1. Results of study in five states of India Study Conducted by Study supported by Oxfam India Prayas, Rajasthan

2. Partner Organisations: Rashtriya Grameen Vikas Nidhi, Assam Child In Need Institute, Jharkhand Rural Women’s Social Education Centre, Tamilnadu Chirag, Uttarakhand

3.  OoPE are non-reimbursable fees which a patient or family is responsible for paying directly to health practitioners or suppliers, without intervention of a third party. It often occurs, when publicly funded facilities are unable to provide the required health services and supplies for free or through insurance.  India was ranked as having the 42nd highest average OoPE, with 74.4% of private expenditure being paid as out of pocket. (WHS 2011)  OoPE accounts for an average increase in poverty by as much as 3.6 and 2.9 percent for rural and urban India respectively (Gupta 2009) Out of Pocket Expenditure (Oope) in Health Care

4. Spending on Health in Different Economies of World WHO, World Health Report 2008

5. Aim of the Study  Assess the nature of out of pocket payments of households in health care and examine its relationship with post 2004 new nation wide health initiatives viz. NRHM, RSBY and many state led programmes. Objectives of Study  Assess the change in out-of-pocket expenditure of households for health care between 2004-10.  Examine the change in OoP expenditure in various social and economic groups.  Analyse the pattern of OoP expenditure in relation to various parameters of new post 2004 national health initiatives viz. NRHM & RSBY

6. 6 Research questions  Is there any reduction or increase in out-of-pocket expenditure for households on health care post 2004?  Is there any reduction or increase in out-of-pocket expenditure on health care in proportion to total consumption expenditure of households?  Is there any difference in the pattern of OoP across different (a) social and (b) economic categories?  Is there any effect of post 2004 new national health programmes on the pattern of out-of-pocket expenditure on health care?

7. 7 Sampling strategy  Districts and village in states were selected through PPS technique (Probability Proportional to Size Sampling Technique).  Sample size was fixed to 200 HH per district. This was obtained by selecting 10 villages per district and 20 households per village. S. No.StateDistrict 1.AssamKamrup 2.Sonitpur 3.Cachar 4.JharkhandSahibganj 5.Purbi Singhbhum 6.RajasthanBharatpur 7.Nagaur 8.Tonk 9.Baran 10.TamilnaduVellore 11.Coimbatore 12.Virudhunagar 13.UttarakhandTehri Garhwal 14.Nainital  Number of States : 5  Number of Districts : 14  Number of Villages : 140  Number of Households surveyed: 2723

8. Sample design  Stratified multi-stage design The first stage units (FSU) were the 2001 census villages. The ultimate stage units (USU) were households in villages. In case of large villages requiring hamlet-group (hg) formation, one intermediate stage was the selection of two hg’s from each FSU. Formation of Second Stage Strata and allocation of households Composition of SSSNo. of households to be surveyed Without hg formation With hg formation (for each hg) SSS 1Households with at least one member hospitalized during last 365 days 84 SSS 2From the remaining households, households having at least one child of age group 12-23 months 42 SSS 3Other households84

9. Survey tool  Survey tool was adapted from NSSO 60th round.  There were two schedules – for listing of households and for in-depth interview of selected households  Field data of the study was collected in the months from March to May 2011

10. Profile of the sample group Background Variables Percentage TotalAssamJharkhandRajasthanTamil NaduUttarakhand Sex Male50.251.350.15249.445.3 Female49.848.749.94850.654.7 Age Group 0-1432.432.539.532.725.331.9 15-2928.627.725.531.227.628.6 30-4419.523.318.716.923.117.0 45-5911.510.19.811.714.311.2 60+8.06.46.57.49.711.3 Religion Hindu82.567.151.293.994.5100 Islam11.627.523.16.12.1- Christian2.25.44.1-3.4- Others3.7-21.6--- Social Group ST15.224.926.417.6-0.1 SC19.79.914.818.234.824.9 OBC40.026.453.551.354.90.7 Others25.138.75.312.810.974.2 Literacy Illiterate24.21234.527.512.315.4 Literate75.88865.572.587.784.6

11. Basic Household Amenities and Infrastructure S.N o Household Characteristics Percentage TotalAssamJharkhandRajasthanTamilnaduUttarakhand 1. Household Type Pucca39.69.5943.149.895.4 Semi Pucca22.625.323.715.442.41.3 Kachha37.865.267.341.67.83.2 2 Source of Drinking Water Tap38.91.90.321.599.079.0 Tube Well/Handpump 36.141.174.056.40.03.0 Pucca Well11.721.921.613.20.20.3 Others13.335.14.18.90.817.7 3.Bathroom Facility38474136766 4.Toilet Facility31565122766 5. Distribution of Household by MPCE (Monthly Per Capita Expenditure) MPCE less than 50015.419.923.718.78.83 MPCE 500-100051.350.260.166.941.626.1 MPCE 1000-20002626.414.413.434.550.4 MPCE 2000 and above 7.43.61.8115.120.5

12. S.NoHousehold CharacteristicsPercentage SC/STOBCOthers 1. Distribution of type of household by social group Pucca28.738.356.1 Semi Pucca19.329.915.5 Kachha51.931.828.3 2. Distribution of main source of drinking water by social group Tap31.94046.4 Tube Well/Handpump43.23823.6 Pucca Well12.9138 Others12921.9 3 Distribution of household having bathroom facility by social group 27.235.257 4Distribution of household having toilet facility by social group 17.827.156 Basic Household Amenities and Infrastructure

13. Morbidity and Health Care (Non-hospitalised case)

14. Proportion of Ailing persons (per 1000) during last 15 days prior to the survey

15. Proportion of Ailing persons (per 1000) during last 15 days prior to the survey (Comparison with NSSO 60 th round)

16. Proportion of Ailing Persons (per 1000) during last 15 days by sex and age group

17. Proportion of Ailing Persons (per 1000) during last 15 days by socio-economic characteristics

18. Proportion (Per 1000) of persons ailing and Proportion of persons reported commencement of ailment one day before the survey

19. Proportion (per 1000) of ailing persons treated in outpatient

20. Proportion (per 1000) of ailing persons treated in outpatient (Comparison with NSSO 60 th round)

21. Proportion (per 1000) of untreated spells of ailment by reason for no treatment and comparison with NSSO 60 th round

22. Per 1000 distribution of treated spells of ailments during 15 days by source of treatment for each MPCE class and social group

23. Per 1000 distribution of treated spells of ailments during 15 days by source of treatment (Comparison with NSSO 60 th round)

24. Average total expenditure (Rs.), Average total medical expenditure (Rs.) and expenditure on medicine (Rs.) for non-hospitalized treatment per ailing person during last 15 days

25. Average total expenditure (Rs.) for non hospitalized treatment for each MPCE class

26. Average total expenditure (Rs.), Average total medical expenditure (Rs.) and other expenditure (Rs.) for non-hospitalized treatment per ailing person during last 15 days (Comparison with NSSO 60 th round)

27. Proportion (per 1000) of household expenditure on treatment during last 15 days by source of finance for each MPCE class

28. Morbidity and Health Care (Hospitalised case)

29. Proportion (per 1000) of population hospitalized during last 365 days

30. Proportion (per 1000) of population hospitalized during last 365 days (Comparison with NSSO 60 th round)

31. Proportion (per 1000) of population hospitalized by MPCE class

32. Per 1000 distribution of persons hospitalized by type of ailment

33. Proportion (per 1000) of hospitalized cases by type of hospital

34. Proportion (per 1000) of hospitalized cases by type of hospital (Comparison with NSSO 60 th round)

35. Proportion (per 1000) of hospitalized cases by type of hospital in each MPCE class

36. Average Duration of Stay (in days) in Hospital by Type of Hospital

37. Average Medical Expenditure (Rs.) per hospitalization by sex and type of hospital

38. Average medical expenditure per hospitalization by type of hospital for each household MPCE class

39. Average total expenditure (Rs.), Average total medical expenditure (Rs.) and expenditure on medicine (Rs.) for hospitalized case in last 365 days

40. Average total expenditure (Rs.), Average total medical expenditure (Rs.) and other expenditure (Rs.) for per hospitalized case during last 365 days (Comparison with NSSO 60 th round)

41. Proportion (per 1000) of household expenditure on treatment during last 15 days by source of finance for each MPCE class

42. Maternal and Child Health

43. Proportion of children Immunized (per 1000)

44. Expenditure incurred on Immunization (in Rs.)

45. Per 1000 distribution of childbirth by place of delivery for each broad age group

46. Average expenditure (in Rs.) per childbirth by place of delivery

47. Proportion (per 1000) of women who availed antenatal care services (PWANC) by source of institution for availing the facilities

48. Average expenditure (Rs.) on antenatal care services (ANC) by woman by source of service

49. Proportion (per 1000) of women who availed post-natal care services (PWPNC) by source of institution for availing the facilities

50. Average expenditure (Rs.) on post-natal care services (PNC) by woman by source of service

51. Change in oop spending and treatment seeking from public institutions between 2004 - 2011 Average expenditure (Rs.) for non-hospitalised per ailing person All (avg. of 5 states) AssamJharkhandRajasthanTamil NaduUttrakhand NSSO 60 th round(2004) 365261370436208551 NSSO 60 th round after inflation adjusted 628449636750358948 Prayas study(2011)1063530105958818481732 % change69.26 %18.04 %66.50%- 21.60 %416.20 %82.70 % All (avg. of 5 states) AssamJharkhandRajasthanTamil NaduUttrakhand NSSO 60 th round(2004) 262270130440290180 Prayas study(2011) 54185764490310656 % change106.48 %217.40 %-50.76 %11.36 %6.89 %264.44 % Non –hospitalized ailing persons (per 1000) seeking care from public health institutions

52. Change in oop spending and treatment seeking by from public facilities between 2004 & 2011 Average expenditure (Rs.) for hospitalised per ailing person All (avg. of five states) AssamJharkhandRajasthanTamil Nadu Uttrakhand NSSO 60 th round(2004)6967469753388294577510731 NSSO 60 th round after inflation adjusted 119838079918114266993318457 Prayas study(2011)1470455629069176201833120905 % change22.70 %- 31.15 %- 1.22 %23.51 %84.54 %13.26 % All (avg. of five states) AssamJharkhandRajasthanTamil Nadu Uttrakhand NSSO 60 th round (2004)514742466521408431 Prayas study (2011)479847195553271408 % change- 6.80 %14.15 %-58.15 %6.14 %-33.57 %-5.33 % Hospitalized persons (per 1000) seeking care from public health institutions

53. Chief findings of the study  There is three fold increase in oope in out patients and two fold increase in hospitalised patients.  Tamilnadu which supposedly has better public health system and free medicine scheme since 1995 has recorded highest increase in oope amongst out patients.  Maximum oope in Tamilnadu is on medical expenditure other than medicines.

54. Chief findings of the study  Significant rise in out patients seeking care from public health institutions but marginal decline in hospitalised patients.  Jharkhand showed highest decline in use of public health facilities both by hospitalised and non-hospitalised patients.

55. Lessons learnt  Oope is an important indicator to determine over all health services utilisation.  Oope assessment assists in identification of the components of health services which require improvement. For instance in Tamilnadu, there is a need to examine the quality and actual availability of public health services to arrest decline in utilisation of public health services.

56. Recommendations Urgent need to reduce oope considerably.  Expenditure on medicine ought to be completely eliminated.  other medical expenditure also should be close to zero in all public and trust (charitable) hospitals.  Oope relating to total medical expenditure should be considerably reduced by increasing physical access.  Quality of care provided by the health institutions is required to be strictly as per IPHS guidelines both in public and private.

57. Recommendations  Private practice by the providers of public health system should be completely banned.  User fee completely aolished.  Standard treatment guidelines are required to be followed by all health service providers and directorates of rational therapeutics should be established at national and state headquarters.

58. Recommendations  Accessibility and quality of health services ought to be evaluated and monitored through community groups regularly for feedback and improvements.

59.  Thank you