Introduction:
Good health refers to a complete physical, mental and social well-being apart from the non-existence of any kind of ailment. Health care is the prevention and treatment of any type of illness by offering medical services. Health comes under the social sector, and the development of health sector is essential as economic development is linked with a better health structure. A healthy working population can lead a nation to the path of sustained development. Easy and affordable access to health care services is essential for a population to be healthy. Ill health hampers the productivity of the people and hence hinder developmental activities. The health status of an individual is influenced by a number of factors viz. adequate food, housing, sanitation, healthy lifestyle, protection against environmental hazards and communicable disease etc. Good health and access to healthcare is considered as fundamental human right.[1] In India, health and healthcare services are considered as basic needs.
The Indian health sector is still suffering from various hurdles in achieving its goal of providing essential healthcare services in the country. Indian healthcare system features low spending on healthcare, unbalanced doctor population ratio, inadequate health infrastructure and all these lead to popularization of private health sector. One prime reason for the low level of achievement in the Indian health sector is the lack of systematic investment by the government.[2] Very less amount of GDP is spent in the health sector with only 1.26 percent of GDP towards health care.[3] It falls among the low health care spending countries. Most of the rural areas of the country deprive of quality health care services. The rural population is always observed to have difficulties in accessing health care services. In rural areas health institutions are set up at different levels but the delivery of the service is not as per the requirement. For the rural people who are completely dependent on public health system, doctor to patient ratio is seriously low with 1:10,926 doctors while the WHO recommended doctor patient ratio is to be 1: 1000. The urban population have easy access towards healthcare services as private health institutions along with public health institutors are easily available in urban areas.
Poor infrastructure in rural health sector is a responsible for lower utilization of health care services in these areas. Despite of increase in public and private expenditure on provision of advance health care utilization of health services is still low in India.[4] Not only the healthcare services available in that area is solely responsible for healthcare utilization but socio-economic condition of individuals is also a factor. Inability to provide adequate health care services by the public sector is responsible somewhere for the dominance of private health sector in the country. Dominance on private sector contributes to inequities in accessibility and utilization of healthcare services. [5] Majority of Indian population still depends on private health service providers; in rural areas 52 per cent people sought treatment from private sectors whereas in urban area 35 per cent people went to government hospitals.[6]
As India overall lacks sufficient health infrastructure, Assam is not an exception too where insufficiency of public healthcare services still is an issue. Of the population in the state, 86 percent live in rural and remote areas and many people from rural and remote parts of the state were and still depends on traditional methods of healthcare. Difficult geographical terrain, frequent flood, hilly and forest areas spread across the country comes as major accessibility and utilization issue in the state. Therefore, this paper tries to find out the pattern of utilization of healthcare services among the rural and urban households of Assam. While analysing the utilization pattern towards healthcare services this study seeks an answer to the research question- whether demographic or socio-economic factors influence household healthcare utilization pattern.
Materials and Methods
This study was done in four districts of Assam. The study has been taken up to analyse the extent of utilization of healthcare services and choice of healthcare providers and other related issues, along with this, factors affecting utilization pattern at household level and therefore for a better representation of results both rural and urban households from selected districts have been considered. Multistage sampling method was used to select sample households. The sample districts were considered on the basis of Human Development Index (2014) of the district. Based on state (Assam) Human Development Index, which is 0.557, and corresponding HDI values of the particular district those four districts were selected. The HDI of Kamrup (M) is the highest (0.703) whereas Baksa stands at the lowest position (0.437) in terms of HDI ranking within the state. The HDI of Dibrugarh district is just above the HDI of Assam whereas the HDI of Golaghat is just below the state HDI. From each selected districts one sub-division having the highest population has been considered as sample sub-division. From each sample sub-divisions, one development block and one town having highest rural and urban population have been considered. In the next stage from each development blocks 5% gaon panchayats were considered and thereafter from each gaon panchayats 5% of villages has been considered. Finally, 10% rural households from each sample villages were randomly selected as sample rural households. On the other case, for sample urban households, from selected sample town 5% of wards were considered and from each ward, 10% households selected randomly as sample urban households. Thus, a total of 771 households were considered including 393 rural and 378 urban households. The required information was collected from sample households during recall period of six months for outpatient services and one year for inpatient services prior to interview. A structured validated questionnaire covering information regarding household’s socio-economic, demographic, morbidity details and healthcare service utilization was prepared and used to assess information from sample households.
This study has also investigated the predictors of utilization of healthcare services. Factors influencing utilization of healthcare services was analysed by a binary logistic regression analysis.
Results
Utilization of healthcare services depends on socio economic and demographic condition of households and for socio economic and demographic condition of households- age, occupation and educational qualification of the household head, type of house, household’s income were considered and analyzed.
| Table 1: Socio-economic and demographic information |
Variables |
Rural |
Urban |
N (%) |
N (%) |
Age of the household head |
21-40 |
89 (22.64) |
71(18.78) |
41-60 |
215(54.71) |
241(63.76) |
61 and above |
89(22.65) |
66(17.46) |
Highest education of the head of the household |
Illiterate |
9(2.28) |
- |
Primary |
75(19.1) |
14(3.7) |
Intermediate |
270(68.70) |
196(51.86) |
Graduate/Postgraduate |
39(9.92) |
168(44.44) |
Occupation of the household head |
Service |
89(22.65) |
201(53.17) |
Business |
105(26.72) |
106(28.04) |
Agriculture |
70(17.81) |
10(2.64) |
Wage earner |
122(31.04) |
6(1.59) |
Others |
7(1.78) |
55(14.55) |
Monthly income of the household (Indian Rupees) |
Below 10,000 |
237(60.31) |
28(7.41) |
10,001-30,000 |
125(31.81) |
231(61.11) |
Above 30,000 |
31(7.88) |
119(31.48) |
Caste |
General |
59(15.01) |
154(40.74) |
OBC |
199(50.64) |
99(26.19) |
Schedule caste |
56(14.25) |
26(6.88) |
Schedule Tribe |
79(20.10) |
99(26.19) |
Type of house |
Pucca |
133(33.84) |
332(87.83) |
Kutcha |
116(29.52) |
12(3.17) |
Semi-pucca |
144(36.64) |
34(9) |
The analysis revealed that (Table 1) more than half of the households' heads were in the age group of 41-60 years in both rural and urban areas, 2.28% rural households' heads were illiterate, 31% rural households' heads were wage laborers, 53.17% urban households' heads were in service, 60.31% rural households had monthly income below Rs 10,000, whereas in urban areas 61.11% households were having monthly income in between Rs 10,001-30,000. Regarding caste wise distribution, 50.64% of rural households belonged to OBC constituting the highest percentage in rural areas and in urban areas majority households were of general caste (40.74%). Of the rural households, 36.64% had pucca houses while 87.83% urban households had pucca houses.
To study the utilization pattern, information regarding morbidity over one year recall period was collected from 771 sample households consisting of 2944 family members. In the study area practically all sample households have reported one or more episodes of morbidity, however none of them has reported about the existence of multiple episodes of disease per person. Morbidity analysis showed that out of 2944 family members, 829 (28%) members had some sort of illness during the recall period and as no multiple episodes of disease per person found, total no of illness episodes were 829. In the study areas, pain and aches is the most common disease reported both in rural and urban areas accounting 17.13% of the total reported illnesses. Unspecified fever pertaining 10% in rural areas and 7% in urban areas. Hypertension is also a common health issue observed in the study area. Digestive diseases (8%), infectious disease (5%) and cardiovascular diseases are some other most reported health issues faced by the sample population.
The illness suffered by the household members have been classified into four categories- infectious diseases, non-communicable diseases, gynaecological problems, accidents and injuries on the basis of the WHO’s international Classifications of Diseases. For all illness cases, the disease group-non-communicable diseases constituted major share of all reported illness (Table2). The prevalence rate of non-communicable diseases was the highest among the study population (Table 2).
| Table 2: Disease categories- percentage distribution and prevalence rate |
Disease Group |
Rural |
Urban |
Percentage distribution |
Prevalence rate |
Percentage distribution |
Prevalence rate |
Infectious Diseases |
22.30 |
6 |
12.65 |
4 |
Non-communicable diseases |
72.54 |
20 |
76.17 |
22 |
Gynaecological Problems |
1.40 |
0.39 |
2.48 |
0.71 |
Accidents and injury |
3.76 |
1 |
8.58 |
2 |
For all illness cases, the disease group non-communicable diseases constituted 72 percent in rural areas and 76 percent in urban areas of all reported illnesses. The prevalence rate of non-communicable disease is the highest (20.00 for rural and 22.23 for urban population) among the study population.
There were 829 household members fallen ill during the recall period, but not all these illness cases were treated at medical institutions; some were self-treated, some were not treated. Households can choose among both public and private healthcare institutions as both were available in the study area.
Table 3: Healthcare services utilization information |
Description |
Rural |
Urban |
N (%) |
N (%) |
Household’s members with illness |
426(100) |
403(100) |
Illness cases treated at medical institute |
357(83.8) |
370(91.81) |
Self-treated illness cases |
20(4.7) |
21(5.21) |
Illness cases not treated |
49(11.5) |
12(2.98) |
| Source of treatment |
N=377 |
N=391 |
Government |
145(38.46) |
63(16.11) |
Private |
192(50.92) |
289(73.91) |
Both Government and Private |
20(5.31) |
18(4.61) |
Others |
20(5.31) |
21(5.37) |
| *Others including treatment done at home, treating diseases using indigenous medicines |
Majority of illness cases in both rural (83.8%) and urban areas (91.81%) were treated at medical institutions, a portion of illness cases, 4.7% cases in rural and 5.21% cases in urban areas, were self-treated, 7.36% illness cases were found untreated, the untreated illness cases were higher in rural areas (11.5%). Regarding institutional healthcare services utilization, in this study 27.08% household members went to government healthcare facilities and this was higher in rural (38.46%) as compared to urban (16.11%) areas. In both rural and urban areas, for nearly 63% of illness cases treatment was sought from private health facilities including private clinic. About 4.95% household members sought treatment from both public and private health facilities, 5% illness cases in both rural areas and urban areas were cured by using indigenous medicines rather than visiting medical institute.
The average incomes of the urban households were more compared to rural households and therefore private health services were affordable for urban households. But inefficiency of public health services compelled rural households to go for private health services at time of emergency by paying higher charges. This study reported that private health services were mainly preferred in the study areas.
Table 4: Utilization of healthcare service by place of treatment and household characteristics |
Rural |
Particulars |
Public |
Private |
Both public and private |
Self-treated |
Not treated |
Monthly income |
Up to 10,000 |
96 (72.18) |
50(28.74) |
9(52.94) |
14(70.0) |
44(89.8) |
10,001-20,000 |
31(23.31) |
75(43.10) |
6(35.29) |
6(30.0) |
5(10.20) |
Above 20,001 |
6(4.511) |
49(28.16) |
2(11.76) |
- |
- |
All N (%) |
133(100) |
174(100) |
17(100) |
20(100) |
49(100) |
Education |
Illiterate |
2(1.50) |
5(2.87) |
|
2(10.0) |
2(4.08) |
Up to Primary |
38(28.57) |
20(11.49) |
3(17.65) |
15(75.0) |
15930.61) |
Intermediate |
89(66.92) |
115(66.09) |
14(82.35) |
3(15.0) |
31(63.26) |
Graduate/Postgraduate |
4(3.01) |
34(19.54) |
1(5.88) |
|
1(2.04) |
All N (%) |
133(100) |
174(100) |
17(100) |
20(100) |
49(100) |
Urban |
Up to 10,000 |
15(23.81) |
3(1.15) |
6(33.33) |
6(28.57) |
12(100.0) |
10,001-20,000 |
40(63.49) |
86(32.56) |
9(50.0) |
12(57.14) |
- |
Above 20,001 |
8(12.7) |
175(66.29) |
3(16.67) |
3(14.29) |
- |
All N (%) |
63(100) |
264(100) |
18(100) |
21(100) |
12(100) |
Education |
Illiterate |
- |
- |
- |
- |
- |
Up to Primary |
10(15.87) |
7 (2.66) |
1(5.56) |
3(14.29) |
2916.67) |
Intermediate |
49(77.78) |
96(36.36) |
17(94.44) |
18(85.71) |
10(83.33) |
Graduate/Postgraduate |
4(6.35) |
161(60.98) |
- |
|
- |
All N (%) |
63(100) |
264(100) |
18(100) |
21(100) |
12(100) |
Regarding utilization of healthcare services, households were classified by household’s monthly income and educational attainment of head of the household. Most of the rural households who utilized public healthcare services were low-income households (72.18%) whereas households that utilized private healthcare services were comparatively high income households in both rural and urban areas. Some households also reported of self-treatment and not treatment at all and these households were the low-income households in majority in both rural and urban areas. This situation confirmed the fact that possibility of seeking any kind of medical treatment is decreased by financial difficulty of the household. Monthly income of rural and urban households showed that higher income encouraged households to avail treatment in private health facilities and lower income group preferred public health facilities. In the same way, health institution wise utilization indicated that households having head with intermediate and above education primarily utilized private healthcare facilities.
Satisfaction in service provision is increasingly being used as a measure of performance of a health system.[7] Quality of health services was and still is an issue in particular public health systems India. Rural areas in India lacks sufficient number of public health institutions and also lacks quality in terms of adequate equipment and infrastructure. Private health system in the country is known for quality healthcare services though these services are expensive.
| Table 5: Overall satisfaction with healthcare services from public and private health institutions |
Level of Satisfaction |
Public health services |
Private health services |
Frequency |
Percentage |
Sig.(p) |
Frequency |
Percentage |
Sig.(p) |
Very satisfied |
12 |
6.12 |
.000*** |
181 |
41.32 |
.000*** |
Satisfied |
46 |
23.47 |
103 |
23.52 |
Average |
83 |
42.35 |
143 |
32.65 |
Dissatisfied |
34 |
17.35 |
8 |
1.83 |
Very dissatisfied |
21 |
10.71 |
3 |
0.68 |
| ** Significant at 0.01 level |
Overall satisfaction regarding utilization of healthcare services showed that (Table 5) maximum household utilized public healthcare services were not very satisfied and not dissatisfied (42.35%) whereas maxim households (41.32%) were very satisfied by utilizing private healthcare services. Test of significance showed the result to be significant.
Determinants of healthcare utilization
The utilization of healthcare services is a multidimensional subject and is influenced by several factors. Binary logistic regression models were performed to estimate the factors believed to influence a household’s decision on utilization of healthcare services. Logistic regression analysis measures the relationship between a categorical dependent variable and by estimating the probabilities by using the logistic function. Data were analyzed using two logit models for rural and urban households; utilization of healthcare services is the dependent variable which is in binary form; 1 if the household utilized healthcare services, 0 if the household didn’t utilize healthcare services
| Table 6: Logistic regression estimates of the likelihood of utilizing healthcare services |
Variable |
Rural |
Urban |
Co-efficient |
Exp (B) |
Co-efficient |
Exp (B) |
LN_Age |
2.052 |
7.784 |
-.756 |
.469 |
LN_Income (LN_I) |
1.455** |
2.285 |
4.158** |
1.936 |
Household Size |
.632*** |
1.756 |
.290 |
1.331 |
Distance to the nearest health facility (in Km) |
.255 |
1.290 |
-.156* |
0.855 |
Education (EDU) |
|
Below High school |
Ref |
|
|
|
High school and above |
-0.098 |
.907 |
.345 |
1.348 |
Occupation |
|
Others |
Ref |
|
|
|
Employed |
1.526* |
4.599 |
-1.447** |
.235 |
Nature of illness |
|
Acute |
Ref |
|
|
|
Chronic |
.039 |
1.039 |
1.968** |
7.155 |
Health Insurance |
|
No |
Ref |
|
|
|
Yes |
.656** |
1.926 |
.530 |
1.700 |
Healthcare Provide |
|
Private |
Ref |
|
|
|
Public |
.287 |
1.333 |
-.562 |
.570 |
-2 Log likelihood |
258.342 |
|
171.044 |
|
Cox & Snell R square |
.207 |
.120 |
Nagelkerke R square |
.351 |
.272 |
| *** Significant at 1 percent level, ** Significant at 5 percent level, * Significant at 10 percent level |
Table 6 represents the results of the logistic regression analysis on the likelihood of utilizing healthcare among the households by socio-economic and demographic determinants. Out of the nine influential variables included in the model, six variables – household’s monthly income, household’s size, distance to the nearest healthcare facility, occupation of the head of the household, nature of illness and insurance status have found to be statistically significant. It was revealing to note that some variables which were significant in one region were not significant in the other region.
LN_I had a significant positive relationship with the utilization of healthcare services in both rural and urban areas. Higher the monthly income of the household, the higher is the probability of utilizing healthcare services. A rise in income would increase the likelihood of utilizing healthcare services by 128 percent in rural areas and 93 percent in urban areas. The likelihood of healthcare services utilization increased with the household size in rural areas of the state. It was statistically significant at the 1 percent level. Accessibility of healthcare services is still a significant issue of healthcare services utilization in rural areas of India. However, accessibility in terms of distance to the nearest health facility was not statistically significant in the rural areas of the study. Distance to the nearest health facility was found to have negatively influenced the probability of institutional utilization of healthcare services in urban areas. Occupation of the head of the household was positively associated with the utilization of healthcare services in rural areas. In rural areas, individuals from households where head of the household were employed were about 4 times more likely to utilize institutional healthcare services than households with unemployed head. Contrary to rural areas, unemployed headed households were .235 times less likely to go for institutional healthcare services in urban areas. Further as per the analysis, households with chronic illnesses were about 7 times more likely to go for institutional healthcare services than households with acute illnesses. Urban households having chronic illness episodes are more likely to visit healthcare institutions as chronic diseases requires more care and frequent treatment. The regression results also reveal that having health insurance improved the likelihood of utilization of healthcare services by 92 percent compared to households without health insurance in rural areas. Health insurance is an effective instrument that can protect households in the time of health emergencies; however, it was statistically insignificant in determining utilization of healthcare services in urban areas.
Conclusion:
Examining the utilization pattern and factors associated with utilization of healthcare services, the study observed that private facilities were the most preferred healthcare provider, vast majority households sought treatment from private health facilities irrespective of socio-economic status. But a significant portion (12.47%) of rural households had not sought treatment as well. Lack of quality services, inadequate medical staff, and lack of modern medical equipment forced households to go for private healthcare services by paying higher charges. This situation can improve only households can get proper health facilities by paying less. Expansion of public health infrastructure particularly in remote and rural areas is much needed.
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