Changing Attitudes Toward Health and Healthcare in India: A Comparison of Three Rounds of the National Sample Survey

This blog post is the second in a series on the Indian National Sample Survey. Click here to see the first post. This post was coauthored by Arun Nair. 

The healthcare round of the National Sample Survey is a survey of healthcare attitudes and practices in India that is conducted every ten years. The last three rounds were conducted in 1994, 2004, and 2014. The Indian healthcare system has undergone massive changes in this time. While the 1990s were marked by economic reforms, the decade also saw substantial improvements in several health indicators, including under five mortality and life expectancy.[ref]Deolalikar, A., Jamison, D., Jha, P. & Laxminarayan, R., 2008. Financing Health Improvements In India. Health Affairs, 27(4), pp. 978-990.[/ref] Despite thse positive developments, improvements in other maternal and child health indicators between 1990 and 2008 have been more modest in India than in other South Asian countries.

In the 1980s and 1990s, consistently low government spending in health as a percent of the Gross Domestic Product (GDP) drew criticism. Government spending as a percent of the GDP has remained stagnant, despite the launch of the National Health Mission, a government initiative intended to increase public spending on healthcare. Yet the National Health Mission has been successful in some areas. It has given more structure to the public health system, launched a number of focused health programs, and improved awareness of various government programs. The National Health Mission has led the states to think innovatively about how to spend the funds allocated to them. At the same time, there has been more experimentation with health insurance to address persistent problems of access and affordability to healthcare services.

Somewhere among all these different changes it is worth understanding changes in people’s attitudes toward healthcare and in their health seeking behavior. In this second blog post of the series on the National Sample Survey, we discuss some of the changes in how Indians have used health services over the last thirty years.

Proportion of People Ailing per Thousand Population

Graph1Over the years, the number of people self reporting illness has increased, especially in urban areas. This increase could signify increased awareness of health, which has been a byproduct of the health financing reforms. The government has launched many awareness campaigns. The government has been proactive in using print, audiovisual, and, more recently, social media tools in its awareness campaigns. Noteworthy examples include the Mamta Rath in Madhya Pradesh (a van carrying audiovisual aids village to village), the Aarogyamithras of Andhra Pradesh (workers at the primary health centers who generate awareness about government health insurance), a monthly village health and nutrition day in every village, the Mitanin program of Chhattisgarh in which over sixty thousand women are working as community health workers, the successful mass media campaign of the National AIDS Control Organization, and many other vertical programs. A number of awareness programs have also been started by the private companies as a part of their corporate social responsibility initiatives.

Improvement in access to public and private healthcare facilities could also be a cause for the increase in illness reporting.

 Hospitalization Rates

Graph2For both rural and urban areas, the rate of hospitalization has increased. This is both a welcome change and a cause for alarm. In rural areas, the change in the number of people reporting illness – those who might seek outpatient care – is not as great as the increase in the number of people being hospitalized. This high level of hospitalization relative to reported illness is concerning. Taken together, this survey data provides quantitative evidence of an unprepared and ailing primary care system in India. On the positive side, the survey also provides quanititative evidence that access to and use of hospital care has increased following the introduction of government sponsored insurance. This change could indicate that the insurance programs are improving access to care. The best way to analyze this change would be to compare states with such health insurance programs to those without. We will take a look at this in a subsequent blog post.

Hospitalization in the Private Sector

Graph3There has been much discussion in published literature on whether the use of the private sector, especially for hospitalization, has increased or not. While urban areas do show such a trend, there is no visible change in the use of the private sector in rural areas. This is indicative of the fact that private hospital availability is more of an urban phenomenon and has only increased over the years .

The massive shift in private sector hospitalization between 1990s and 2000s is also indicative of the effect of the overall economic reforms of the 1990s. These reforms may have widened the market for private healthcare, given that the huge influx of investment from various corporations. Increased rates of hospitalization and use of the private sector, however, has not led to a massive improvement in maternal and child indicators, especially when compared to indicators from other South Asian countries like Sri Lanka and Bangladesh.[ref]Deolalikar, A., Jamison, D., Jha, P. & Laxminarayan, R., 2008. Financing Health Improvements In India. Health Affairs, 27(4), pp. 978-990.[/ref]

Percentage of Deliveries at Home

Graph4Research shows that women in both rural and urban India now prefer hospital deliveries over deliveries at home. The massive reduction in homebirths between 2000s and 2010s further illustrates this preference (figure 4). This shift in attitude may be due to the focus on maternal and child health by many of the states in India. Another major cause could be the national introduction of a conditional cash transfer program for maternity benefits called Janani Suraksha Yojana. Many studies and data sources indicate that homebirths have decreased and hospitalization rates have increased since the launch of the program. Yet, despite the increase in hospital births, maternal mortality has not significantly decreased, a major cause for concern.[ref]Lim, S. et al., 2010. India’s Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation. Lancet, Volume 375, p. 2009–2023.[/ref]

Next Blog

In the next blog, we will compare these indicators across several states. We will look at states that used insurance to improve access to healthcare which Andhra Pradesh, Karnataka, and Tamil Nadu. Anecdotal evidence indicates that these states have more private sector usage than states that are currently undergoing health systems reforms, like Himachal Pradesh and Kerala, and those that are underperforming, Madhya Pradesh, Uttar Pradesh, and Rajasthan and do not have many private facilities. It will also be worth looking at the change in the rates of home deliveries in the states Madhya Pradesh, Uttar Pradesh, and Rajasthan, which have high maternal and child mortality.

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