Inequity in Utilization of Health Care Facilities in Urban India: An Application of Marginal Benefit Incidence Analysis

Bose, Montu (2016). 'Inequity in Utilization of Health Care Facilities in Urban India: An Application of Marginal Benefit Incidence Analysis' Paper presented at the annual conference of the HDCA, Tokyo 2016.

The role of public sector is important in ensuring healthcare delivery to all sections of the society to enhance the capability and functioning of a nation. However, the public expenditure on health always remain very low in India. In 2005, with the goals to achieve universal access to healthcare through strengthening of health system, institutions and capabilities in the rural sector National Rural Health Mission (NRHM) has been successfully implemented by India and her states. The positive impact of public investment has been observed in utilization of public health care facilities in the country. However, no such initiative has been taken to strengthen the urban health system.
In this backdrop the objectives of the study are -  
a)      to capture the utilization pattern of public healthcare facilities for in-patient and out-patient services in urban India,
b)      to examine the equity in utilization of public healthcare facilities,
c)      to analyze the marginal impact of expansion of public healthcare facilities across economic classes of urban sector and
d)     to study the other socio-economic factors influencing the choice of provider,   
Data & Method:
For the present study National Sample Survey 71st round unit level data on Morbidity and Healthcare has been used.
a)      To estimate the utilization pattern of public healthcare facilities during in-patient and out-patient care exploratory data analysis has been carried out;
b)      Benefit Incidence Analysis (BIA) has been applied to measure the equity in utilization of public facilities in the urban sector;
c)      Impact of an increase in public sector provisioning of healthcare services has been verified by Marginal Benefit Incidence (MBI) analysis;
d)     Decomposition analysis has been implemented to check intra-household equity in access.
e)      To identify the correlates of choice of provider, logistic regression has been applied;
Results show that both morbidity reporting and hospitalization has increased in urban India over time. Morbidity reporting and hospitalization in the urban India has increased more than doubled during 1995-96 to 2004. Moreover, in all counts and for all socio-economic groups, the urban sector is reporting higher morbidity compared to the rural sector. However, the share of public institutions in providing ambulatory health facilities remain stagnant for the urban sector. Whereas, for the in-patient services the share of public institutions has decreased over time. Benefit incidence analysis of utilization of public healthcare services for out-patient and in-patient care services shows a pro-poor distribution in the urban India. Twenty per cent poorest people of the sector utilizes about 28 per cent of the in-patient and out-patient public facilities. Corresponding utilization figure for the second lowest income quintile group is 22 per cent for the out-patient and 24 per cent of the in-patient care services. Lowest utilization rate for both in-patient and out-patient care has been observed for the richest income quintile.
Therefore, economically weaker sections prefer public institutions for their treatment. However, one crucial question here is that ‘what would be the impact of increase (or reduction) in public provisioning of healthcare services on different economic groups’? Would it benefit (or impair) the financially weaker sections or not? To answer these questions we have run the marginal benefit incidence analysis on utilization of public healthcare facilities in urban India. It has been observed from the results that both for out-patient and in-patient care facilities poorer economic classes would be benefited with an expansion of provisioning of public health care services in the sector. According to MBI, highest hospitalization share would be for the second lowest quintile group (more than 24 per cent) followed by the poorest class (about 24 per cent). For out-patient care, the utilization share for the last three economic classes would be 24 per cent, 22 per cent and 24 per cent respectively. Other than income, social group, education and gender has come out as major determinants of choice of provider for utilization of healthcare services in the urban areas. Socially better off classes, families with higher educational attainment have a pro-private choice. Interestingly, male have higher preference for public facilities than female. This result has come as a surprise to us. So, to verify the underlying facts we have run the decomposition analysis. The result reveals that the gender disparity in access to public facilities within household persists in the urban geographical areas in India.           
In spite of the high growth rate and stable economic and political condition, India has failed to make significant progress in health. The urban sector shows a pro-poor utilization of healthcare facilities for in-patient and out-patient services. However, the overall utilization of public facilities of the sector is substantially low. Therefore focused policies and strengthening would benefit the poorer sections of the society. Steps should be taken to address the barriers to access public facilities and to arrest high out-of-pocket expenditure in the urban areas. Policies should be designed to address the gender disparity in access to healthcare facilities in urban India.  
 Key Words: Benefit Incidence Analysis, Marginal Benefit Incidence, Equity in Urban healthcare access
JEL Code: I14, I18

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