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ORIGINAL ARTICLE  
Year : 2013  |  Volume : 6  |  Issue : 4  |  Page : 472-478
Preference of hospital usage in India


Centre for the Study of Regional Development, Jawaharlal Nehru University, New Delhi, India

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Date of Web Publication26-Feb-2014
 

   Abstract 

Health is important and money is not matter, if people are concerned for the treatment of various ailments. A collective acceptance with regard to hospital usage is that most of the people prefer to use private hospitals even if the cost of private hospital tends to be high. Public hospitals are not preferred due to poorer quality of their services, even though these services are provided at low cost. At the time of independence, nearly 15% of the people used private sector. In a recent study by World Bank, it has been found that about 80% of the people use the private hospitals in India. In order to understand the preference of hospitals of ailing persons, we make use of the National Sample Survey Organization's 60 th round data on morbidity and health-care conducted in 2004. Using this data, we first described the demographic, social and economic characteristics of person who use the hospitals. We have also used primary data collecting during May-September 2010 in Bundelkhand region, Uttar Pradesh. There were 360 farmers have interviewed from three villages from each Banda and Hamirpur districts. We have tried to understand the preference of hospital usage among the migrant and non-migrant households. We have found that migrant households preferred private hospital for any type of treatment whereas non-migrant households still have faith on herbal and magician for the treatment. Migrant household preferred institutional delivery and spent money on healthy food such as fruits and vegetables. Migrant households were more health conscious and more exposed about the health awareness programs such as polio, immunization and health check-up of the children. Interesting to note that migrants households have first aid box and some general medicine such paracetamol, B-complex table and syrup. Some of them have thermometer and they are able to measure the body temperature and apply medicine to control fever if any time appeared among the member of households.

Keywords: Ailment, hospitals, morbidity, treatment

How to cite this article:
Prasad S. Preference of hospital usage in India. Ann Trop Med Public Health 2013;6:472-8

How to cite this URL:
Prasad S. Preference of hospital usage in India. Ann Trop Med Public Health [serial online] 2013 [cited 2019 Oct 22];6:472-8. Available from: http://www.atmph.org/text.asp?2013/6/4/472/127804

   Introduction Top


The public hospital is basically good for majority, poorest of the poor or low income household member in society. Most of the patients in India using Private hospital so much rush, lack of sufficient doctors and lack of faith in terms of the hospital services, rude behavior of the medical staff, lack of sanitations etc. In contrast to that private hospital provides proper clinical services and standard of health-care. Hospital is an institution for the care of the sick or health-care, [1] a health facility where patients receive treatment, often but not always provide for longer-term patient stays. According to web-dictionary, an institution operating under the guide of a professional physician primarily for the care and treatment of injured and sick persons confined as in-patients having organized facilities on the premises for diagnosis. In ancient cultures, religion and medicine were linked and the aim was to provide a cure in the religious places. Boyd [2] have reported that 15% of the population were 19 year or under, who have used public hospitals, 59% and 26% were the age group of 20-44 and 45 and above respectively. Desai [3] also reported that in Gujarat 34% of rural and 55% of urban women who underwent hysterectomy had utilized a government hospital under Rashtriya Swasthya Bima Yojna (RSBY). Distance of hospitals influencing usage of hospitals and 41% of the people of sub-urban and cities went to the nearest hospital. [4]

In India, proportion of the private hospitals is nearly 66% of the total hospitals and government own hospitals constituted for around 31% of local bodies own the rest. In-terms of beds in hospital government have higher 62% than private hospitals 35%. [5] Dhar [6] mentioned that public health system will now be asked to compete with the private sector to attract patients. Duggal mentioned that there are two types of private hospital ownership, i.e., for-profit and not-for-profit and more than 80% of ambulatory care is provided by the private sector for the country.

In India, facing various types of ailments that are required serious treatments. Based on two rounds of National Sample Survey Organization (NSSO) (1998 and 2006) data, a study by Prasad [7] showed that "the 52 nd round survey reported the highest percentage of persons ailing 1 day and 15 days before the survey and these were due to diseases such as eye diseases (25.6% and 28.6%), endocrine (21.1% and 24.5%), circulatory (18.7% and 24.3%), genito-urinary (16.7% and 22.5%), neuro-psychiatric (12.8% and 18.7%) and neoplasms (14.5% and 18.5%). However, I have found in 60 th round survey highest ailing was due to circulatory (55.6% and 60.0%), followed by endocrine (55.4% and 58.4%), respiratory (50.1% and 56.8%) and neuro-psychiatric (48.4% and 54.3%)".

There are three main sources of health-care services in India such as a public hospital, private hospital and traditional health-care. It is interesting that in the modern age 8% of the population of developing countries rely on traditional medicines, mostly plant drugs, for their primary health-care needs World Health Organization (WHO). In modern source of medicine, about 25% drugs derived from the plants and many others that are synthetic analogues built on prototype compounds isolated from plants. The demand for medicinal herbs is increasing in both developing and developed countries due to the growing recognition of natural products, being non-narcotic, having no side-effects, easily and affordable for poor. There are many rural residences using the medicinal plant as self-treatment. [8] The McKeown [9] explained the medical contribution in decline of mortality and he also explained the protection of diseases by immunization and therapy. The immunization helps to prevent the some infectious diseases. Medical treatment may also influence infectious diseases by serum transfer, as treatment of diphtheria with antitoxin; or by therapy, which acts directly on the microorganism, as in the case of sulfonamide and antibiotics.

Numbers of the studies have showed that people generally prefer private hospitals. The cost of treatment in both (public and private) the sectors much differ in both the sector rural and urban. [5] It is typically seen that usage of the hospital is affected by social, economic, racial and environmental factors.

In India, there are 29 states and 6 Union Territories (UTs). These states and UTs are clubbed into six regions. The North region includes Jammu and Kashmir, Himachal Pradesh, Punjab, Haryana, Delhi, Rajasthan and Chandigarh. In the Central region Uttar Pradesh, Uttaranchal, Madhya Pradesh, Chhattisgarh are included. Bihar, Jharkhand, Orissa and West Bengal form the eastern region while Arunachal Pradesh, Assam Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura are in the northeastern region. The Western region contains Goa, Gujrat, Maharastra, Daman and Diu and Dadra and Nagar Haveli. Andhra Pradesh, Karnataka, Kerala, Tamilnadu, Lakshadweep, Pondicherry and Andman & Nicobar Island in the Southern region.

The traditional health sector offer treatment without prescribed and charge for that was very low. Most of them believe in worship of God and donation for cure rather than prescribed medicine. The traditional medical practitioner charges for treatment on the basis for the cost of production the medicine. They also convince the patient for high expense on the traditional medicine and its superior quality than modern medicine. [10] In the public hospital practitioner indirectly ask the money as kindness (khusi). If the patients are not willing to give that offer the behavior changes and do not take it serious. Most of the patient reported that, staff rudely behaves and if they give some money, then they smile and treated better. Some of the public hospitals Doctors ask to come their residence for better treatment with an additional charge. [10]

The progress and gains in some of the major indicators of health in India in the post-colonial period have not been insignificant. The prevailing public sector health infrastructure consists of a three-tier structure with around 3000 Community Health Centers, 2300 Primary Health-Centre and 137,000 Sub-Centers spread in semi-urban and rural areas. Tertiary medical care is provided at multi and super specialty hospitals and medical colleges. There are around 5 lakh doctors, 7.4 lakh nurses, 3.5 lakh chemists, 1600 hospitals and 870,000 beds. When compared to the other developing countries, India behind the health facilities. India has merely 94 beds per 1,00,000 persons as compared to the minimum of 333 beds prescribed by the WHO. According to health infrastructure surveys carried out by the International Institute for Population Science, Mumbai has only 69% of the primary health centers have at least 1 bed and only 12% have been found to be in a state of perfect maintenance. [11]

As we know, the health system in India comprises of two broad categories namely public and private sector. The public sector health system created, run and maintained by the Central and State Governments and covers national disease control programs. Public health programs are concerned mainly with preventive, promotive and rehabilitative aspects giving importance to primary health-care. Government concentrates on basic primary health-care, whereas private sector covers secondary and tertiary health services.

NSSO clearly indicates that the pattern of hospital usage have change from 1998 (NSS 52 nd round) to 2006 (NSS 60 th round) across the regions. There were big gaps found in the usage of public versus private hospital in India. Thus, present study have been conducted with two specific objectives-to examine the factors of usage of public versus private hospitals for treatment and the reasons for not using public hospitals.


   Data and Methodology Top


In this study, we have used secondary source of NSSO 60 th round data on morbidity and health-care collected during January-June 2004. [12] In this data, we have selected block 3, 4, 7 and 9 for the purpose of the study. Block 3 provides household characteristic and in block 4 demographic characteristics. We have merged these blocks. We have described the characteristics of the hospitalized persons and usage of the hospitals by them. The data have been analyzed Univaraiate, Bivariate and Binary regressions by using statistical package for social sciences (SPSS), 16 th Version.


   Result and Discussion Top


Statistical analyses have been carried out in order to study the factors influences usage of public versus private hospitals in NSS 60 th round. In the analyses that follow, we first present the description of the variables used in the study. Second, the bivariate relationship between the response and predictor variables has been examined. The response variable is a type of hospital (public = 0 and private = 1). The predictor variables are demographic (sex and residence), social (religion, social group and marital status), economic (education, activity status and land holding) and region (north, central, east, northeast, west and south).

The figures in [Table 1] clearly shows that male have used more hospitals than female in both residences (rural and urban). Currently, married have used more hospital followed by never married and widow. Among the social group, OBCs have used more hospitals in both residences followed by others. Hindu used more hospitals followed by Muslim. The illiterates were more who have used hospitals. Not in labor force people were more used hospitals than labor force categories. Among the labor force self-employed and casual labors went to the hospital. The people who have low land holding used more hospitals. Across the regions, the south region has used more hospitals at both the residences. These indicate only percentage distribution of the user of the hospitals. We cannot justify here who have used what type of hospitals. Therefore, we have used bivariate analysis to know the use of hospital types [Table 2].

Univariate analysis does not show the relationship between the variables, it just shows the frequency and percentage distribution. Bivariate analysis expresses the association between the variables. This analysis was performed by cross-tabulation between response and predictor variables. The cross-tabulation shows the gross effect of the relationship between two variables. The association is shown between use of hospital type and demographic, social, economic factors and region. Bivariate analysis results are shown in [Table 2].
Table 1: Percentage distribution of the respondents by residence and hospital usage

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Table 2: Association between usage of hospital type and variables by residence

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Figures in [Table 2] indicate that more than half of people have used private hospitals in both the residences. However residents of urban areas have preferred more private hospitals than public hospitals. In marital status, the currently married (59%) people have used private hospitals followed by never married. However the higher gap was found in the urban areas between usage of public and private hospitals. In the social group, ST/SC have used public hospitals than private hospitals, whereas OBCs and others have used private hospitals in the rural areas. But in urban areas, there were lower differences were found for using public versus private hospitals among ST/SCs. It indicates that urban areas have sufficient public hospitals and ST/SCs were able to afford the cost of treatment in the private hospitals. In the rural areas, we have found that other religion (68%) has used more private hospitals than Hindu (58%) and Muslim (51%). But in the urban areas it appears equal percentage of the hospital users. Even though, all the people preferred private hospitals over public hospitals for treatment, but high educated people have used more private hospitals in both the residences. Among the labor force casual labors have used both the hospitals equally, but in urban areas they have used public hospitals. Here, we can expect that the condition of hospitals and availability of the doctors in the urban areas. The highest landholders preferred private hospitals more than lowest landholders. [Table 2] further focused the use of private hospitals across the regions, but the people of east and north-east region of India preferred public hospitals in both the residences. The NSS 60 th round also shows that the availability of public and private of hospital in India and we have found that east and northeast region have very low numbers of private hospitals

A total of 42 ailments are listed in the 60 th round survey respectively. For the purpose of the survey, some of the ailments have been grouped into categories. For example, heart diseases and hypertension have been grouped as cardiovascular diseases. However, some ailments such as, diseases of skin, goiter, diabetes mellitus, under nutrition, anemia and sexually transmitted diseases have been only listed. Since some of the ailments have not been grouped and others have not been grouped into manageable categories, the 42 ailments have been classified so that a meaningful analysis can be conducted.

In order to group the ailments we have used the latest classification of disease by World Health Organization (WHO, 2007). We have used the International Classification of Diseases, 10 th version, to group the ailments and the WHO category. We have also examined the preference of hospitals for the treatment of particular diseases. [Table 3] clearly shows that people have different choices of choosing a hospital for treatment for different diseases. We have found that people preferred more private hospitals for the treatment of serious ailments such as genito-urinary, circulatory, endocrine, nutritional and metabolic, neoplasm and Neuro-psychiatric diseases in both the residences. They have preferred public hospital for out-patient department services for less serious diseases [Table 4].
Table 3: Usage of hospital for particular disease by residence

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Table 4: Reasons for not using public hospitals

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The reasons for not using public hospitals are not satisfy with doctors and facilities (49%) followed by distant of the public hospitals (17%) and long waiting (13%). Some of them also reported that in public hospitals required specific services not available. There were 16% of them also reported other reasons for not using public hospitals.

The logistic regression shows the net effect of the independent variables on the dependent variables. The dependent variables in the type of hospitals and independent variables are demographic, social and economic factors for influencing usage of the private hospitals. [Table 5] shows that urban residents and female were more likely to used private hospitals than rural residents and male. Among the marital status never married, widow and separated were less likely to be used private hospital than currently married people. Among the castes OBCs were more likely to be used private hospitals than other castes whereas, SCs and STs were less likely to be used private hospital than other castes. There were other religions were more likely to be used private hospital than Hindu people but Muslims were less likely to be used private hospitals. The illiterate and educated up to primary level were less likely to be used private hospitals than higher educated people. Among the activity status groups we found that self-employed and not in the labor force were more likely to be used private hospitals than salaried. However, casual labor and seeking job categories were less likely to be used private hospitals than salaried. Again we found in [Table 5] than low landholders have low chances of using private hospitals than large land holders. Across the Indian regions, west region have a high chance of using private hospital than south regions. But north, central, east and northeast regions were less likely to be used private hospitals than south region.
Table 5: Odds ratio for the use of private hospital

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We concluded that economic factors (education, activity status and land holding) are influencing more for using private hospitals.


   Conclusion Top


The public hospital is basically good for majority, poorest of the poor or low income household member in society. Most of the patients in India using Private hospital so much rush, lack of sufficient doctors and lack of faith in terms of the hospital services, rude behavior of the medical staff, lack of sanitations etc. In contrast to that Private hospital provides proper clinical services and standard of health-care. After independence, nearly 15% of the people used to private sector and now the study by World Bank found that 80% of the people go to the private sector. [13]

Health and illness are the most important issue in the discussion about the hospitalization. Often we heard by laymen, that illness occurs due to curse of God and good health is the blessing of the God. They also believe that cause of illness is due to malnutrition (over and under nutrition). [14] Both conditions show the path to the hospital. Nobody go to hospital by choice, but go by chance.

The eight Millennium Development Goals (MDGs) are to be achieved by 2015 that represent the World's main development challenges. The MDGs are drawn from the actions and targets contained in the millennium declaration that was adopted by 189 nations and signed by 147 heads of state and governments during the UN millennium summit in September 2000. Out of eight goals the goal number 4, 5 and 6 are related to reduce child mortality, improve maternal health and combat human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), malaria and other diseases respectively. A total of 93 countries, with 62% of the world's population, are not on track to reduce under 5 years of mortality by two-thirds by 2015 (United Nations Development ProgrammeProgram). Under the goal number four the target is reduce by two-third the mortality rate among children under five. The reduction of maternal mortality ratio by three-fourth is the target of the goal five and sixth are stop and begin to reverse the spread of HIV/AIDS and stop and begin to reverse the incidence of malarial and other major diseases.

The major health system performance is related to how the health is being financed and health-care provided. It is estimated that only 5% of the India's Gross Domestic Product spent on the health-care system. The main goal for any health system is to achieve the highest level of health for all people. The Human Development Index is a composite measure of the quality of human life in terms of development in health (life expectancy), wealth (per capita income) and education.

Health sector has received just 3.33% share from the total outlay during the First 5 year Plan in India. This has decreased to 3.0% during second plan and during eighth plan just 1.75%. It is indicated that the health sector has been neglected by the government. Hence, it is utmost need for investment in health and other social sectors to improve the quality-of-life. [15] We have observed that poor and labor class people preferred private hospitals due to saving time and money (wage) that will earn from work instead of saving money from the public hospitals. As poor and labor class people do not have Central Government Health Scheme (CGHS) card or Employee State Insurance cards and there is no benefit as expected by the poors. That is why poor and labor class people prefer private hospital over public hospitals. On the other hand, salaried government employees prefer public hospitals to get benefits of CGHS and other health schemes.

 
   References Top

1.White K. The Sage Dictionary of Health and Society. New Delhi: Sage Publication; 2006.  Back to cited text no. 1
    
2.Boyd S. The use of the public hospital services by non-residents in New Zealand. Department of Labour, 2006. Available from: http://www.immigration.govt.nz/NR/rdonlyres/BF41670C-C83A-46B0-8CC59628C94D689/0/FINALHealthReportQuantitativeJuly2006.pdf. [Last accessed on 2008 Feb 23].  Back to cited text no. 2
    
3.Desai S. Insurance does not cover the womb′s woes, 2012. The Hindu.[Aug 09]. p. 11.  Back to cited text no. 3
    
4.Morril RL, Earickson RJ, Rees P. Factors influencing distances traveled to hospitals. Econ Geogr 1970;46:161-71.  Back to cited text no. 4
    
5.Rafei UM, Sein UT. Role of private hospital in health care. Reg Health Forum WHO′S East Asia Region 2001;5:1-5. Available from: http://www.searo.who.int/en/Section1243/Section1310/Section1343/Section1344.htm.  Back to cited text no. 5
    
6.Dhar A. Activists up in arms against new proposal on health care, 2012. The Hindu. [Aug 09]. p. 13.  Back to cited text no. 6
    
7.Prasad S. Morbidity pattern and treatment in India. Ann Trop Med Public Health 2012;5:459-67.  Back to cited text no. 7
    
8.Chakravarty B. Traditional and modern health care services in tribal areas: Problems of accessibility, affordability and acceptability. Kurukshetra 2008;56:37-41.  Back to cited text no. 8
    
9.McKeown T. The Modern Rise of Population. New Delhi: Arnold Heinemann Publishers; 1979. p. 91-109.  Back to cited text no. 9
    
10.Nichter M. Paying for what ails you: Sociocultural issues influencing the ways and means of therapy payment in south India. In: Nichter M, Nihcter M, editors. Anthropology and International Health. Gordon and Breach Publishers; 2003. p. 239-61.  Back to cited text no. 10
    
11.Prasad S, Sathyamala C. Securing Health for All Dimensions and Challenges. New Delhi: Institute of Human Development; 2006. p. 12-4.  Back to cited text no. 11
    
12.National Sample Survey Organisation. Morbidity, Health Care and the Condition of the Aged. 60 th Round. (Jan-June, 2004). New Delhi: National Sample Survey Organization; 2006.  Back to cited text no. 12
    
13.World Bank. World Bank funding for the construction of private hospitals in Mumbai. Available from: http://www.worldbank.org. [Last accessed on 2008 Feb 23].  Back to cited text no. 13
    
14.Sujatha V. Health by the People: Sociology of Medical Lore. New Delhi: Rawat Publications; 2003. p. 43-66.  Back to cited text no. 14
    
15.Uma HR. Financing of health services in India under five year plans. Kurukshetra 2004;52:19-21.  Back to cited text no. 15
    

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DOI: 10.4103/1755-6783.127804

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