Correspondence Address:
Sanjoy Kumar Sadhukhan
Associate Professor, Department of Public Health Administration; A.I.I.H. and P.H., 110 C. R. Avenue, Kolkata - 700 073
India

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Health expenditure is sky-rocketing in almost all countries of the world. Pharmaceutical companies that develop powerful and expensive new drugs, priced beyond the reach of the majority who need them the most. [1] An alarming situation has been observed in many areas where health care costs lead to selling of land, house, ornaments, cattle and other precious things. It was observed that over 40% of hospitalized Indians borrow heavily or sell assets to cover hospital expenses and more than 25% of them fall below poverty line because of hospital expenses. [2]

For a developing nation like India, catering of health and medical service is always sparse. By analyzing the National Health Accounts Statistics (2001-02), a glaring picture was observed by Chandrashekhar CP and Ghosh J, [3] showing GDP contribution of health is only 0.9% as public expenditure, whereas 4.9% as private expenditure with 100% from out of pocket of people, in contrast to UK, where it is just reverse with 6.2% and 1.4%, respectively with 55.3% out of pocket expenditure. It shows that India has the lowest public / private expenditure ratio among similar countries, putting much stress on the poor. This was also observed by KSA TECHNOPAK study, [4] showing health expenditure as 9.4% of Indian consumer's spending with 91% from out of pocket.

About 70% of Indian population lives in rural areas, where facilities for health care are far behind their urban counterpart. Regarding health expenditure, most figures are indirect statistical estimates from different national and international organizations. Overall, the health expenditure in Indian community is less studied, even less in rural areas. In this regard, community based study on health expenditure is a rarity. Therefore, it was thought of importance to make a community based study about the health expenditure in a rural community with the objective of finding out the health expenditure with special reference to direct treatment cost, cost of travel related to treatment and relevant loss of wages and certain pertinent factors influencing it.

This longitudinal community based observational study was conducted in a village, named Jaulgaon, in Central India (state Maharashtra), over a period of 12 months (from March 2004 to February 2005). This village belongs to the field practice area of Mahatma Gandhi Institute of Medical Sciences (MGIMS), Sewagram. It had a total population of 594, residing in 144 houses. All the persons of all age groups, permanently residing in the village constituted the study population with exclusion of any guests and temporary visitors of the village. Sample size was determined following the WHO guidelines for field work. [5],[6] With an allowable error of 20%, the minimum sample size came to be 150. Allowing non-response of 20%, the final minimum sample size was 180. An interview schedule was prepared and pre-tested following WHO guidelines for investigating the medicine use by the consumers. [5] A prior approval from the Institutional Ethical Committee of MGIMS and consent from village head was taken. 50% of all the households (72) were selected by systematic random sampling comprising 265 persons, who were investigated with the schedule. Relevant background information was obtained for each villager e.g. age, sex, family income, occupation and education. They were interrogated retrospectively, about the diseases they had suffered during last one month and relevant questions regarding its management e.g. disease episodes, doctor consulted, cost of treatment including associated costs like travel cost, loss of wage of the involved family members etc. The same procedure was continued for 12 consecutive months for every person. During the study period, there were 2 births, 2 deaths and attrition of 2 families with 9 members. Therefore, the final analysis done among 70 families with 256 persons. Data analysis was done by SPSS 16, Windows compatible software. Suitable statistical tests (e.g. t-test, Anova) applied, and a probability (P) value of < 0.05 was taken for statistical significance.

Age wise, majority (64.1%) belonged to 15-59 yrs. followed by < 15 yrs. (23.8%) and the elderly (12.1%). It was a relatively mature community with mean age of 32.16 years. Sex wise, the study subjects were almost equal [51.2% (male) vs. 48.8% (female)]. The sex ratio is 954 female per 1000 male, more than the national average. The socio-economic status of the family is classified by per capita income (Prasad BG), [7] inflation updated for year 2004-05 with nearest multiple of 5. Majority (82%) belonged to the middle income group (social class II, III and IV), whereas the lowest income group (class V) constituted 12.5%. Only 14 persons (5.5%) belonged to highest income group (social class I). Average per capita annual income was observed to be about [INSIDE:11] 10,020/-. Occupation wise, almost 50% of the study subjects had no income (unemployed, student and housewife). Among the remaining, majority were farmer and skilled labor (32%), followed by manual labor (12.9%) with service and business becoming the minority (5.1%). Education status of the villagers (≥ 7 years) was observed to be poor with about 30% illiteracy and only 3% graduate and above. Majority (67.4%) had education from primary to secondary levels.

About 78% of the study subjects suffered during the study period, almost equal for male and female (39.8% vs. 37.9%). Interestingly, family wise, nearly all the families (94%) had sufferings in that year. Total illness episodes come out to be 446, which is 1.74/person and 6.37/family. The health expenditure of the community reveals that major part of the expenditure (82%) is the direct cost of treatment e.g. for doctors, drugs, hospital, attendant etc. The loss of wages account for 12%, and travel and related costs comprise 6% of total expenditure. Mean Annual Health Expenditure of the community is about [INSIDE:12] 1,576/family (1,671/affected family) and [INSIDE:13] 431/person (554/affected person), with every episode of illness costing about [INSIDE:1] 242. Roughly, this comes out to be about 4% of their income (total health expenditure of [INSIDE:2] 110,330 out of the total income of [INSIDE:3] 2,564,400).

[Table 1] depicts the association of health expenditure (per capita) with certain pertinent variables. Income and Education were observed to be significantly associated with health expenditure, but age, sex and occupation were not. It probably depicts the concern for health in Indian situation is almost universal, cutting across all variability within the society. {Table 1}

This community based longitudinal study reveals the health expenditure pattern in a rural community of Maharastra, India. More than 3/4 th (77.7%) of the study subjects were ill during the study year, belonging to 94% of the families. Rajaratnam et al[8] observed an illness prevalence of 42.7% in a rural community of Tamilnadu, in year 1990-90, but it was a cross-sectional study, which might explain this low figure.

Health expenditure of the community was observed to be 4.3% of their income with an annual figure of [INSIDE:4] 1,576 per family, [INSIDE:5] 431 per person and [INSIDE:6] 242 per episode. Similar study in the same area e.g. Jaulgaon ,conducted by Duggal R. in year 1987, noted it to be 5.2% of their income and among Mumbai, middle class and working class people, it was observed to be 6.9% and 12.5%, respectively, in year 1984. [9] In Rural Tamilnadu, Rajaratnam et al observed a relatively lower per capita health expenditure to be [INSIDE:7] 90 per person and [INSIDE:8] 449 per family, in year 1990-91, [8] which comes to about [INSIDE:9] 240 per person and [INSIDE:10] 1,197 per family after making it cost inflation compatible for the year 2004-05. This expenditure was observed to be significant with income and education. Other variables like age, sex and occupation did not achieve such significance although some trend may be noted. In rural Tamilnadu, Rajaratnam et al[10] and Duggal et al in Jaulgaon [9] observed income only to be associated with health expenditure while from modeled data from year 1971-91, Rahaman observed both income and education in Indian states to be significantly associated with health expenditure, same as the present study. [11]

Present study is a small one whose results are not generalizable. Moreover, the recall period of 1 month might not be considered ideal. Definitely, it would have been better if it could be made 15 days. Resource constraints were responsible for it, which will be taken care of, in future similar study. In the light of paucity of study on health expenditure, more and more community based studies on health expenditure need to be done to have an actual picture.

 Acknowledgement

References