Here is why they are sceptical. Total health expenditure has two major components – government spending and OOPE – with the rest being accounted for by a combination of private health insurance, spending by employers, NGOs, and so on. While government spending is easy to measure, OOPE or what is spent by people at the point of care is estimated by using data from the most recent survey on health expenditure conducted by the National Statistical Organisation (NSO).
In this case the 2017-18 survey data was used, and experts point out it showed an inexplicable and sharp fall in hospitalisation rates and even in the proportion of ailing persons. It was the fi rst fall in hospitalisation rates (excluding for childbirth) since the 1995-96 survey, for which there was no logical explanation. It was across states and economic strata.
Hospitalisation rates usually keep rising as access to healthcare services improves. “This could indicate a serious state of hardship, because of which people withdraw from accessing healthcare as they are scared of healthcare costs. This is diffi cult to believe, because one can postpone hospitalisation, but cannot avoid it altogether. Hence, the data indicating reduced hospitalisation seems problematic,” explained Dr Indranil Mukhopadhyay, health economist and professor at the School of Government and Public Policy, OP Jindal Global University.
The proportion of ailing persons also saw an unaccountable decline in the 2017-18 survey compared with 2014-15 and 2004. Thus, though a fall in OOPE is considered a good thing in general, the 2017-18 fall – if true – would indicate a reduction in utilisation of the health system, clearly not a welcome development.
“The 2017-18 health expenditure survey showed a 20% decline in the proportion of those seeking outpatient care in India and a 25% decline in the proportion seeking hospitalisation services from the 2014 survey. The per capita total health expenditure, when adjusted for infl ation, has also remained stagnant over this period. There is also a steady decline in total expenditure as a percentage of the GDP from 4% in 2013-14 to 3. 2% by 2018-19. In the context of a fast expanding healthcare sector, such fi nancial shrinking seems unlikely and so the OOPE estimates need a closer look. Since the 2018-19 OOPE is an estimate based on the estimate derived from unaccountably low utilisation in the 2017-18 survey, it is bound to have the same problems,” explained TR Dilip, associate professor at the International Institute for Population Sciences, Mumbai. He added that the sharp fallin OOPE estimates based on the 2017-18 survey was an error that would continue to hobble OOPE estimates based on it till the next expenditure survey.
Till 2016-17, the share of OOPE in total health expenditure was falling gradually as government expenditure rose. However, there was a dramatic fall in 2017-18 to 49% from 59% the previous year, though there was no proportionate increase in government health spending on the operational aspects of healthcare referred to as current health expenditure.
The government is implying that a fall in OOPE is due to greater government spending on health. “A look at NHA over the years shows that though the total government spending on health has been rising, in 2017-18, the year which showed the sharpest drop in OOPE, the highest increase has been in capital expenditure of the Defence Medical Service. Capital expenditure is what is spent on health infrastructure like hospitals, medical equipment etc. If you take this component out, there is hardly any increase in public spending on health as a percentage of GDP. But capital expenditure cannot cause a dramatic fall in OOPE in a particular year.
Moreover, increased spending on Defence Medical Services might be necessary, but is not accessible to the general population. Thus, that too is unlikely to have caused OOPE to fall that year,” explained Dr Mukhopadhyay.
