Social and Systemic Determinants of Utilisation of Public Healthcare Services in Uttar Pradesh

Building on an earlier publication using the same data set plus case studies of three facilities, the reasons for the low utilisation of public health facilities in Uttar Pradesh despite the prohibitively high costs of care in the private sector are explored. The likelihood of choosing a public provider for hospitalisation care was 4.8 times higher in the poorest quintile and 3.4 times as high for women. Where access to public sector services is an issue, many go without any treatment and this could appear in the data to be a higher proportion of private sector utilisation. Inadequate facility density is one barrier to access. Facilities, which are by policy designed to offer very limited types of services—to collect user fees and prescribe drugs and diagnostics to be bought outside, and with no continuity of care between primary and secondary levels—lead to the diminishing of credibility of the public healthcare services. When services are available and there are incentives that facilitate access, like for childbirth, the choice shifts in favour of public services. Market-defined perceptions of what is good healthcare and an understaffed and demoralised workforce also contribute to poor utilisation.

The authors would like to acknowledge ICSSR for funding this project and the anonymous reviewer for giving valuable comments to strengthen the paper.

In an earlier paper we had presented the incidence and intensity of catastrophic health expenditure in Uttar Pradesh (UP) and the impoverishing effect that healthcare expenditures have on the state (Verma et al 2017). The government’s strategy to the problem of impoverishment due to health costs is through the provision of free or subsidised care in public health facilities and through publicly funded health insurance (PFHI). We noted that the state had introduced PFHI but officially only 23% of the eligible beneficiaries had been enrolled and our study showed that only 10% of households in one of the three districts had been enrolled (Verma et al 2017). Thus, financial protection rests largely upon the population’s access to public healthcare facilities. However, the majority of the population is utilising private rather than public healtcare. This dependence on the private health sector contributes to inequities in access and utilisation of healthcare facilities, and in the health status of people (Verma et al 2017). It also reflects the gap between formulation, implementation and execution of health policies in the country (Dey and Mishra 2014).

Being one of the poorest states in the country, with almost 809.1 lakh people (39.8%) below the poverty line (BPL) in 2011–12 (Planning Commission 2014), with the poorest health indices in the form of high infant mortality rates (48 per 1,000 live births) (Census of India 2016) and maternal mortality ratios (285 per 1,00,000 live births as of 2011–13), and with a high burden of disease, Uttar Pradesh requires to put in place a healthcare system where financial barriers to access are less and financial protection against the costs of healthcare is more. But, what we find from the National Sample Survey Office (NSSO) 71st round is that the average burden of healthcare expenditure on the people in UP is much higher as compared to that at national level (NSSO 2016). The average total medical expenditure per hospitalisation case in UP is ₹ 22,515 as against ₹ 18,260 in India. The average total medical expenditure per hospitalisation case in rural and urban areas of the state is ₹ 18,650 and ₹ 31,653 as against ₹ 14,922 and ₹ 24,443 in the rural and urban areas of the country respectively (NSSO 71st round).Much of this low health status and high costs of care is not only due to the social determinants, but also due to the lesser utilisation of public health services.