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.