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Utilisation of OP and IP Health Care Services
7.1 ~ntroduction
In thir chapter we examine the u ~ l ~ s a t i o n of outpatient t o p ) and inpatient (Ip) health
care services. The specific Issues addressed include the utilisation pattern across sectors
and systems ol' medicme for OP and LP health care services. Two weeks recall for OP
and one year for hospitalisation services In the Kerala context, people ut~lise
specialised medical servlces even for short duration or acute ailments and assign more
importance in maintaining health. This is one of the reasons for the sustained expansion
of the private health care sector in Kerala. The study has revealed that two-third of the
sample households utilised OP health care services during the reference period. The
two-liiih of the households reported one OPs and one-fifth, two OPs. That is, one-third
of thc households reported no OP.On the other hand, hospitalisation or inpatient (IP)
care during the last one year before the date of survey indicated that two-fifth of the
sainplc lhouscholds utllised iiipatienr medical care services, and around one-third of the
households reported one 1P In other words. three-fifth of the households reponed no
IP and on an acerage. one person per household has utilised medical care as an OP and
at least one hospitalisation (IP) per two households (table: 7.1). It is significant that 77
percent of the households reported either OP or IP, 36 percent only OP, 10 percent only
IP. 30 percent of the households reported both OP and IP and 23 percent reported
nc~thel OP nor IP (table: 7.2) . That is, three-fourth of the sample households reported
health care visits either as OP or as IP.
7.2 Caste and Religion
Caste and religion constitute a summary measure of the differential cultural
determinants of morbidity and health seeking behaviour. Caste wise break-up shows
that 60 percent. 66 percent and 68 percent of the FC, OBC and SCiST households
respectively reported utilisation of OP health care services. On the other hand, 30
percent. 41 percent, and 44 percent of the households reponed to have been utilised
hospitalisation services as inpatient, respectively. The average number of patients per
household is the same at 1.03 for OBCs and SCsISTs whereas it is only 0.67 for the
FCs. Inter-community differences in the distribution of households reporting both OP
and IP health care services are more revealing. For instance, 61 percent, 29 percent and
75 percent of the Hindu. Christian, and Muslim households respectively reported OP
care visits and 37 percent. 29 percent. and 46 percent respectively for hospitalisation
services as IP. The distribution of the number of patients across rel~gious cornrnun~ties
indicutes that the frequency of visits is relatively higher in Muslim households
compared to non-Muslim households. Life style related factors odand food habits
appear to be the important reasons for higher prevalence of illness among the Muslim
community.
Table: 7,! Distr~butio~i of Households Reporting OPs and IPS W b e - T I P _- 1 OP j per liousehuld -. - ,~umh~rof)louscholds/ % Number of Households 1 %
33.81
F~ve -- - - Source sample survey. 2004
7.3. Socio-Economic Group (SEG)
'I'able 7 ? Dls!mbul~on of the Households Reporting OPs and IPS
Socio-economic groups have been constructed ro strengthen the analytical content of
Variable Outpatlent
Yes - -. - - .- No --. -- Total
t--- Inpatie111 - -. - - - - Yes
-. .- . -~ - No , . Onl\ A Ourpat~ent
Onlb In atlent
both OP and IP health care serv~ce utilisation. In general, there is no consistency, in the
OP and IP prevalence rates across SEGs. The average number of OP per household
Number I Percentage
differs across socio-economlc groups. The average number of OP is the highest In the
232 117
l 339
'--- -- Bo;hO;&lP: 105
poorest socio-economic group (SEG,) and on an average 1.1 OP per household is
66.48 33.52
100.00
30 09
reported to have been utilised OP health care services and it is the lowest (0.92) in
119
OPor lP / 268 / 76.79 Ne~ther OP nor 1P 1 81 1 23.21
Source sample survey. 2004
141 208 127 36
40.40 59.60 36.39 1031
SEGI. In other words, on an average, there is one OP per household. The study
estimated one inpatient per two OP or one inpatient per two households (see table: 7.3).
The poorest SEG reported largest number of both OPs and IPS, even though it is not
consistently the same across all SEGs. For instance, the average number of IPS is the
highest in SEGI (0.64) and lowest in SEG, (0.42) whereas it is 0.51 in SEGP.
Source sample survey. 2004
7.4. Morbidity Analysis
We have used the lntemat~onal Classification of Diseases and the NSSO classification
o f s h ( r ~ durat~on and long duratiun morbidity as the general guideline for analysing the
illness types into14 groups (see table 6 6 ) . This is useful to understand and
conceptualise thc broad trend in the patterns of diseases in the rural society. The survey
estimated the share of infection, and fevers at 25 percent of the OPs whereas it is only a
little more than 8 percent for the IPs.Around 16 percent of the IPS reported digestive
and intestinal disorders. The most striklng feature is that cardio vascular and central
nervous system rc1a:ed diseases or disorders accounted for almost 16 percent of the
total inpatients. whlch Indicates the transit~on to neo-plastic and the affluent diseases.
This pattern is generally observed in industrially advanced countries. Another
imporlanr finding is the increased prevalence of diseases relating to ENT and specla1
senses. It accounted for more than 10 percent of the outpatients and 8 percent of the 120
inpatients and the composition of long standing diseases gets enlarged and widened
(table: 7.5). The public health care system at all levels in Kerala should accept it as a
policy option to address the morbidity transition to degenerative and chronic diseases.
Similarly, morbidity analysis across socio-economic groups indicates inverse
relat~onshlp between SEG and the proportion of inpatients. The first quartile group
reports 29 percent of the IPS and 26 percent, 24 percent and 21 percent for the second,
thlrd and fourth quartiles, respectively. On the other hand, the differences in OP across
SE(I also indicate more or less the same pattern (table: 7.6). This type of a morbidity
transition to long standing diseases, particularly, has important implication for health
policy and health care financing in Kerala.
Source sample survey. 20
7.5. Heal th C a r e Sector
The prlvate sector is the significant health care provider of both OP and IP health care
services in Kerala For Instance. the sun.ey results have shown that only 22 percent of
the OPs reported to have utilised public health care facility and the rest private health
care licilities Only a little more than I2 percent utilised public health care facility for
hospltalisation as Inpatient and 88 percent utilised private sector health care services
(see graph: 7.1). The dominant role of the private sector and lack of state intervention
have contributed for an undue increase in the cost of health care and have invited
unethical medical practices. This is, panially attributed to the poor quality of public
health care services and lnfrastructural constraints particularly in the rural areas. I21
Source sample survey, 2004 Note: Figures In parenthes~s are percentage shares
7.6 Age and Gender
'The number of OPs and IPS is only marginally higher among the females and
differences in morbldrr) are obsrnled across family structure, gender of head of
household and broad age group. Compared to the male headed (24.50 percent) a lesser
proportion of female headed households ( 1 8.6 percent) utilises public health care sector
for OP care where as it is 13 percent and I I percent for IP care respectively. Similarly,
a higher proportion of nuclear family utilises public health facility compared to joint
family. A greater proportlon of females utilises public health care sector for both OP
and IP medical care services A higher proportion (24 percent) in the 0-14 age group
utiliscs public health care services compared to 21 percent for the work~ng age group
Four-fifth (8Opercent) of the 601 age group has utilised private health care services for I22
OP geriatric health care and it is more than 90 percent in the case of IP health care
(table. 7.7).
Structure,Gender, Age and Sector: OP and IP
Note. Figures In parenthes~s are the percentage shares
OP
49 151 ! (24 50) 1 (75.50)
Female 27 I I8 -- 118.62) 1 ( 8 1 3 8 )
Total 176 269
The average age o f an OP is lower than that of an IP. It implies that the nature
and type o f disease is an important determinant o f OP and 1P care. The average age of
lemale OP and I P is higher than the average age of male O P and IP, which may be due
to physiological. or d~sease related factors. For instance, 28 is the average age of an OP,
24 for males and 32 for females and ~iiuch different across caste groups. Similarly, 39 is
the average age o f an IP, 36 for males and 42 for females. Patients belonging to the
forward castes reported a higher average age than the other backward communities for
both O P and IP The same pattern is observed across marital status of both OPs and IPS
able 7.12). Similarly, the average age across marital status is different for OPs and IPS
and across gender(tab1e 7. 13).Average age across socio-economic group and gender
123
i P
zoo 1 Public__._LPrivate i 'Total 1 Public 1 Private 1 Total
T s e of Head o f Household , . .. - -. .
14 (13.33)
8 (10.81)
22 . ( 2 0 3 7 97) j 4
Family structure
A , I
( 2 2 9 )
13 ( I l l )
9 (14,52)
10 (10,34)
12 (14.13)
. - - - - Joint 4 7 .. - 1
l 29
L ( 2 2 , b b )
I 1 35 1 Ma" .. i.l?-~o)_. 1 Female i 4 1 , . i (22.401
(ao.o,) 66
(89.19)
170 ( u f ~ l . . - p 8 3 4 1 l 7
99 (77,34) 1
Gender wise Distribution 127
(78.40) 1 142 i
(77 60) ( 183
id
( 8 "9
I Abe wiseJistribution
0-14 1 - 3 0 1 95 t
37
1 1 ' ~
179
3 (8.1 1 )
16 (14.41)
3 (9.68)
22 (12.29)
(rjpo).
104 (88.84
53 (81,48)
34 (91.89)
95 (85.59)
28 (W32)
157 (87 71)
_.-l!6.00) ' .
' 1 7 ~
62
1 2 5
78 (89.66)
79 (85.87)
15-59 1- 40 1 (21.05)
6 1 (2gOO) - I
rota1 i '6 I : ( 2 0 3
8s
91
Source sample survey, 2004
150 (7895)
24
I9O
(80 00) ~ -3' 269
(77.97) ;
provides an interesting pattern. The average age of both the female OPs and the IPS is
much higher than the males. For instance. average age of OP males is 24 years and that
of females 32 years as against 28 years for both combined. On the other hand, the
corresponding figures for inpatients are 36 years, 41 years and 39 years, respectively.
The studies relating to hospitalisation and utilisation of health care services are very
few in the country The study by NSSO IS the major data source and it gives
information regarding the number of persons hospitalised. The number of persons
liospllalised in rural Kerala during the last 365 days reveals that it is 70 and 78 per
thousand population in the NSSO and the present sample survey studies, respectively.
The hospitalisation rate is very low in both urban and rural India compared to Kerala.
For instance. ~t IS as low as 1.3 and 20 per thousand population in rural and urban India.
respect~vely (see table 7.8). As per the NSSO (1998) study, the urban-rural differences
in Kerala are marginal and the geographical differences are not crucial determinants of
hosp~tallsation.
. - - . -. - Persoris Hospitallsrd Duringthe Last 365 Days ( 1 995-96 and 2003-04) per thousand population Keralai Urban India Kerala' -. 19%3 6 _ 9 _ ~ Keralag. Indta* 20
Suursrs 'NSSO. I Y Y B
7.7 Average Number of Times Hospitalised
Gender differences are more pronounced with regard to both average number of times
hospilallsed and duration of hospitalisation. On an average, males are hospitalised 1 4
times as against 1.2 times for females. It indicates that the males are more concerned
ahout their diseasc, illness reco\ery and health status compared to the females. On an
average, an inpatient has been hospitalised for seven days for medical treatment. More
importantly, the average length of hospitallsation is also much higher for the males
(8 35 days) cornparcd to the females (5.61days) Family responsibility of the rural
female folk compels them to seek earlier discharge from the hospital to resume work as
the main family feeding agent in rural areas. That is, the males are keener in availing of
prolonged and better institutional/non institutional medical care as part of
hospltalisation compared to the females (table 7 9). 124
7.8 Average Duration of Stay for Hospitalisation
Average duration of stay for hospitalisation as an IP is different across caste group and
gender. For instance, the duration of stay is much higher for the FCs (12.5) and the
lowest for the OBCs (6.59). Gender differences are more striking and significant. The
average number of days hospitalised is much higher for the males (8.35) compared to
the females (5.61) which is an important determinant of medical expenditure. Apart
from the morbidity related factors, one explanation for the low average duration of
hosp~tal stay for the females is their family concern which compels them to get earlier
discharge and return home (table: 7 10). The average number of times hospitalised is
- - . . .. - - - .- .
Male
Source sample aurve), 2004
also lower among the females w h ~ c h ~ndicates that they usually conceal illness
symptoms initially and seek delayed health care service (table: 7.11). In the Kerala
society. the proportion of patients resorting to self-medication is nearly 12 percent.
Caste Grou -.-- ~ - --
Female Persons I? 15 6.89 Source sample survey. 2004
- ... - -. . .
.. - 1.19 Persons 1.28 Source sample survey, 2004
Table 7 12 Distribution of average age of OPs and IPS by Caste Group and Gender Caste Group - - - - - -- .- LC . Male 1 F e : : l r i FC -- 26.00 48.29 41.60 49 67 53.22 52.40
23.28 30.99 27.70 34.19 40.86 37.37 17.89 24.10 21.51 39.36 41.08 40.08 S C ' S L . - .
AI! Group 24.43 / 32.14 27.84 35.93 42.07 38.71 Source sample survey. 2004
Table 7.13 Average Age of OPs and IPS by Marital Status, Caste and Gender ----
*includes divorced, w~dowed, separated etc
7.9 Sector of Medicine
Privale sector is the dominant health care provider in Kerala. For instance, 78 percent
of thc outparients utilises prkate health care facilities and only 22 percent utilises
government medical f i c l l ~ t ~ e s . Similarly, 88 percent of the inpatients utilises private
Source a m p l e surve). 2004 health care system and 12 percent utilises government health care system. The
util~sation of public health care system for both OP and IP consistently declines as we
mo\c the socio-cconomic group For instance. even in SEGI, only 37 percent utilises
pubhc health care system and 63 percent prhate health care system for OP care and the
corresponding shares for IP care are 20 percent and 80 percent. Thus, at least 50
perccnt of the patients belonging to the lowest socio-economic group is not utilising
public health care system. Similarly, it is not surprising that not even 10 percent of the
OPs belonging to SEGl utilisrs government health care system. It is striking to note
that. In our sample, not even a single inpatient from SEG4 is reponed to have utilised
public health care servlces for hospitalisation (table: 7.16). This raises certain important
policy questions and identifies cenaln weak links in the functioning of the public health
care system. 126
Sectoral Distribution of OP Care
Public i
- Private
I -- I
m Publlc O Prlvate I - - -
I - - - - -- ----
Sectoral Distribution of IP Care I
Pr~vate I 1
88% 1 - - I
5 Public m Private '
Table 7.15 Dist r ibut~on o f OPs and IPS by SEG and Gender OP IP
4 5
45 23 21 84 (54.29) (45.71) 44
1 Total 162 183 87 92 179
. .- I (5 96) (53 04) it:- (1 .60) (51.40) Sour~e sdmple survey, 2004 Note. t~gures In parrnrhes~s are the percentage sharer
7.10 Systems of Medicine
Allopathy, ayurveda. homeopathy, unani and sidha are the different systems and
streams of health care providers in era la'. Allopathy is the dominant system of 127
medicine and health care for both OP and IP health care services in Kerala. As we
move up the socio-economic status (SEG)the use of the allopathic system for OP care
cons~stently increases.
Source sample survey. 2004 Note. F~gures In parenthesis are correspond~ng percentage shares
Comb~ned response of outpatients and inpatients revealed that only less than 19 percent
utilised public health care facilities as a treatment option At the same time, the highest
SE(i uses the lo\best proponion of both ayuneda and homeopathy for OP care whtch
~mplies that easy disease reco\,ery, their spend~ng ability and affordability are the main
reasons for their preference for allopathy or modern medicine (table: 7.1 7).
- . - - - - -- - Fig. 7.2a:Systemwise Distribution of
I
Homeopathy, R%
I . . . - - . --- ! MAllopathy l Ayuweda ~omeopalhy j - -- - - - =..= 8 . ..
Fig. 7.Zb: Systemwise Distribution of IP Care
Homeopathy, 1 % I
Allopathy 98%
I -- L.
!&Allopathy .- ... - 8 Ayurveda . 8 Homeopathy 1
7.11 Waiting Time and OP Health Care
Most OPs had to watt a relattvely longer time at the health care institutions or clintcs
for obtaining medical sewtce or physician consultation. More than 38 percent of the
OPs had to wait 30 mtnutes or more and a little higher than 8 percent more than 60
mlnutes for consultation at the hospitals or clinics or health care centres (table: 7.18).
Even tn this age of spec~alisat~on or super specialisation patients had to wait longer
tlme In the medical centre or hospitals which creates double negative effect on their
lncolnc in [ e m s of labour hours or man days lost This also increases the delay in
seeking health care
Note' Figure, in parenthesis are percentage shares 129
78
Table 7.1 7 Distribution of OPs and Ips by SEG and Systems of Medicine (%) OP
SEG? 64 \ \ 8 -- ) 42 \
. .. (8 96) - 66 13 2 3 7 SEG3 (83.08)
I
- 37 (I5 38)
sEG4T.(94,29) , (I;?) -- 282
1 8 1 7 4 ) ( 1 7
(1.54) (100) 5
Source sample survey. 2004
(4:)
(7.54)
43 84 --- (97.22
176 (98,32:
I
2 ( l l 2 ) - : 0 . 1 6 )
2.78) 1
44
l i p
Delay in seeking medical care is basically attributed to two reasons. One is the nature
of the disease and second the problems relates to health care financing. For instance, 83
Table: 7 I8 Distribution of OPs by Waiting Time in Health Care institutions
percent of the OPs and 72 percent of the IPS utilised medical services only on the
Walling t~me (in minutes) 0- l s . - - - - - .
- - I 5:!o . . ... . 30-45 45-60 60-90
2 P 3 0 . - . .. .- . - 2' .. . - . ._ .- Total -. . . - .-
second day and 8 percent and I2 percent of them visited the health care provider on the
th~rd day The economic status of the patients1 head of the households constitutes an
Source sample survey. 2004 7.1 2 Delay in Seeking Medical Care
Frequency - 78
-- 136 27 76 13
. 14 I
345
Important determinant of delayad health care. The perceptions, ignorance and their
Percentage - 22.61
39.42 7.83
22.02 3.77 4.06 0.29
I
100.00
~nabrlity to ident~fy the nature of the d~sease ~nitially also increase the frequency of the
delaj The delay in seeking health care is basically attributed to the nature of diseases,
the poor economrc status and relatively higher medical expenses for both OP and IP
care (table. 7 19) Most of the patients have utilised health care services on the second
day I t shows Increased health awareness among the patients.
1 dblfI.!~-~~la~!n__+I Medical Care for OP and 1P Care
7.13 Mode of Travel
Access is nor a serious problem in rural Kerala compared to other Indian states. The
cross sectional household sample survey has revealed that 12.5 percent of the OPs and
OP
1.7 percent of the IPS had the medical facility at a walkable distance. Similarly, 4
source sa~nplc survey. 2OU4
Frequency 5
26
IP
percent of the OPs and 8 4 percent of the IPS utilised own vehicle. More than two-fifth
% 1 4 7 5
82.9 8.1 .--
Frequency --- 27
129 22
I 179
utilisrd public transpon and around two-fifth utilised auto as the as the convenient
mode of travel for obtaining OP and IP care (table: 7.20). 130
, l otal 34545- , 100.0
%
15.1 72.1 12.3 0 6
100.0 J
7.14 Travel Time
Travel time to reach the health care provider reveals that it is not a serious constraint on
the utilisation of outpatient health care services. Around one-thirds travelled more than
three hours to utilise the quality IP health care services.
. . . .
Source sample survey. 2004
I t implies thal travel time is not a serious constraint on the utilisation of IP health care
servlces in rural Kerala. At the same time around three-fifth travelled less than 30
minutes. On the other hand, the average travel time in rural Kerala is much lower than
rural India. Duc to supply constraints In the public sector, the people of Kasaragod, in
general, depend private health care providers In the boarder city of ~ a n ~ a l o r e ' (table:
7 . 2 1 ) . The average travel time for OP health care across gender is less dissimilar. On
thc other hand. gender differences are significant in the case of inpatient health care
sennice utilisation The average time taken for one way travel to IP care service
provider by males 1s 58 minutes where as it IS 49 minutes for females. As we move up
the StG the akcrage l r a ~ e l lime Increases consistently except for SEG]. The average
trabel time for both OP and IP health care service utilisation in SEG4 is much higher
compared to other socio-econom~c groups. The average travel time for utilising
hospitalisation services among the SEGl IS around 87 minutes whereas it is less than 51
minutes on the average. Thus, socio-economlc status of the patient is not a consistently
significant determinant of average travel time for utilising both OP and IP health care
service (see table 7 . 2 2 )
Table: r. 7.21 - . . Distributio~i - - -. x- of Travel . Time* to the OP and IP Care Provider (in minutes - Note: 'One way travcl t11ne LO the health care prov~der in minutes
Source sample surve)
Travel Titne- Frequency
Note 'One way travel tltnr to the health care prov~der in minutes
7.15 Distance and Health Care Service Utilisation
%
In Kerala, compared to other Indian states, access is not a serious constraint on the
utilisation of health care services. Distance 1s an imponant determinant of utilisation of
both OP and I t ' care serLices In the Kasaragod district. Around 33 percent travelled
more than 10 k~lomrtres to serk outpatient care and around 39 percent travelled five
k~lolnetrea or less for the same. On the other hand, more than 22 percent travelled 50
k~hrmcl ro 111. I n a e ti1 u ~ i l ~ s c hospital~sat~on services and around 36 percent travelled 10
kllometres or less as to serk health care service as an inpatient (table: 7.23). Transport
infrastructure and health care infrastructure in Kasaragod district is relatively poor and
much lower than the state average. The general behaviour is that irrespective of the
soc~o-economic status patients prefer private health care services and consider quality
of the private seclor much better than the public sector. As a result patients, in general.
traicl relat~vel) 1dngi.r distsncc for obtaining quality health care services This attitude
of the patients, of course. among other factors, act as an important determinant of better
health status in rural Kerala.
bT'-FiF- - 42.6 0-30 107 59.8 % Travel Time Frequency
15-3!--- 30-60 i 16
Source ~arnple survey, 2004
45.2 4.6 7.5
100.0 60+ 26
30-60 60-120
120+ Total Total 1 345
14 --- 58
179
7.8 ---
32.4 100.0
7.16 Conclusion
Private sector is the s~gnificant provider of health care services and it accounts for 78
percent of the OP and 88 percent of the IP health services. On an average, one person
per household is reported to have utilised health care services as an OP and at least one
hospltaljsat~on per two households. In terms of the number of times and days
hosp~lalised males are at an advantage and gender discrimination is reported to have
been dominant. Increased frequency of both OP and IP health care visits to modem
medicine in the private sector has implications for health care financing and health
polic) The specific issues rclat~ng to health care financing are discussed in the next
chapter
Notes
I. Compared to the national average, the proponion o f patients utilising Indian Systems of Medicine and
Homeopathy 1s much h~gher in Kerala Effective steps to Improve its utllirat~on for general, reproductive
and child health servlces and encourage the utillsatlon o f standard remedies and cures and promote low
cost health care In Kerala, ayurveda and homeopathy are two dominant medical streams and effective
stepr should be taken to standardise these systems and regulating the cost o f health care (See Gol, 2002).
2. lllncss classlfi~atlon based on sclf-perce~ved morbrdlty 1s a difficult task We have grouped diseases
retalnlng the broad symptoms Into one group for analyt~cal purposes. See WHO, 1989; NSSO, 2000.
3. Even for outpatlent consultat~onr patients prefer private health care service providers panicularly at
the hoarder clty o f Mangalore in Karnataka. Mangalore is one o f the important and special~sed prlvate
med~cal centres In South lndla In other words, 32 4 percent ofthe patients travelled more than two hours
to reach the health care fac~l i ty for hospitalisation as an IP In the advanced and speclalised medlcal
centres and hosplrals at Mangalore (Only 50 k~lometres from the Kasaragod d~strlct head quarters) and
Marilpal ( I I 0 klli~lneirec from tlie Kaiaragod D ~ s t r ~ c ~ head quaners) In Karnataka state.