Increasing morbidity, a rising burden of lifestyle diseases, an ageing population, the high health-seeking behaviour of people and increased reliance on private healthcare institutions is pushing up out-of-pocket expenditure (OOPE) on health in Kerala.
Despite increased health spending by the State, health insurance coverage and increased investments in health infrastructure at secondary and tertiary care public hospitals, OOPE on health in Kerala remains one of the highest in the country.
NHA figures
According to the latest National Health Accounts (NHA) for 2021-22 period, the per capita OOPE on health in Kerala is the highest in the country at ₹7,889. The same figure in neighbouring Tamil Nadu is just ₹2,280.
This high OOPE is despite the fact that Kerala also has the highest per capita expenditure on health at ₹13,343. NHA figures show that Kerala tops the list when it comes to the per capita government spending on health, at ₹4,338.
Kerala spends about 5.2% of the Gross State Domestic Product (GSDP) on health. The total health expenditure of the State in the accounting year was ₹48,034 crore. And of this, ₹28,400 crore was money spent by people from their own pockets or the State’s total OOPE on health .
OOPE as a percentage of the total health expenditure (THE) of Kerala came to 59.1%, which means that more than half of the State’s expenditure on health is money spent by people from their own pocket. However, this is a drop from 2020-21, when OOPE as a percentage of total health expenditure was 65.7%
Trends remain unchanged
Since 2013-14, when the first-ever NHA was released, these trends in Kerala have not changed. Health spending by the government has been increasing, but so has OOPE.
In 2019-20, Kerala’s total expenditure on health was ₹37,124 crore, of which ₹25,222 crore was money spent by people on their own or OOPE. The State’s per capita OOPE was ₹7,206 in 2019-20.
Comprehensive Annual Modular Survey 2022-23
While many health experts in the State are sceptical about the survey methods used by NHA to arrive at its figures, the just-released Comprehensive Annual Modular Survey (CAMS) 2022-23 report by the National Sample Survey Office (NSSO) reiterates the same story.
Since 2013-14, when the first-ever NHA was released, these trends in Kerala have not changed
| Photo Credit:
istock
The CAMS report says that the average medical expenditure incurred by a household for hospitalised treatment in Kerala – calculated for the last 365 days during the survey period – is ₹10,929 (rural) and ₹13,140 (urban). And of this, OOPE on health in rural area is ₹8,655 and in urban area, ₹10,341.
When it comes to non-hospitalised or outpatient care – calculated for the last 30 days of the survey period – the household expenditure is ₹1,193 (rural) and ₹1,190 (urban). Of this, OOPE comes to ₹1,177 (rural) and ₹1,163 (urban), indicating that when it comes to non-hospitalised care, almost all of the money spent on one outpatient hospital visit goes from the people’s own pocket
Kerala’s health Budget has seen a steady increase over the last decade with focus on enhancing primary care facilities and increased investments in health infrastructure and facilities. During the Covid pandemic, heavy investment went into improving hospital infrastructure in secondary and tertiary care facilities.
Reliance on private sector for care
“But the continued dependence of the middle class on private hospitals, despite the high cost of care, would mean that the public hospitals have not been able to rise to the demands and aspirations of the public,” says V. Ramankutty, a health economist and former Emeritus Professor of Achutha Menon Centre for Health Science Studies..
“People care about the quality of care and the hospital experience they get. The shortage of human resources, drugs and supplies and cumbersome processes affect the quality of care rendered in public hospitals,” Dr. Ramankutty points out
Former Director of the Gulati Institute of Finance and Taxation D. Narayana feels that while the NHA numbers are true, crude comparisons would be meaningless.
“These numbers cannot be interpreted meaningfully unless these are normalised for age composition. The disease composition changes as one ages. A larger burden of lifestyle diseases and terminal procedures would raise the cost of care drastically. Bulk of these costs are not met by the government. The effect of longevity should also be taken into account. What the NHA fails to put out is the medical expenditure incurred by households just before the death of a family member, which is very high,” he says.
A study published in JAMA in May 2022, ‘Components of out-of-pocket expenditure and their relative contribution to economic burden of diseases in India’, reported that medicines accounted for 29.1% of inpatient and 60.3% of outpatient OOPE.
Outpatient expenditure goes uncovered
Outpatient expenses, drugs and diagnostics constitute a chunk of the OOPE on health in Kerala too and this is not covered by any health insurance scheme. Outpatient expenditure would be high because of the State’s huge burden of both communicable and non communicable diseases. A significant section of the people – not just the middle class – seem to trust private hospitals, even when the private health sector remains totally unregulated.
And it is high time the government explored why the increased investments in improving primary care, health infrastructure and facilities in the State since 2016 have not translated into a reduced OOPE. What are the gaps in service, why are public hospitals failing people? Most of all, the State should introspect if its policies in the health sector are in the right direction.
Published – October 20, 2024 06:13 pm IST
