Objective
Morbidity Patterns and Differentials
Utilization of Health Care (Out-patient & In-patient)
Out-of-pocket Burden; and Financial Risk Protection
Maternity and Child Healthcare
Policy relevance & implication
Access
Determinants of Self-Reporting and Health Seeking Behavior(HSB) in Tamil Nadu
Financial Protection
Equity/Responsiveness

3. Source of Data/Sample Design
It’s a two-stage stratified sample and the state was divided into four regions, the Coastal Northern, Coastal, Southern and Inland
The survey covered 3,917 households (1,960 rural and 1,957 urban) in Tamil Nadu
No. of persons covered: 8,237 in rural and 7,853 in urban areas
Information used for the analysis:
household characteristics and demographic particulars
particulars of spells of ailment of household members during the last 15 days (including hospitalisation) and expenses incurred.
particulars of medical treatment received as in-patient of a medical institution during the last 365 days and expenses incurred for treatment

4. Morbidity Pattern
in the absence of clinically validated surveys, self-reported illness can be used to measure health status of the state (people)
Important from policy perspective as those who did not perceive the need would not be seeking health care even though the health care service is fully available

5. Demography Pattern
The age pyramid in Tamil Nadu reflects considerably higher bulging in higher age groups compared to that in all India.

6. Changes in proportion (per 1000) of ailing persons (PAP) during reference period of last 15 days – Tamilnadu and All India
The morbidity prevalence rate has increased significantly from 95 to 165 per thousand population during the period 2004 to 2014.
the perception of being ´ill´ can vary systematically by cultural, regional and other socio-demographic factors including expectations for own health and disease awareness. For example, a person with simple cough and cold who belongs to a backward region is less likely to consider himself/herself  ´ill´ and may not report illness in the survey, as compared to a person from a developed region. 
due to differences in perception of illness, which may be influenced by age, gender, education, income, language and personal experience of illness.

7. Proportion of ailing population reporting chronic and/or other ailments by age group in Tamil Nadu – 2014
 Sector
Age groups in years
0-4
1-14
15-29
30-44
45-59
60-69
70 & above
Total
Rural
Chronic 1 14 8 57
189
301
289 86
Other
191 77 41 59 54 42 13 63
All
192 91 48
111
234
335
298
146
Urban 5 9 15 85
239
512
434
120
166 72 65
101 71
171 80 62
306
551
487
184 3 12
212
406
354
103
179 75 44 66 45 53 67
182 55
126
268
443
383
165
the share of chronic ailments in total ailments increases with increasing age;
The disaggregated data on morbidity prevalence showed a ‘J’ shaped relationship between age and morbidity which indicates the fact that elders and children are susceptible to higher prevalence of illness.

8. Policy Relevance
Does higher levels of illness reported indeed reflects higher real burden of illness?
Not Necessarily!
Change in the composition of the demography
Change in level of Expectations for own health
Change in cultural, regional and other socio-demographic factors (higher literacy, urbanisation)
increase in Awareness about diseases & improved Access (better health system)

9. Gender wise distribution of reporting of chronic and/or other ailments by age groups in Tamil Nadu – 2014

10. Percentage distribution of reported disease conditions (Top 10) among all ailing persons (15 days recall)_2014
Males report significantly higher share in comparison to women— diabetes (30.1% versus 21.8%) and respiratory diseases (12.2% versus 8.9%). Women have higher reporting of musculo-skeletal ailments (13.5% in women versus 6.6% in men), mental health problems (6% in women versus 2.3% in men) and genito-urinary ailments (2.4% in women versus 0.6% in men)

11. Sector wise Distribution of reported disease conditions of major ailments in Tamil Nadu_2014

12. Policy Relevance

13. Concentration curves and Concentration Indices
Policy Relevance
CI: 0.015
CI:-0.028
71st Round
71st Round
Communicable Diseases
Non-Communicable Diseases

14. Probit Results of Illness Prevalence in Tamil Nadu
Probit Regression Results
2014
Independent Variables
Coefficient
HH Size
***
Sector (Ref category : Rural)
Urban
***
Education (Ref category: Illiterate)
Upto Primary
***
Above Primary
Income (Ref category :Poorest)
2nd Poorest
Middle
***
2nd Richest
***
Richest
***
Social Group (Ref category: SC/ST) SC
OBC
Others
Sex (Ref category :Male)
Female
***
Age (Ref category: 0-4)
5 to 9
***
10 to 14
***
15 to 29
***
30 to 44
***
45 to 59
***
Above 60
***
Constant
Note: ***(Significant at less than 1% ), **(Significant at less than 5%) *(Significant at less than 10%)
Probit Results of Illness Prevalence in Tamil Nadu
Policy Relevance
strong evidence of reporting differences by age, gender, income, education.
Individuals from households with high consumption tend to have more probability of self reporting.
We found strong evidence of reporting differences by age, gender, income, education. ( are the main socioeconomic determinants of self reporting). individuals from households with high consumption tend to have more probability of self reporting. Persons living in urban area have the higher probability to report an ailment compared to those who live in rural areas. The probability of reporting decreases with increases in household size.
Persons living in urban area have the higher probability to report an ailment compared to those who live in rural areas.

15. Utilisation of Healthcare

16. Percentage of population utilising healthcare as outpatient and inpatient – All India and Tamilnadu
Notes: 1. Outpatient and hospitalisation (15days recall) are not mutually exclusive; 2. Hospitalisation with 365 days recall includes hospitalisation with 15 days recall; per 1000 population.

17. Percentage population utilising hospital services as inpatient in Tamilnadu and All India during , 2004 and 2014

18. Trend in % episodes (15 days recall) treated in formal care in TN and All India in , 2004 and 2014

19. Trend in share of public sector in total outpatient care in Tamilnadu and All India during , 2004 and 2014.

20. % share of disease categories % share of Public sector
Share of major disease categories treated in public and private sector as outpatient and share of public sector in each major disease categories
Disease categories
% share of disease categories
% share of Public sector
Public
Private
All
Diabetes
27.1
28.4 28
33.5
Fever*
12.7
22.5
19.1 23
Cardiovascular 22
15.4
17.7
42.9
Musculoskeletal
12.8 9
10.3
42.8
Respiratory
8.4
8.1
8.2
35.6
Gastro
4.9
3.6
4.1
41.7
Mental/Neuro
4.5 3
3.5
44.2
Skin
1.6
2.3 2
26.9
Eye/Ear 1
1.4
25.6
Genito-urinary
1.3
32.8
Injuries
0.6
0.8
52.6
Other Metabolic
0.5
0.9
20.6
Vector-borne
0.2
0.7
11.2
Cancers
44.5
Blood disease
0.3
5.2
Obstetric
0.1
25.5
TB/Filer/Tetanus
STD/HIV/AIDS
100
Others
0.74
1.26
1.08
23.69
Total
34.57
the four major disease categories (diabetes, cardiovascular, musculoskeletal and respiratory diseases) constitute more than 64%of all the conditions treated as outpatient.

21. Share of public sector in total hospitalisation in Tamilnadu and All India over the years

22. % share of treated disease in % share of public in each disease
Percentage distribution of treated disease conditions in public and private hospitals and percentage share of public hospital in the treatment of each disease in Tamil Nadu – 2014
Disease conditions
% share of treated disease in
% share of public in each disease
Public
Private
Public + Private
Fever
23.5
17.8
19.8
41.1
Injuries
13.6
9.8
11.1
42.5
Cardio
11.0
34.5
Gastro
8.3
8.4
34.3
Genitourinary
5.8
9.5
8.2
24.5
Eye/Ear
4.1
10.4
17.13
Mental/Neuro
7.4
3.8
5.1
50.5
Vector borne
4.9
5.0
34.1
Musculoskeletal
2.7
6.0
19.1
Respiratory
4.2
4.8
4.6
31.77
Diabetes
2.6
3.6
25.4
Cancers
2.3
1.9
2.1
38.9
Others
2.4
1.7
2.0
43.1
Obstetric
2.9
1.4
52.9
Blood disease
1.2
1.6
1.5 29
Skin
1.1
1.3
29.33
TB/Filer/Tetanus
0.6
1.0
59.9
Other Metabolic
0.3
0.7
18.34
STD/HIV/AIDS
0.1
0.0
100.0
All
100
34.63

23. Average (mean) length of stay of hospitalized rural and urban Population in Tamilnadu
Sector
Public
Private
Total
Rural
9.8 (6)
6.3 (4)
7.7 (5)
Urban
9.6 (6)
7.3 (5)
8 (5)
Rural + Urban
9.7 (6)
6.8 (4)
7.8 (5)
Note: 1:Values in parenthesis are median, 2: Excluding child birth cases

24. Share of public and private sectors in total hospital care utilisation by Socio-economic groups in Tamilnadu, 2014

25. Distribution (%) of all inpatient episodes in public and private hospitals by types of wards in TN and All India

26. Log likelihood = -876.43699 Pseudo R2 = 0.0802
Treatment
Odds Ratio
P>z
[95% CI]
hhsize
0.95
0.20
0.89
1.02
Sector (Ref: Rural)
Urban
0.88
0.35
0.67
1.16
Education (Ref:illiterate)
Upto primary
0.52
0.00
0.37
0.72
Above primary
0.47
0.34
0.64
Quintile (Ref: Poorest)
2ndpoorest
2.05
1.35
3.11
Middle
1.81
0.01
1.17
2.80
2ndrichest
1.50
0.05
0.99
2.27
Richest
0.85
2.14
Social Group (Ref: SC/ST)
OBC
0.91
0.57
0.66
1.26
Others
1.53
0.36
0.62
3.78
Sex (Ref: Male)
Female
0.76
0.04
0.59
Religion (Ref: Hindu)
Islam
0.96
1.56
Christianity
0.22
0.48
1.18
Scheme (Ref: Yes) No
0.60
0.42
Chronic (Ref: Yes)
0.26
_cons
55.10
30.29
100.20
Policy Relevance
Logistic Regression Results of Health Seeking Behavior in Tamil Nadu
Household from rural area, male members , education, economic status, ailment condition (chronic), insurance schemes are more likely to seek health care .
Household from the 2nd quintile is more likely (2.05) to seek health care if fallen ill, compared to the household from poorest quintile.
Females are 24% less likely to seek care compared to the male counterpart.

27. Reasons for not seeking medical advice
Policy Relevance

28. Reasons for not availing Government Facility
Policy Relevance

29. Out-of-pocket Burden; and Financial Risk Protection
the expenditure on outpatient experienced an increase from Rs 114 to Rs 158 between and 2004.
the average hospitalization expenditure has gone up by 90% from Rs rose to Rs.6,285 in 2014.

30. Average out of pocket per OP visit and per hospitalisation case (per admission): medical expenditure (Rs.) and non-medical expenditure (Rs.)
Type of expenditure
Public sector
Private sector
Public + Private
Out-patient
Medical 40
603
406
Non-medical 50 94 79
Total 90
697
485
In-patient
600
27228
18006
1816
2456
2234
2416
29684
20240

31. Percentage population covered under different schemes for financial support to meet expenditure in Tamilnadu, 2014

32. Share (%) of different sources of health expenditure financing for outpatient and inpatient in TN and All India, 2014
Note: Only first source of finance has been considered

33. Maternity and Child Healthcare

34. Distribution of women aged 15-49 by place of childbirth
Share of Public sector in total pre- and post-natal care in Tamilnadu is 56.1 and respectively.
Distribution of women aged by place of childbirth

35. Equity in distribution (%) of place of childbirth amongst women (aged 15-49) in TN, 2014

36. Important Observations
The evidence of disaggregated morbidity prevalence in India showed a ‘J’ shaped relationship between age and morbidity, an indication that elders and children are susceptible to higher prevalence of illness
The age pyramid in Tamil Nadu reflects considerably higher bulging at higher age groups. chronic ailment significantly increases after the age of 45 years; and the share of chronic ailments in total ailments increases with increasing age.
Gender differences: are observed with women reporting higher levels of morbidity than men. The outpatient utilization rate in Tamil Nadu is higher among females (17.1%) than among males (12.7%).
disease burden between rural and urban population: greater burden among urban population than in rural population
Level of education, economic profile, HH size and Gender, Age are the major determinants of self-reporting.

37. The share of public institutions in all the rural outpatient episodes is approximately 50% as against less than 29% in the urban areas.
the public sector significantly increased its share in the total outpatient care from 26.3 % in to 34.6% in 2014.
In the public sector hospitals, almost all the episodes (99.4%) were admitted free of any ward-charge as against the all India average of 85%.
Drugs constitute the single largest proportion of the total OOPE (56% ) for outpatient.
Outpatient OOPE among the richest quintile households is Rs. 332 as against Rs. 74 among the poorest.
Total OOPE constitutes up to 11-12% of the total monthly per person consumption expenditure.

38. Thank you