Study finds public health spending has not resulted in significant pro-poor services in India

An analysis of equity between urban and rural health services using Benefit Incidence Analysis (BIA), a tool to estimate the equity of healthcare benefits accrued to individuals across socio-economic groups, has found that public spending has not resulted in significantly pro-poor services in India.

The paper titled ‘Benefit Incidence of Public Health Expenditure in India: Urban–Rural Equity Matters for Universal Health Coverage’ has been published in the Journal of Health Management, a Sage Journals publication.

A team of researchers led by faculty from the Indian Council of Medical Research (ICMR) and M.S. Ramaiah University of Applied Sciences used data from the 75th National Sample Survey (NSS) round done in 2017-2018 for the analysis. Disease burden, out-of-pocket expenses, and non-utilisation of public health services for outpatient and inpatient care were analysed. Concentration curves and indices were calculated for rural and urban areas.

Public health spending

“This article represents the most recent BIA completed in India and presents an analysis of the distribution of public spending in outpatient and inpatient care. The results help illustrate the extent of the effectiveness of resource allocation on public health by the government in meeting the needs of vulnerable populations,” said Denny John, professor - Public Health, Faculty of Life and Allied Health Sciences at M.S. Ramaiah University of Applied Sciences in Bengaluru.

Dr. John, who is the corresponding author of the paper, told The Hindu that when both outpatient and inpatient care are considered together, public health spending approaches a more equitable distribution. However, for inpatient care, public health spending is more pro-poor, whereas for outpatient care, it is more pro-rich. In rural areas, public health spending on outpatient and inpatient care is more pro-poor compared to urban areas, where it tends to be more pro-rich, he explained.

“To fulfil the health needs of the urban and rural populations, public health funding must be appropriately allocated. This study sought to determine whether such practices were present in India. Results at the national level show a patchy distribution of equality in public spending between urban and rural people,” the doctor said.

The launch of Ayushman Bharat in 2018 marked India’s start toward universal health coverage (UHC). However, various studies have shown that only 1.28% of India’s GDP, or roughly ₹1.58 trillion, is allocated to public health spending, one of the lowest rates in the world. Besides, there are disparities in access to healthcare between urban and rural areas, and a lack of accountability.

Conclusions

In rural areas, the utilisation of public health facilities for both outpatient and inpatient care is concentrated among non-poor individuals but is more pro-poor for outpatient care.

“This research yields a number of important conclusions. Overall, at the national level, the non-poor are the main users of public health facilities for both inpatient and outpatient care. Our examination of public spending reveals that we are getting close to achieving equality. Spending on public health is getting closer to parity when outpatient and inpatient treatment are taken into account jointly. However, public health spending is more pro-poor for inpatient care, but more pro-rich for outpatient care. Outpatient and inpatient public health spending in rural areas benefits the poor, whereas in urban areas, it tends to benefit the wealthy,” Dr. John said.

In order to better target the underprivileged in rural and urban areas and achieve UHC in India, policymakers should use these statistics to increase the amount of detail in their work and monitor levels and equity patterns in government health spending, he added.