HEALTHCARE UTILIZATION AND EXPENDITURE

PATTERN:
A CASE STUDY OF BPL FAMILIES IN BHARATHEEPURAM,
YEROOR PANCHAYATH

DISSERTATION
Submitted to University of Kerala in partial fulfilment of
requirements of the award of the Degree of

MASTER OF ARTS IN ECONOMICS

UNIVERSITY OF KERALA
2022
 CONTENTS

Sl No Chapters Page No

1 Introduction 1-6

2 Review of Literature 7-12

3 An Overview of Health Status in 13-21

India and Kerala

4 Data Analysis 22-50

5 Findings, Suggestions and 51-55

Conclusion

6 Bibliography 56-59

7 Appendix 60-64
 LIST OF
TABLES AND DIAGRAMS

Sl Table/Diagram Chapters Page

No No No
1 4.1 Age Distribution 23
2 4.2 Type of Family 24
3 4.3 Pattern of Settlement 25
4 4.4 Religion wise Division 26
5 4.5 Gender Wise Distribution 27
6 4.6 Social Group 28
7 4.7 Marital Status 29
8 4.8 Educational Qualification 30
9 4.9 Ownership of House 31
10 4.10 Habitat Details 32
11 4.11 Ownership of Land 33
12 4.12 Occupation wise distribution 34
13 4.13 Total Income 35
14 4.14 Type of Disease faced by Sample 36-37
Unit
15 4.15 Use of intoxicants 38
16 4.16 System of Treatment Preferred 39
17 4.17 Place of Treatment Preferred 40
18 4.18 Out of pocket expenditure 41
19 4.19 Able to met health expenditure 42
with you income
20 4.20 Source of financing for health 43
expenditure
21 4.21 Are you covered by any health 44
insurance scheme
22 4.22 Households enrollment in 45
insurance
23 4.23 Financial situation been affected 46
by medical expense
24 4.24 Reason for selecting health care 47
services
25 4.25 Problem to access government 48-49
hospital
26 4.26 Problem to access private 50
hospital
CHAPTER 1

INTRODUCTION

India is the second largest populated country in the world. Health is an important
determinant of wellbeing and health care is regarded as a public right and an important
responsibility of government is to provide the care to all people respective of race, religion,
caste or creed, rural or urban, rich or poor and so on.

The basis for the state’s health standards is the state-wide infrastructure of primary
health centres. There are over 9491 government and private medical institutions in the state,
which have about 38000 beds for the total population, making the population to bed ratio 879
one of the highest in the country.

Health status is generally measured in terms of mortality indicators like death rate,
infant mortality rate and expectation of life at birth among others. Mortality indicators shows
that health status of Kerala is far advanced and higher than the all India average and is even
comparable with developed countries. This outstanding progress of health status is achieved
through widespread growth of the 3 systems of medicine in public, private, corporative sectors
companied with peoples health awareness .Though Kerala has attained better healthcare
indicators, people are now facing the problem of high morbidity both from communicable and
non-communicable diseases. Kerala is having the highest number of healthcare institutions as
per the 1991 census. About 26% of total healthcare institutions in India are located in Kerala.

The improvement of the health status of people is connected to number of factors such
as household income, public expenditure on healthcare delivery system, availability of private
healthcare facilities and general environmental conditions affecting incidence of diseases.

Kerala’s rating of HDI is 0.790 is the highest in India, resulting mainly from the vast
improvements the state has made in the fields of sanitation, health, education and poverty

1
reduction. The states poverty rates lingers at 7.05%. Thus Kerala has the highest literacy rate
in India 93.91% (census of India 2011) and life expectancy is now the highest in India.

The sixth five year pan adopted the goal of “health for all”. In 1983 the first National
Health Policy (NHP) was announced. Most recently The Ministry of health Development of
India prepared the National Health Policy 2002. The main objective of NHP 2002 is to achieve
an acceptable standard of good health among the general population of the country.

In India, there is a significantly large public health care sector, the larger provide health
sector mostly of curative care completely weakness the former presence. The National Sample
Survey Organisation (NSSO) data clearly shows a major decline in utilisation of public health
care facilities for inpatient care and a corresponding increase in utilisation of the same from
public health providers in both rural and urban areas of the country. Despite the higher cost in
the private sector, this shift shows that the people are losing trust in the public health care
system. The reason for low utilisation of public health care sector appear critical shortage of
health personnel, inadequate incentive, poor working condition, lack of transparency in posting
doctors in rural areas, poor outreach, time of services, inadequate salary and poor monitoring
of services or facilities. The availability of the infrastructure and manpower in terms of quantity
is almost precondition for achieving better healthcare services.

The health infrastructure in India has a long way to go towards achieving 100% quality
technology and superior healthcare delivery system. The private sector provides 80% of the
healthcare services and 20% are provided by the government,. India’s private health sector
accounts for about 80% outpatient treatment for both rich and poor, more than 55% of all
inpatient admissions or hospitalisations or 40% of prenatal care, 55% of institutional deliveries
and as low as 10% of immunisation delivered. It provides 40% of hospitalisation for the poor
and 60% for the privileged.

In India the general government expenditure on health was only 1.36% of the GDP in
2012-13 estimates. The public expenditure represented 1.28% of GDP as of 2013. It’s the

2
highest value over the past 18 years was 1.28% of GDP in 2013, while its lowest value was
1.00% of GDP in 2005. However the private health expenditure was 2.69% of GDP as of 2013.
It’s the highest value over the past 18 years was 3.56% of GDP in 2004 while its lowest value
was 2.69% of GDP in 2012.

Kerala has made significant gains in health indices like high life expectancy, low infant
mortality rate, birth-rate and death rate. The state must ensure that these things are sustains.
Besides, the state also needs to address problems of lifestyle diseases (non-communicable
diseases) like diabetes, hyper tension, coronary heart diseases, cancer and geriatric problems.
Increasing incidents of communicable diseases like chikungunya, dengue, leptospirosis, swing
flu are also a major cause of concern. The health status of the marginalised communities like
Adivasis and fishing workers is also poor compared to that of general population. To tackle
these, concerted and committed efforts with proper inter sectoral co-ordination is essential. The
effort to improve the health status of the population is a major thrust and it is under the social
development program being undertaken in India. Public health program play a very significant
role in physical and mental wellbeing of every nation. The improved health status of the people
helps the process of economic development in a positive way.

In Kerala the disturbing trend is that the public healthcare system is getting alienated
from the people since 1980’s. about 30% of the lower income families seeks medical services
from the government hospitals. In the present situation, the rate of utilisation of private sector
can be increased drastically pointed to the poor performance of public healthcare system. The
government hospitals have some problems like poor physical or infrastructural facilities,
ineffective leadership and unsatisfactory supply of drugs and medical supplies facility of
staffing procedure. These above stated problems do not exist in private hospitals. The poor
quality of services in public sector and the attraction of high tech facilities in private sector
diverted the people to private services. This shows that utilisation of healthcare services from
primary or lower level were reduced or shifted to higher or specialised centres. This was
probably due to increase in literacy level and expectations of high quality care.

3
SIGNIFICANCE OF THE STUDY

Ageing in India is leading to an increase in chronic diseases. Given the limited health
insurance coverage, this would lead to variety of economic and access-related consequences
for the households.

Chronic diseases (including cardio muscular and respiratory diseases, mental disorder,
diabetes and cancer) are leading causes of death and disability. There burden will continue to
increase during the next 25 years as a consequence of the rapidly ageing population in India.
Risk factors for chronic diseases are highly prevalent among the population. Although a wide
range of cost effective prevention strategies are available but there coverage or implementation
is generally low, especially among people who are poor and those living in rural areas.

Most healthcare is provided by the private sector which often causes high out-of-pocket
expenditure that lead to debt and impoverishment.

The present study attempt to advocate the need to strengthen public policy
commitments to chronic diseases and immediate action scale-up cost-effective intervention for
chronic disease. The significance of the study is really great. It is observed to compare the out-
of-pocket expenditure for treating the morbidity of government and private hospitals patients
in Kollam district.

4
 OBJECTIVES

1. To understand the socio-economic status of BPL families.

2. To analyse the treatment cost across different types of hospitals (private and public)
and examine the methods of the health care financing.
3. To examine the change in structure of health care system.
4. Possible suggestions and policy measure to improve the health conditions of BPL
families.

METHODOLOGY

Both primary and secondary data are used in the study. Available secondary data are
obtained from published sources such as journals, magazines, books, news papers and the
unpublished sources.

Since the available secondary data are found to be inadequate to carry out a
comprehensive analysis of the objectives of the study, a primary survey was conducted in
Bharatheepuram at Yeroor panchayat.

Households survey was conducted with questionnaires and interviews in yeroor

panchayat. For empirical supports 50 households from rural populations were randomly
selected and relevant data collected in order to comprehend their socio-economic status.

LIMITATIONS
➢ The study focused on BPL population based on ration card, hence there is a possibility for
omission of households without ration cards.
➢ The respondents especially women were reluctant to furnish proper information.
➢ The study has taken one year recall period for data collection. So the data available may not
be accurate.
➢ A few households with better standard of living have come under the study as they have BPL
ration cards.

5
CHAPTERISATION
This study has been derived into 5 chapters.

CHAPTER 1 : INTRODUCTION OF THE STUDY,

OBJECTIVES OF THE STUDY,

SIGNIFICANCE OF THE STUDY

METHODOLOGY,

CHAPTERISATION.

CHAPTER 2 : IT DEALS WITH REVIEW OF LITERATURE ABOUT PATTERN OF

HEALTHCARE EXPENDITURE IN INDIA, KERALA.

CHAPTER 3 : IT GIVES AN OVERVIEW ABOUT HEALTH STATUS IN INDIA AND

KERALA.

CHAPTER 4 : IT CARRIES OUT AN ANALYSIS OF THE PRIMARY DATA

COLLECTED FROM THE BHARATHEEPURAM LOCALITY IN YEROOR
PANCHAYAT.

CHAPTER 5 : IT BRINGS THE SUMMARY FINDINGS AND SUGGESTIONS OF THE

STUDY.

6
CHAPTER 2

REVIEW OF LITERATURE

P.G.K Panikar (1992) this article explains that In spite of a wide network of public sector
medical care institutions, where medical services are supposed to be easily accessible and
freely available, private expenditure on medical care in Kerala remains very high.

Ramesh Bhat (1993) The objective of the study are to review the role of private healthcare
sector in India and the policy concerns it engenders policy interventions in health should not
ignore their existence and this sector should be explicitly involved in health management
process.

V B Tulasidhar (1993) this study highlights recent changes in the allocation of resources to
reviewed and an attempt is made to identify the threats to sustainability of present levels o
spending on health care.

Brijesh C Purohit and Tasleem A Siddiqui (1994) had explained the pattern of utilisation in
our country had some desirable outcomes namely, growing popularity of indigeneous non-
allopathic system and growth in private sectors involvement in expensive tertiary care.

S K Sangal (1996) In his article “Household Financing of Health care” had identified health
care expenditure and utilisation of elicit information on pattern of household expenditure on
government and private sources of treatment, changes in utilisation pattern and differentials
across economic classes. Revenue earnings of hospitals are computed to arrive at plausible
macro level estimates of additional resources which could be generated from small and large
hospitals.

T P Kunjukannan and K P Aravindan (1996) has made a sincere attempt to study the
household expenditure covering a small but representative sample over the last 4 years shows
that medical expenditure has risen sharply.

7
Harold Alderman and Victor Lavy (1996) this article describes the types of services for
which households indicate they are willing to pay increased fees. It also indicates the potential
gains from improving these services as well as the consequences of moving faster on cost
recovery than on providing improved or better targeted services.

Basanta K Pradhan, P K Roy, M R Saluja and Shanta Venkartram (2000) This paper is
based on the most recent primary household level data obtained from a survey on income,
expenditure, poverty measures for 1994-95 and human development indicators for 1996 in
rural and urban India as a part of the project Micro Impact of Macro and Adjustment Policies
(MIMAP).Empirica; results shows wide disparities in levels of living in terms of economic and
social indicators in rural and urban India. This survey shows the changes in pattern of income
distribution and the gap between the shares of income in rural and urban areas during the last
two decades.

Ramankutty V (2000) this paper explains that many developments outside health probably
fuelled the demand for healthcare already created by increased access to health facilities. Since
the government institutions could not grow in number and quantity at a rate that would have
satisfied this demand, health sector development in Kerala after the mid 1980 has been
dominated by the private sector. Expansion in private facilities in health has been closely linked
to developments in the government health sector.

Rajeev Sadanandan (2001) the author explained that one of the reason cited to justify
government intervention in healthcare is to correct the inequities in service provision that might
arise if services are provided by private sector. But in practice governments decisions are taken
by a few individuals and groups and these decisions might reflect there interests than that of
the community.

Albert Lee (2003) while evaluating the primary healthcare research in Hong Kong, point out
that the need to have a strong primary health care team with trained family physicians and
trained health professionals, rehabilitation and supporting self help activities of individuals,

8
families, groups. This would minimize compartmentalization in health care delivery and is also
a cost effective way of providing high quality care that meets the need of the majority of
population.

Ashish Thomas George (2005) Based on NSSO 55th round data shows that a high percentage
of the population spends a substantial amount of its monthly income on health care, this
analysis also reveals that individuals at the lower end of income adder spend a disproportionate
share of their income on health. Given Kerala’s growing unregulated private health sector and
the limited coverage by public health care, this calls for a rethink on providing “good health at
low cost”.

Mohammad Sohail (2005) this paper deals with accessibility and quality issues of health
sector reforms since 1998. The results indicate that majority of service users are dissatisfied
with the existing levels of quality of care at the public health care institutions.

Ramesh Bhat and Nishant Jain (2006) had observed that the financing of healthcare a
significant bearing on the way healthcare is delivered and also has implications for the health
policy goals of equity, efficiency and sustainability. This paper examines the relationship
between income and public and private healthcare expenditure.

Jeffrey Hammer, Yamini Aiyar and Salimah Samji(2007) the paper develops an analytical
framework to understand the status of healthcare in India. High absenteeism, low quality in
clinical care, low satisfaction levels with care and rampart corruption plague public services
in India. This had led to mistrust of the system and the rapid growth of private services.

William Joe, U S Mishra and K Navaneetham (2008) has made sincere attempt to
comprehend the relationship between income inequality and health status in the Indian context,
the analysis reveals that the degree of health inequalities escalates when the rising average
income levels of the population are accompanied by raising income inequalities.

9
Charu C Garg and Anup K Karan (2009) this paper aims to access the differential impact
of out-of-pocket expenditure and its components such as expenditure on impatient care,
different incomes quintiles, between developed and less developed regions in India. It also
attempt to measure poverty at disaggregated rural-urban and state level.

Anbari Ali, Sirajon Noor Ghani, Hematram Yadev, Aqil Mohammad Daher (2010) has
identified the improvement are required to achieve high quality health care services in the
private hospitals in Yemen and increase loyalty among patients. Findings from this study could
inform private sector healthcare developed in low and middle income countries.

T R Dilip (2010) This research aimed at understanding changes in the consumption of inpatient
care services from private hospitals between 1986 and 2004, with a particular focus on
equitable outreach. However while the gap inn utilisation has closed , the burden of out-of-
pocket expenditure is higher among the poor.

Chandan Kumar, Ravi Prakash (2011) in the article “public-private dichotomy in utilisation
of health care services in India”, attempts to highlight the differences in utilisation of healthcare
services provided by the public and private hospitals.

Peter Berman, Rajeev Ahuja and Laveesh Bhandari (2010) This paper analysis of the
NSSO survey data with some new approaches to correcting some of the biases in previous
assessments of the “impoverishing” effect of health spending the results suggests that the extent
of impoverishment due to health care payment ids higher that previously reported.
Furthermore, outpatient care is more impoverishing than inpatient care in urban and rural areas
alike.

Chandan kumar, Ravi Prekash (2011) In the article “Public-private dichotomy in utilisation
of health care services in India”, attempts to highlight the differences in utilization of health
care services provided by the public and private hospitals.

C.U Thresia (2013) In her comprehensive study investigating the public health challenges and

10
associated medical care induced impoverishment. This study argues that the fundamental roots
cause of heath challenges. In these regions are often neglected in policy and in practice and
that policy makers, planners and researchers should make it a priority to address health
inequities.

Shankar Prinja, Man Inder Kumar, Andrew D Pinto, Stephen Jan and Rajesh Kumar
(2013) Had observed the situation in India, the use of public and private sector hospital services
economic class was analysed and the relationship between utilisation and public sending on
health services and the reported out-of-pocket payment where accessed. High out-of-pocket
expenditure corrected with high degree of inequity and was a likely barrier to accessing care
for the poor.

Mehamet Sahin Gok and Erkut Altindag (2014) This paper analysis the effects of the pay
for performance system (PFP)on the efficiencies of public and private hospitals in turkey. This
study shows that increased health cost might reduce efficiency in private hospitals in contact
the public hospitals.

Sanjay K Mohanty, Rajesh K Chauhan, Sumit Muzamdar and Akanksha Srivestava

(2014) According to national sample survey, 2009-2010, this paper test the hypothesis that the
monthly per capital household health spending of elderly household is significantly higher than
no elderly household in India. Based on the finding it suggest to increase access to health
insurance and public spending geriatric care to reduce out-of-pocket expenditure on health care
in India.

Debasis Barik, Sonalde Desai (2014) This book attempts to trace the nature of health care
expenditure. The world health organisation (WHO) estimates of causes of death in 2008
indicates that in the more developed regions, a majority of all deaths were attributable to non-
communicable diseases. Together with the high life expectancy at birth, the pattern of deaths
by cause reveals that this group of countries as in whole is the advanced stages of the
demographic and epidemiologic transition. India is in the middle stage of epidemiological
transition with a dual burden of diseases- communicable diseases among younger age
population and non-communicable diseases among population of age 45 years or more.
11
Healthcare system in India are ill-equipped to address these challenges. Healthcare spending
in India is slightly higher than the average spending of her south Asian neighbours, but
considerably lower than the developed nations.

Karekar Preshant, Aparna Tiwari, Saksham Agarwal (2015). Conducted a study was
centred around to access the distinction among government and private hospital benefit quality
in Yavatmal city. Sympathy, physical assets, conformation, courses of events and
responsiveness are the five quality measurement which are used as a part of request to estimate.
The patient’s observation about the service quality of government heating centres. This
examination was predominantly in light of essential information and to additionally presumed
that the private hospitals were conveyed better nature of governments to their patients when
contrasted with government hospitals.

Sankar P Sarma (2016). This study aimed to compare the sociodemographic, healthcare
utilisation patterns and out-of-pocket expenses of 149 uninsured below poverty line household
insured under the comprehensive health insurance scheme, through a comparative cross-
sectional study. The finds was only 40% of inpatient service utilisation among the insured was
covered by insurance. The mean out-of-pocket expenses for inpatient services among insured
was higher than among uninsured households.

Dhiman Das (2017). In article “Public expenditure and healthcare utilization: the case of
reproductive healthcare in India” discusses the important reasons for public interventions in
health in developing countries.

Tarundeep Singh, Nidhi Bhatnagar, Gopal Singh, Manmeet Kaur (2018). Main objective
of this study is to determine the pattern of healthcare utilization and extend of out-of-pocket
healthcare. Expenditure in rural areas of Punjab in India.

Findings of the study is that majority of the participants had used public sector health facilities
from outpatient and inpatient care. Expenditure in private sector was significantly higher
compared to the public sector facilities. Public sector facilities were utilised more often for
communicable disease, whereas private sector services were used more commonly for
accidents and non-communicable diseases
12
CHAPTER 3

AN OVERVIEW OF HEALTH STATUS IN INDIA AND KERALA

Health Status In India

India is the second most populated and the seventh largest country in the world. India
is home to over 1.21 billion people, the country’s birth rate at 21.8 for every thousand
population. That same year the country’s death rate was recorded at about 7.1 deaths for every
thousand inhabitants. Infant mortality has also been on a steady decline over the years due to
increased attention to providing special newborn care units, routine immunization and access
to basic mother and child care facilities. Despite the positive indicators, India had the highest
number of undernourished people in Asia pacific region. And even though undernourishment
was largely seen among low income families, it was surprisingly also observed among Indians
who were from higher socio-economic classes. Growing fast food consumption, unhealthy diet
trends and an inactive lifestyle were some f the main contributing factors for this.

Heart disease has been one of the leading causes of death in India for over two decades,
along with an increasing propensity for cancer and diabetes. India has made significant
progress in reducing the number of vector-borne-disease fatalities but it remains a problem in
many regions of the country. Life threatening diseases that were prevalent in the country where
dengue typhoid tuberculosis and HIV AIDS. In addition to this the share of Mental Health
disorders among adults stood at around 14.3%. Even the awareness about mental health and
access to help was relatively low in the country leading to high suicide rates.

In 2020 the coronavirus outbreak came as a blow to India this like the rest of the world.
The first cases were reported in the country in late February and since then the number of
infected people has been growing consistently

13
Health Status of Kerala

Kerala is a state in India on the Malabar coast in the southern west region of the country. Kerala
has an estimated population of 35 million up from 34.8 million in 2011. It is the most populous
state in India with an overall population density of 2200 people per square mile or 860 per
square kilometre. Kerala is home to almost 3 percentage of India's population and its land in 3
times more density settled than the rest of the country.

Kerala has a Human Development Index of 0.79 which is “very high” and the highest
in India. Kerala also has the highest literacy rates among all Indian states at 93.91% and life
expectancy of 74 years which is among the highest in the country.

In many respects Kerala health status is almost on a par with that of developed
economies. The state has succeeded in increasing life expectancy as well as reducing Infant
and Maternal mortalities.

The effective implementation of the public distribution of food played an important role
in improving nutritional status. Kerala publicly funded Healthcare system has help in providing
treatment facilities to people of all strata of society, the high literacy rate, especially among
females also played a major role in improving health scenario. The Kerala model of health is
often described as a “good health based on Social justice and equality”.

The health sector had begun to face crisis by early 1980s. Communicable diseases like
Malaria which were once eradicated came back and new viral diseases like dengue and
Chikungunya emerged. The incidence of non-communicable diseases (NCD) like diabetes
hypertension and cancer also increased.

Health status is generally measured in terms of mortality indicators like death rate,
infant mortality rate and expectation of life at birth among others. Mortality indicators shows
that the health status of Kerala is far advance higher than all India average and even some

14
variable with developed countries. This outstanding progress of health status is achieved
through widespread growth of the three systems of medicine in public private corporate is
combined with people's health awareness. The basic health indicators of Kerala and India are
given below.

Health Indicators of Kerala : Comparative figures of Major Health and Demographic Indicators
of State and National levels as per Census 2011 are given below:

Sl. No. Indicators Kerala India

1 Total population (in crore) (Census 2011) 3.34 121.06
2 Decadal Growth (per cent) (Census 2011) 4.9 17.7
3 Sex Ratio (Census 2011) 1084 943
4 Child Sex Ratio (Census 2011) 964 919
5 Birth Rate 14.8 21.8
6 Death Rate 7.6 7.1
7 Infant Mortality Rate 12 44

8 Neo Natal Mortality Rate 6 24

9 Perinatal Mortality Rate 10 23
10 Child Mortality Rate 2 9
11 Under 5 mortality Rate 11 39
12 Early Neo-natal Mortality Rate 4 18
13 Late Neo-natal Mortality Rate 2 5
14 Post Neo-natal Mortality Rate 4 11
15 Death Rate
(a) Children (0-4) 2.3 9.4
(b) Children (5-14) 0.2 0.6
(c) Persons (15-49) 2.5 3.1
(d) persons (60 and above) 43.5 41.9
(e) Per cent of death receiving medical attention*
Government 41.6 28.5
Private 35.8 17.7
Qualified professional 15.7 33.8

15
 Untrained/others 6.9 20.1
16 Total Fertility Rate 1.8 2.4
17 General Fertility Rate 54.2 81.2
18 Total Marital Fertility Rate 4.2 4.3
19 Gross Reproduction Rate 0.9 1.2
20 Maternal Mortality Ratio 46 130
21 Expectancy of Life at Birth 75.1 63.5
Male 72.2 62.6
Female 77.9 64.2

Kerala has made significant games in health in devices such as high life expectancy low
infant mortality rate birth rate and death rate. The people are now facing the problem of high
morbidity both from communicable diseases like (Chikungunya dengue leptospirosis swim
flow and non-communicable diseases like diabetes hypertension coronary heart disease cancer
and gastric problems

Kerala is having the highest number of Healthcare Institutions as per the 1991 census.
About 26 percentage of total Healthcare institutions in India are located in Kerala.

District wise details of health care institution, beds and waste generation are given

16
Major Health Problems in Kerala

Communicable diseases:

Kerala is witnessing an increasing burden of communicable and non-

communicable diseases. Although the State has been successful in controlling a number of
communicable diseases earlier, the emergence of dengue, chikungunya, leptospirosis, malaria,
hepatitis, H1N1, in recent years has led to considerable morbidity and mortality. Instances of
vector borne diseases like dengue, malaria, Japanese encephalitis, scrub typhus etc. have seen
a marked increase in many Districts. Water borne infections like different kinds of diarrhoeal
diseases, typhoid and hepatitis are showing persistence in many Districts. Cholera has surfaced
in many Districts after few years of relative low incidence. Vaccine preventable diseases like
diphtheria and whooping cough are yet to be eliminated despite years of effort.

Dengue:

Dengue fever, which surfaced in Kerala as early as 1998, has now become the
single largest vector borne disease. Till 2015, the disease was more prevalent in Districts like
Thiruvananthapuram, Kollam, Kottayam, Pathanamthitta, Kozhikode and Malappuram. But in
2017, all the Districts reported Dengue in large numbers. Districts located at higher altitudes
were having low prevalence, but all others showed high incidence. The main reason for this
wide spread distribution is believed to be due to the changes in the environmental factors
causing proliferation of the dengue vector-Aedes mosquitoes. These mosquitoes, which in the
earlier days seen more in rural settings have now spread to urban areas also.

Leptospirosis:

Leptospirosis is another emerging public health challenge faced by the State.

Considered as a rare disease in the early 1980’s, it has now spread to all Districts. In 2012-13
a major epidemic of the disease occurred, affecting most of the northern Districts, following
which the disease has become endemic in Kerala. Most recently the mortality due to
leptospirosis is also on the rise, and joint efforts of veterinary and animal husbandry
departments are essential for effective control of this disease. Out of the 1098 leptospirosis

17
cases reported in 2015, 43 deaths were reported. The number of cases increased to 1,710 with
35 deaths in 2016. In 2017, a total of 1,408 cases were confirmed resulting in 80 deaths. In
2018, there were 625 cases and 30 deaths reported upto September 2018.

Chikungunya:

Chikungunya is a newcomer among the vector borne infections. The past two years
have seen only sporadic cases in Kerala, annual total being less than 200 cases and no deaths.
In 2014, out of the 139 cases of chikungunya reported, 106 were from Thiruvananthapuram. In
2015, 104 cases were reported and 99 were from Thiruvananthapuram District alone, while it
was 90 and 67 respectively in 2016-17. A total of 20,46,455 viral fever cases were reported in
Kerala during 2014 and in 2015 it was 19,25,690 cases. It was15,41,441 cases in 2016-17 and
rose to 34,17,698 in 2017-18.

Water Borne Diseases:

There was a decrease in Acute Diarrhoeal Diseases (ADD) in 2018 compared to

previous years. There was a considerable decrease in typhoid in 2018, but death due to
suspected Hepatitis increased. The main reason for waterborne diseases is attributed to the
unavailability of safe drinking water in many parts of the District especially in tribal and coastal
areas. Health Department has formulated a yearlong action plan called “Jagratha” which will
be implemented from November 2017 to December 2018 for prevention and control of
communicable diseases.

The number of cases and deaths reported from 2017 to 2020 are given below:

Year 2017 2018 2019 2020

Disease cases death cases death cases death cases death

Dengue Fever 21993 165 4090 32 4651 14 2420 5

Malaria 1194 2 908 0 656 1 132 0

18
 Chikungunya 54 0 76 0 109 0 411 0

Japanese 1 0 5 2 11 2 0 0
Encephalitic

Leptospirosis 1408 80 2079 99 1211 57 568 19

Hepatitis - A 988 24 1369 5 1620 7 407 1

Cholera 8 1 9 0 9 0 2 0

Typhoid 314 1 109 0 27 0 0 0

Diarrhoea 463368 8 540814 12 544027 6 194193 1

Scrub Typhus 340 5 400 6 579 14 321 6

H1N1 1411 76 823 50 853 45 61 2

Measles 508 1 190 0 199 1 48 1

Chickenpox 12698 1 27856 20 29583 20 13719 1

Non-Communicable Diseases (NCD):

Common non-communicable diseases causing great threat to a healthy life are diabetes,
hypertension, cardio vascular diseases, cancer and lung diseases. Considering the high cost of
medicines and longer duration of treatment, this constitutes a greater financial burden to low
income groups.

In India, it is estimated that 42 percent of total death are due to NCDs. In Kerala, the
situation is more serious as more than 52 percent of the total death between the productive age
19
group of 30 and 59 is due to NCD. Studies show that 27 percent of Kerala adult males are
having diabetes mellitus compared to 15 per cent at national level. 19 per cent of adult female
population is diabetic compared to 11 percent in India. 40.6 percent of adult males and 38.5
percent of adult females are hypertensive compared to 30.7 percent and 31.9 percent at national
level. Incidents of obesity, hyper lipedemia, heart attack and stroke are also high. Cancer
mortality is extremely high in males in Kerala compared to national average.

Health Status of BLP Population in Kerala

Going into a survey due for a decade, India's central government is undecided on criteria
to identify families below poverty line. Internationally, an income of less than ₹150 per day
per head of purchasing power parity is defined as extreme poverty.As per 2011-12 estimate
about 21.9% of Indians are living below poverty line.

In Kerala the marginalised are generally constituted by those who live in the hilly
terrains, back water and sea coast. The marginalised of Kerala society encompasses SC (9.1%),
ST (1.45%) and fisherman (2% of the nine coastal districts of Kerala. 11% of Kerala population
is constituted by SC and ST population, while the 19% and 3% respectively and 22% of total
BPL population.

Kerala started scaling down public expenditure on education health, sanitisation,

housing etc with deliberate policies and these responsibilities were increasingly transferred to
private sector. As a result, there has been a sharp deterioration in the conditions of the poor and
marginalized, particularly, SC/ST/Dalit and other backward communities and that of women
and children in each of these social group resulting in unequal access to healthcare with greater
inequalities in the health care system. The data on health outcomes among SC/ST population
show consistently that these group are at a disadvantage. Among the different disadvantaged
groups of India SC tend to have the highest rates of infant and child mortality, malnutrition and
morbidity followed by SC's and other disadvantaged groups. In 2014 the Attappadi region of
Kerala alone had 19 in due to condition called anencephaly - a result of the Folic acid
deficiency. More than 80 % of the pregnant and lactating women in the Attapadi are anemic.
Similarly 83 percentage of the children eight below 5 years are underweight ( Health
Department Government of Kerala 2014) IMR and under five mortality among ST population

20
is 84.2 and 126.6 respectively per thousand population compared to the 61.8 and 82.6 in general
category, which was closely followed by SC population within IMR of 83.0 and 119.3 as under
five mortality per thousand population.
(India : Social, Development Report 2005)

21
 CHAPTER 4

DATA ANALYSIS

Bharatheepuram is a small village in Anchal block in Kollam district of Kerala state, India. It
comes under Yeroor panchayath. It belongs to south Kerala division. It is located 52km
towards east from District Head Quarters, Kollam

This chapter makes an analytical examination of the data collected from 50 BPL
household in Bharatheepuram at Yeroor panchayath. These households were randomly
selected from the ration cared list. The data were collected directly from the households through
questionnaires and interviews regarding the various aspects of the health expenditure pattern
and socio-economic conditions like age composition, employment and occupational structure,
income distribution and assets, health problem, expenditure on medical care and its impact on
households. Simple percentages were calculated and tabular analysis was made for arriving at
the results.
50 households from the rural population were selected through deliberate random sampling.

22
 Table 4.1

AGE DISTRIBUTION

Age Respondents Percenta

ge
0-15 3 6
16-50 16 32
51-70 24 48
Above 70 7 14
Total 50 100
Sources : Primary Data

Figure 4.1

AGE DISTRIBUTION

48

32

14

0-15 16-50 51-70 Above 70

From the table 4.1, 14% of the respondents belonged to the age group above 70, 48% of
respondents between 51-70, 32% belongs to between 16-50 and only 6% belongs to
between 0-15 years.

23
 Table 4.2

TYPE OF FAMILY

Type of family Respondents Percentage

Nuclear 46 92
Extended 3 6
Joint 1 2
Total 50 100
Sources : Primary Data

Figure 4.2

TYPE OF FAMILY
100
92
90

80

70

60

50

40

30

20

10 6
2
0
Nuclear Extended Joint

From the table 4.2, 92% of the respondents belonged to the nuclear family, 6% of
respondents are of extended family and only 2% belongs to joint family.

24
 Table 4.3

PATTERN OF SETTLEMENT

Pattern of Respondents Percentage

settlement
Independent 28 56
Colony 22 44
Total 50 100
Sources : Primary Data

Figure 4.3

PATTERN OF SETTLEMENT

56
60

50 44

40

30

20

10

0
Independent Colony

From the table 4.3, 56% of the respondents have independent settlement and 44% belongs
to colony.

25
 Table 4.4

RELIGION WISE DISTRIBUTION

Religion Respondents Percentage

Hindu 32 64
Christian 12 24
Muslim 6 12
Others 0 0
Total 50 100
Sources : Primary Data

Figure 4.4

RELIGION WISE DISTRIBUTION

From the table 4.4, 64% of the respondents belonged to Hindu religion, 24% of
respondents between Christian, 12% belongs to between Muslim.

26
 Table 4.5

GENDER WISE DISTRIBUTION

Gender Respondents Percentage

Male 29 58

Female 21 42

Total 50 100

Sources : Primary Data

Figure 4.5

GENDER WISE DISTRIBUTION

60
50
40
30
20
10 Percentage
0
Male Female

From the table 4.5, 58% of the respondents belongs to Male and 42% belongs to Female.

27
 Table 4.6

SOCIAL GROUP

Social Group Respondents Percentage

General 7 14
OBC 22 44
SC/ST 18 36
Others 3 6
Total 50 100
Sources : Primary Data

Figure 4.6

SOCIAL GROUP

Others
6% General
14%

SC/ST
36%

OBC
44%

From the table 4.6, 14% of the respondents belonged to the General, 44% of respondents
belongs to OBC, 36% belongs to SC/ST and only 6% belongs to Others.

28
 Table 4.7

MARITAL STATUS

Marital status Respondents Percentage

Single 11 22
Divorced 1 2
Married 30 60

Widowed 8 16
Total 50 100

Sources : Primary Data

Figure 4.7

MARITAL STATUS

Widowed 16

Married 60

Divorced 2

Single 22

0 10 20 30 40 50 60 70

From the table 4.7, 22% of the respondents are single, 60% of respondents are married
16% were widowed and 2% is widowed.

29
 Table 4.8

EDUCATIONAL QUALIFICATION

Educational Respondents Percentage

Qualification
Primary or less 10 20
High school 24 48
Higher Secondary 14 28
UG/PG 2 4
Total 50 100
Sources : Primary Data

Figure 4.8

EDUCATIONAL QUALIFICATION

From the table 4.8, 20% of the respondents had completed Primary level or less
education, 48% has only high school, 28% has higher secondary and only 4% has
acquired ug/pg.

30
 Table 4.9

OWNERSHIP OF HOUSE

Ownership of Respondents Percentage

House
Self-owned 37 74
Rented 11 22
Leased 0 0
Kudikidappu 2 4
Purampok 0 0
Total 50 100
Sources : Primary Data

Figure 4.9

OWNERSHIP OF HOUSE

74
80
70
60
50
40
22
30
20
4
10 0 0
0
Percentage

Self-owned Rented Leased Kudikidappu Purampok

From the table 4.9, 74% of the respondents had completed self-owned house, 22% are of
rented and 4% belongs to kudikidappu.

31
 Table 4.10

HABITAT DETAILS

Habitat Details Respondents Percentage

Concrete 8 16
Title roof 39 78
Mud 0 0
Thatched 3 6
Total 50 100
Sources : Primary Data

Figure 4.10

HABITAT DETAILS

78

16

0 10 20 30 40 50 60 70 80

Thatched Mud Title roof Concrete

From the table 4.10, 16% of the respondents had concrete, 78% respondents have title
roofs, 6% has thatched.

32
 Table 4.11

OWNERSHIP OF LAND
Area of land under possession
Ownership Less than 5 Above Above
of land cents 5 cents 10 cents

Titled 13 21 3
Untitled 6 0 0
Unassigned 0 5 0
Sources : Primary data

Figure 4.11

OWNERSHIP OF LAND

25
21
20

15 13

10
6
5
5 3
0 0 0 0
0
Titled Untitled Unassigned

Area of land under possession Less than 5 cents

Area of land under possession Above 5 cents
Area of land under possession Above 10 cents

From the table 4.11, 74% of respondents have a marginal land under their possession and
12% have untitled and 105 have no land in their possession.

33
 Table 4.12

OCCUPATION WISE DISTRIBUTION

Occupation Respondents Percentage

Wage labour 21 42
Self employed 6 12
Others ( artisans) 10 20
Unemployed 13 26
Total 50 100

Sources : Primary Data

Figure 4.12

OCCUPATION WISE DISTRIBUTION

42

26
20
12

WAGE LABOUR SELF EMPLOYED OTHERS ( ARTISANS) UNEMPLOYED

From the table 4.12, 42% of the respondents are age labours, 12% of respondents are self-
employed,20% have other occupation and 26% are unemployed.

34
 Table 4.13

TOTAL INCOME

Total Income Respondents Percentage

Below 25000 14 28
25000-50000 26 52
50001-75000 7 14
75001-100000 3 6
Above 100000 0 0
Total 50 100

Sources : Primary Data

Figure 4.13

TOTAL INCOME

Below 25000 25000-50000 50001-75000 75001-100000 Above 100000

6% 0%

14% 28%

52%

From the table 4.13, 28% of the respondents have a total income below 25000, 52% of
respondents is in-between 25000-50000,14% are in between 25001-75000 and the rest
6% have total income in between 75001-100000

35
 Table 4.14

TYPE OF DISEASE FACED BY SAMPLE UNITS

Type of disease Male Female Total Percentage

Diabetes/BP 12 8 20 40

Cancer 3 0 3 6

Liver Cirrhosis 1 0 1 2

Kidney stone 0 2 2 4

Asthma 3 0 3 6

Tonsillitis 0 1 1 2

Allergy 0 2 2 4

Ulcer 0 5 5 10

Mental Problems 1 0 1 2

Urinary problem 0 6 6 12

Stroke 4 1 5 10
Tumor 1 0 1 2

Total 50 100
Sources : Primary Data

36
 Figure 4.14

TYPE OF DISEASE FACED BY SAMPLE UNITS

Tumour
Stroke
Urinary problem
Mental Problems
Ulcer
Allergy
Tomilletis
Asthma
Kidney stone
Liver Cirrhosis
Cancer
Diabetes/BP

0 5 10 15 20 25 30 35 40 45

Percentage Female Male

From table 4.14,40% is affected by Diabetes/BP,6% by cancer,2% by liver cirrhosis,4%

by kidney stone6% by asthma,2% by tonsillitis,4% by allergy,10% by ulcer,2% by
mental problems,12% by urinary problens,10% by stroke and 2% by tumor.

37
 Table 4.15

USE OF INTOXICANTS

Intoxicant Respondents Percentage

cigarette 12 24
Alcohol 7 14
Tobacco 8 8
None 23 46
Total 50 100

Sources : Primary Data

Figure 4.15

USE OF INTOXICANTS

Table 4.15 shows that 24% of respondents are using cigarettes, 14%
are using alcohol, 8% are taking tobacco and 46% were not
intoxicated.

38
 Table 4.16

SYSTEM OF TREATMENT PREFERRED

System of Respondents Percentage

Treatment
Allopathic 35 70
Ayurveda 11 22
Homeopathic 4 8
Unani 0 0
Others 0 0
Total 50 100

Sources : Primary Data

Figure 4.16

SYSTEM OF TREATMENT PREFERRED

Percentage 8

22

70

0 10 20 30 40 50 60 70

Others Unani Homeopathic Ayurveda Allopathic

Table 4.16 shows that 70% of respondents were using allopathy

as the system of treatment, 22% with ayurveda and 8% chooses
homeopathy.

39
 Table 4.17

PLACE OF TREATMENT PREFERRED

Treatment type Respondents Percentage

Govt Hospital 39 78
Private Hospital 9 18
Doctors Residence 2 4
Others 0 0
Total 50 100

Sources : Primary Data

Figure 4.17

PLACE OF TREATMENT PREFERRED

Others 0

Doctors Residence 4

Private Hospital 18

Govt Hospital 78

0 10 20 30 40 50 60 70 80

From the table 4.17, 78% of the respondents opt government hospitals for medical
treatments, 18% of respondents choose private hospitals and 4% responded as treatment
at doctor’s residence.

40
 Table 4.18

OUT OF POCKET EXPENDITURE

Annual health care Respondents Percentage

expenditure
Below 50000 22 44
50000-100000 17 34
100000-150000 4 8
Above 150000 7 14
Total 50 100
Sources : Primary Data

Figure 4.18

OUT OF POCKET EXPENDITURE

14

34

44

0 10 20 30 40 50

Above 150000 100000-150000 50000-100000 Below 50000

From the table 4.18, 44% of the respondents incurs out of pocket expenditure below
50000, 34% of respondents incurs in-between 50000-100000,8 % of respondents incurs
in-between 100000-150000 and 14 % incurs above 150000.

41
 Table 4.19

ABLE TO MET HEATH EXPENDITURES WITH YOUR

INCOME

Able to meet Respondents Percentage

health
expenditures in
your income
Yes 16 32
No 34 68
Total 50 100
Sources : Primary Data

Figure 4.19

ABLE TO MET HEATH EXPENDITURES WITH YOUR

INCOME

From the table 4.19, 32% responded that they are able to meet their health expenditures
within their income and rest 68% responded as No.

42
 Table 4.20

SOURCE OF FINANCING FOR HEALTH EXPENDITURE

Source Respondents Percentage

Borrowing 14 28
Sale of asset 4 8
Contribution 1 2
Pledging 3 6
Medical insurance 12 24
None 16 32
Total 50 100
Sources : Primary Data

Figure 4.20

SOURCE OF FINANCING FOR HEALTH EXPENDITURE

PERCENTAGE
35 32
30 28
24
25

20

15

10 8
6
5 2
0
Borrowing Sale of asset Contribution Pledging Medical None
insurance

Table 4.20 give the information that 28% of respondents used to

have borrowings to meet their health expenditure, 8% had by sale
of asset, 2% by contributions, 6% by pledging and 24% by
medical insurances. 32% of respondents have no other source.

43
 Table 4.21

ARE YOU COVERED BY ANY HEALTH INSURANCE

SCHEME

Are you covered by Respondents Percentage

any health
insurance scheme
Yes 39 78
No 11 22
Total 50 100
Sources : Primary Data

Figure 4.21

ARE YOU COVERED BY ANY HEALTH INSURANCE

SCHEME

No
22%

Yes
78%

From the table 4.21, 78% responded that they are covered by health insurance and rest
22% responded as No.

44
 Table 4.22

HOUSEHOLD’S ENROLMENT IN INSURANCE

Household’s Respondents Percentage

enrolment
RSBY 42 84
Mediclaim 0 0
Karunya 6 12
Amritam 4 8
Others(specify) 0 0
Total 50 100
Sources : Primary Data

Figure 4.22

HOUSEHOLD’S ENROLMENT IN INSURANCE

84
90
80
70
60
50
40
30
20 12
8
10 0 0
0

Table 4.22 shows that 84% of respondents have RSBY insurance, 12% has Karunya
and 8% opts Amritam insurance.

45
 Table 4.23

FINANCIAL SITUATION BEEN AFFECTED BY

MEDICAL EXPENSE

Financial situation Respondents Percentage

affected by medical
expenses
Yes 41 82
No 9 18
Total 50 100
Sources : Primary Data

Figure 4.23

FINANCIAL SITUATION BEEN AFFECTED BY

MEDICAL EXPENSE

No
18%

Yes
82%

Table 4.23 shows that, 82% of total respondents were facing financial issues due to
their medical expenses and rest of 18% doesn’t.

46
 Table 4.24

REASON FOR SELECTING HEALTHCARE SERVICES

Reason Government Hospital Private Hospital
Only hospital in the area 2 0
Less Expensive 12 0
Good Hospital infrastructure 1 3
Quick diagnosis of diseases and specialized 1 3
Nearness to residence 7 2
Experienced and talented pool medical 5 0
professionals
Reputation of hospital 3 1
Easy to reach transport 4 0
Better Care 4 2
Total 39 11

Sources : Primary Data

Figure 4.24

REASON FOR SELECTING HEALTHCARE SERVICES

Better Care 2 4
Easy to reach transport 0 4
Reputation of hospital 1 3
Experienced and talented pool medical… 0 5
Nearness to residence 2 7
Quick diagnosis of diseases and specialized 1 3
Good Hospital infrastructure 1 3
Less Expensive 0 12
Only hospital in the area 0 2
0 2 4 6 8 10 12 14

Private Hospital Government Hospital

From Table 4.24 we can understand that 78% of total respondents choose government
hospitals due to various reasons for medical assistance where as rest of 22% opt
private hospitals.

47
 Table 4.25

PROBLEMS TO ACCESS GOVERNMENT HOSPITALS

Problems Respondents Percentage

Low maintenance and infrastructure 9 18

Ill-treatment to patients, by standers 5 10

Careless attitude 6 12

Long queue 12 24

Marginal time for consultation 5 10

No queries about history of patients 1 2

Dependence on private facilities for tests 3 6

and medicines
No facility to meet the same doctor who 2 4
treated earlier
Delay in attention and diagnosis 3 6

Inadequate sub-staff 4 8

Total 50 100

Sources : Primary Data

48
 Figure 4.25

PROBLEMS TO ACCESS GOVERNMENT HOSPITALS

24

18

12
10 10
8
6 6
4
2

Table 4.25 shows the problems in accessing government hospitals. 18% responded as low
maintenance and infrastructure, 10% choose Ill-treatment to patients, by standers, 12% choose
Careless attitude, 24% choose long queue, 10% choose marginal time of consultation, 10%
choose No queries about history of patients, 2% choose inadequate queries of patient history,
6% choose Dependence on private facilities for tests and medicines, 4% choose no facility to
meet the same doctor who treated earlier, 6% choose delay in attention and diagnosis and 8%
choose inadequate sub staff.

49
 Table 4.26

PROBLEMS TO ACCESS PRIVATE HOSPITALS

Problems Respondents Percentage

High cost 19 38

No standardization in cost 11 22

Over treatment and tests 7 14

No transparency in billing 9 18

Additional payment for essential care 4 8

Total 50 100

Sources : Primary Data

Figure 4.26

PROBLEMS TO ACCESS GOVERNMENT HOSPITALS

High cost
8
18 38
No standardization in cost

14 Over treatment and tests

22
No transparency in billing

Additional payment for

essential care

Table 4.26 shows the problems faced by respondents while accessing private hospitals. 38%
responded and high cost, 22% as no standardization in cost, 14% as over treatments and tests,
18% as no transparency in billing, 8% as additional payment for essential care.

50
 CHAPTER 5
FINDINGS, SUGGESTIONS AND CONCLUSION

On the basis of extensive analysis of data collected, classified and tabulated using various
statistical tool. We arrive at the following findings of the study.

• 48 percent of respondents belongs to the age group 51-70.

• Analysis of the household types reveals that 92 percent of households are nuclear
families, 6 percent are of extended family and remaining 2 percent belongs to joint
family.

• 56 percent of the respondents have independent settlement.

• With respect to social group, 14 percent of respondents belonged to the general category,
44 percent belongs to OBC, 36 percent belongs to SC/St and only 6 percent belongs to
others.

• A greater proportion of the household heads have only up to high school education. The
remaining respondents have attained either primary/ secondary education or completed
graduation.

• The study found that majority (74 percent) of the respondents have the facility of own
house.

• The study found that 74 percent of the respondents have marginal land under their
possession, just enough for housing, without any space for kitchen, garden or for
domesticating animals and 12 percent have untitled land, 10 percent have no land in
their possession.

• Analysis reveals that 42 percent of respondents are wage laborer’s, 12 percent are self-
employed, 20 percent have other occupation and 26 percent are unemployed.

• Yearly income of 28 percent of the respondents lie below 25000, while 52 percent are in
income range 25000-50000, 14 percent in the income range of 50001-75000, and the rest
6 percent have total income in between 75001-100000.

• The study shows that there are gender difference in morbidity prevalence rate. Life style
diseases like kidney stones, allergy, tonsillitis, ulcer, urinary problem etc are high among

51
 females while degenerative diseases like cancer, liver cirrhosis, asthma, mental
problems, stroke, tumor etc high among males.
• The study found that 54 percent of respondents regularly using intoxicants like
alcohol, tobacco, cigarette etc are prone to various contagious and degenerative
diseases.
• Regarding curative care, 70 percent of respondents were using allopathy as the
system of treatment, 22 percent with ayurveda and 8 percent chooses homeopathy.
• According to the study only 78 percent of respondents utilize the government hospital
while 18 percent of respondents choose private hospitals and 4 percent responded as
treatment at
doctor’s residence.
• The annual health care expenditure of 44 percent of the respondents is below Rs. 50000
while 34 percent fall in the range of 50000- 100000,8 percent of respondents incurs in
between 100000- 150000 and 14 percent incurs above 150000.the expenditure level of
majority of the household is much high when compared to their income.
• The analysis found that 68 percent respondents are not able to meet their health
care expenditure with their income.
• The study reveals that only 32 percent of respondents can meet their health care
expenditure with their income. The number of respondents that meet their expenditure
through borrowings is 28 percent, sale of asset is 8 percent, pledging is 6 percent,
contribution is 2 percent and insurance is 24 percent.
• The study reveals that 78 percent respondents are under the coverage of health
insurance of which 64 percent are under the coverage of RBSY.
• The financial situation of the households has been affected by medical expenses. It is
clear from that medical expenses make a chance in financial situation. That is 82 percent
affirmed that their financial situation was adversely affected by the out-of-pocket health
expenditure.
• The study found that many households do not have any access to government hospitals
owing to reasons such as low maintenance and infrastructure (18 percent), ill- treatment
to patients (10 percent), careless attitude, long queue(24 percent) , marginal time for
consultation (10 percent) , no queries about history of patients (10 percent), inadequate
staff (8 percent), dependence on private facilities for tests and medicines (6 percent) .
• It is found in the analysis that 38 percent of households consider high treatment cost as

52
an impediment in accessing health care from private hospitals. 22 percent of households
consider lack of standardization of treatment cost, 14 percent as over treatment and test,
18 percentas lack of transparency in billing, 8 percent as additional payment for essential
care as the problem for accessing healthcare from private hospitals.

SUGGESTIONS

The findings of the study disclose that there is deterioration in health status of
BPL population. Though adequate infrastructure facilities are available in public as well
as private sector and across different systems of medicine, resultant to relative
inefficiency of government hospitals and high cost treatment in private hospitals. The
major suggestions in this regard are the following
1. Public health care system must be strengthened with adequate public spending to
ensure efficiency and accountability in the system so that the exploitation of the private
hospitals can be minimized.
2. Improving the efficiency of public health institutions and ASHA workers, an
orientation regarding prevention of communicable and non-communicable diseases
must be given to the public along with strengthening of public health activities in the
state in a time bound manner.
3. Effective policy measures that aim at controlling the private sector institutions and
standardization of costs are to be adopted. Similarly the cost of tests in private diagnostic
labs must be standardized through laws to eliminate commission.
4. The government must introduce alternative health care financing mechanisms.
5. Different system of medicine must be co-ordinated to treat various diseases as well
as prevention of the same.
6. Provision for more infrastructure must be made in hilly areas, tribal hamlets and
coastal regions.
7. Creating a broad framework for public-private partnership model to meet the demand
supply gap in health care 8. Steps should be taken to improve the availability of services
of the health personnel to the PHCs and Sab centres in rural areas.

53
 CONCLUSION

From the foregoing summary and findings of the study, the following
conclusion emerge. In the present scenario of globalisation, public health sector in India
is facing a cut in health budget. India, being the second most populous country in the
world, cannot shirk from its responsibility of delivering better health services. In India,
“health for all” Can be attained only through the judicious blending of public health
care services and private health care services. Chronic disease is found to be an
important determinant of excessive healthcare payments. Hence financial protection
schemes would have a greater impact on castotrophic expenses. Community based
health insurance is necessary to the households to avoid high out-of-pocket expenditure
at the time of hospitalization. Moreover, intelligent use of research skill and knowledge
, modern science and technology are needed to secure the best possible outcome of
healthcare and private sector undertake the work needed for the formulation of policy
in public health and social services including community care. A better health care
facility at affordable cost to the needy people will result in quality Human Research
Development which in turn will result in higher economic development. The increasing
cost involved in the purchase of medicines from the market emerges as a cause of worry
for every patient, severity of burden of health care on the poorest. Household
expenditure for hospitalization was higher among rural people because in rural areas
access to healthcare facilities is not enough, so the households spend more on
healthcare. In rural areas, lack of availability of healthcare services leads to higher
expenditure. Increasing demand for health care services and lack of easy access for the
rural people, forces that the proportion of households spending on healthcare has been
increasing considerably for the below average income group to quality healthcare and
that they have to meet a considerable proportion of their healthcare expenditure through
borrowings. Thus, rural people, who do not enjoy much economic power, may not be
able to continue the healthcare treatment. Out -of – pocket payment, signifying method
of financing healthcare, it can lead to indebtedness among the poor and therefore, most
people in the country, especially the rural poor can't afford proper healthcare treatment.
Better public health provision would bring down considerably the loss of number of
working hours and days due to illness and there by, increase the income and reduce the
burden of healthcare expenditure. Patients felt that the services offered at the private
hospitals were unaffordable and beyond their reach. To reduce the out-of-pocket

54
expenses of the people especially of the poor in rural areas, the government spending
on healthcare must increase.

55
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59
APPENDIX

1 AGE

0-15 16-50

51-70 Above 70

2 TYPE OF FAMILY

Nuclear Extended

Joint

3 PATTERN OF SETTLEMENT

Independent Colony

4 RELIGION

Hindu Christian

Muslim Others

5 GENDER

Male Female

6 SOCIAL GROUP

General OBC

SC/ST Others

7 MARITAL STATUS

Single Divorced

Married Widowed

8 EDUCATIONAL QUALIFICATION

60
 Primary or less High school

Higher Secondary UG/PG

9 OWNERSHIP OF HOUSE

Self-owned Rented

Leased Kudikidappu

Purampok

10 HABITAT DETAILS

Concrete Title roof

Mud Thatched

11 OWNERSHIP OF LAND

Titled Untitled

Unassigned

12 OCCUPATION WISE DISTRIBUTION

Wage labour Self employed

Others ( artisans) Unemployed

13 TOTAL INCOME

Below 25000 25000-50000

50001-75000 75001-100000

Above 100000

14 TYPE OF DISEASE FACED BY OTHER SAMPLE UNITS

61
 Diabetes/BP Cancer

Liver Cirrhosis Kidney stone

Asthma Tonsillitis

Allergy Ulcer

Mental Problems Urinary problem

Stroke Tumor

15 USE OF INTOXICANTS

cigarette Alcohol

Tobacco None

16 SYSTEM OF TREATMENT PREFERRED

Allopathic Ayurveda

Homeopathic Unani

Others

17 PLACE OF TREATMENT PREFERRED

Govt Hospital Private Hospital

Doctors Residence Others

18 OUT OF POCKET EXPENDITURE

Below 50000 50000-100000

100000-150000 Above 150000

19 ABLE TO MET HEATH EXPENDITURES WITH YOUR INCOME

62
 Yes No

20 SOURCE OF FINANCING FOR HEALTH EXPENDITURE

Borrowing Sale of asset

Contribution Pledging

Medical insurance None

21 ARE YOU COVERED BY ANY HEALTH INSURANCE SCHEME

Yes No

22 HOUSEHOLD’S ENROLMENT IN INSURANCE

RSBY Mediclaim

Karunya Amritam

Others(specify)

23 FINANCIAL SITUATION BEEN AFFECTED BY MEDICAL EXPENSE

Yes No

24 REASON FOR SELECTING HEALTHCARE SERVICES

Only hospital in the area Less Expensive

Good Hospital infrastructure Quick diagnosis of diseases and

specialized

Nearness to residence Experienced and talented pool

medical professionals

Reputation of hospital Easy to reach transport

Better Care

25 PROBLEMS TO ACCESS GOVERNMENT HOSPITALS

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 Low maintenance and infrastructure Ill-treatment to patients, by standers

Careless attitude Long queue

Marginal time for consultation No queries about history of patients

Dependence on private facilities for No facility to meet the same doctor

tests and medicines who treated earlier

Delay in attention and diagnosis Inadequate sub-staff

26 PROBLEMS TO ACCESS PRIVATE HOSPITALS

High cost No standardization in cost

Over treatment and tests No transparency in billing

Additional payment for essential

care

64