ISSN Online : DOI: 10.17485/ijed/2020/v01i01/144444 ...

ISSN (Print) : 2320-9828 ISSN (Online) : 2320-9836

INDIAN JOURNAL OF ECONOMICS AND DEVELOPMENT

DOI: 10.17485/ijed/2020/v01i01/144444,

© 2020 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Operational Efficiency of Public Healthcare Provision in IndiaManurut Lochav1,*, Bhavna Hooda2 and Mahua Bhattacharjee1

1Amity School of Economics, Amity University, Noida, India2Dept. of Anesthesia and Critical Care, Army Hospital (R&R), Delhi, India

AbstractObjective: Healthcare in India is transforming from communicable to non-communicable lifestyle diseases. The derived demand for healthcare in India has increased exponentially in the last few decades making India a pioneer in medical tourism as well. Methods/findings: However, the public healthcare facilities have not fared very well in comparison to private ones. The study is to check the operational efficiency of selected variable of public healthcare in India. The other objective under the study is to analyze the outcome of people efficiency by the use of primary survey. The study uses both primary as well as secondary data sources. This study begins by defining operational efficiency and by listing its pillars- technological, process and people. It was found that public healthcare in India is having a low operational efficiency. Application: Further suggestions have been made regarding increasing of the operational efficiency of public healthcare.

Keywords: Public Healthcare Provision, Public Hospitals, Efficiency, Operational Efficiency of Healthcare, Indian Healthcare.

1. Introduction

1.1. BriefPublic healthcare plays a pivotal role in the growth and development of a country. India being one of the most populated countries in the world has to pay more attention to health and education. Over several years, India has worked in the correct direction and taken steps in order to ensure that the citizens are healthy and educated. India has made landmark progress in in accomplishing several hurdles such as becoming a polio free country, eradicating plague, increasing it life expectancy, etc. and now is moving towards the goal of attaining food security for all. This progress has however been only in healthcare services and not in healthcare as a good. The distinction between healthcare as a service and as a good can be easily understood. Healthcare service refers to the services which are aimed at combating and preventing diseases. Whereas, healthcare as a good

Article Type: Article

Article Citation: Manurut Lochav. Operational efficiency of public healthcare provision in India. Indian Journal of Economics and Development.

ijed/2020/v001i01/144444

Received date: January 29, 2020

Accepted date: February 18, 2020

*Author for correspondence: Manurut Lochav @ [email protected] Amity School of Economics, Amity University, Noida, India

January 2020, Vol 08(01), 1 – 21

2020; 08(01), 1-21. DOI: 10.17485/

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Operational Efficiency of Public Healthcare Provision in India

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consists of hospitals and other necessary infrastructure for the cure of diseases. This paper refers to healthcare as a public good and not a service. Healthcare is a subject of State as per Indian constitution. The states provide public hospitals and other facilities based on the tax revenue received.

The immediate challenge to India in terms of healthcare is that it needs to provide more and better infrastructure to the public so as to be able to combat and cure diseases and illness. That is having better and more efficient public healthcare provision to provide better public healthcare services. This will not only help make the country a healthier country but will also help in increasing the productivity of people and increase welfare at large.

This study begins by defining operational efficiency and by listing its pillars along with several components of healthcare market as per NSSO report. Further, the paper tries to link all these three operational efficiencies in line with the components of healthcare market. The variables are studied for operational efficiency pillars i.e., technological, process and people. The improvement for each variable in terms of operational efficiency is checked in order to establish whether there has been an increase (or decrease) in the efficiency of these variables. Lastly the paper concludes by giving out suggestions and policy recommendations which are aimed towards improving the healthcare market’s efficiency.

1.2. Objectivea) The objective for this study is to check the operational efficiency over time of

selected variables of public healthcare in India. b) To analyze the outcome of the efficiency achieved via a primary survey of

households.

1.3. MethodologyThe data for this research has been collected by both the primary as well as secondary sources. The studies try to find out the efficiency attained by the use of resources in healthcare. Efficiency in terms of outcome has been measured in the study and not based on output. The inputs have also been taken from several studies conducted previously and national data bank of India. The outcome approach has been focused upon to see the actual benefit that people who use public healthcare attain. Also with time, several papers and organizations have started focusing on the outcome approach, in order to make accessibility and quality of the good/service better. This is done to have a better indicator. HDI being an outcome indicator, for instance is now considered a better indicator than GDP which is an output indicator. The error of measurement in outcome based indicators is least, thus, of prime importance in studies conducted for better policy prescriptions.

This study focuses on two major objectives – improving the public healthcare access and quality to people. There are several variables which may be taken up to study the healthcare

broader study, the variables chosen for choice of public healthcare as compared to private

Vol 08(01), DOI: 10.17485/ijed/2020/v01i01/144444, January 2020

industry and its impact and quality assessment. However, for the benefit of this study in a


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Manurut Lochav, Bhavna Hooda and Mahua Bhattacharjee

Indian Journal of Economics and Development

hospitals by people are- low cost, accessibility (close vicinity), age and specialisation. There are several other variables which critically depend on the available healthcare resources, which will later become part of a broader study on the same lines. All nations have several budget constraints; governemnts initailly focused on improving erquity to access and then creating a social security system. All this involves high collection of taxes, which sometimes may lead to the problem of crowding out, thereby, several nations do not indulge themselves in high spendings on healthcare.

The current status of India is such that, it has to build a highly efficient human capital. This human capital needs to be accounted for in terms of wellness and health. Thereby, making it important prima facie for India to invest in healthcare. The investments in healthcare lead to a higher efficiency in terms of process efficiency. Higher process efficiency leads to better people efficiency. The cycle when completed will result in higher efficiency in terms of the entire outcome.

The sample size for this study has been taken using the Slovin Formula. The survey was conducted in Delhi, national capital of India. The population size is 1.9 crores which is the current estimated population of Delhi, the margin of error is 7.75% and confidence interval is 95%. The recommended sample size through this formula is of 151 respondents, however, for the benefit of the study and keeping in mind the error that could be possible, the number of respondents for this study taken is 162. The formula is depicted underneath.

x = Z(c/100)2r(100 − r)

n = Nx/((N − 1)E2 + x)

[ / 1 ]xE N n n N

Where N is the populaiton size, r is the fraction of responses interested in, and Z(c/100) si the critical value for the confidence interval c.

The period of data collection was of six months beginning from October 2018 to March 2019. Each public hospital had a coordinator to assist with data collection. The coordinators were trained for 2 days and several steps were taken to ensure data integrity. The data so collected was reviewed and checked where ever needed.

Additionally, 10 patients in each public hospital in Delhi, aged above 18, who were under observation post-surgery and who were not scheduled for immediate discharge were randomly selected to be part of the survey. These patients were the key respondents who responded to the question of satisfaction. A total of 162 households were included in the sample size. The study focused on households primarily to understand the behavior of expenditure and the need of families for healthcare, along with their perception of public healthcare. The questionnaire was designed on the basis of certain predefined parameters of public good, operational efficiency and expectation and awareness of people derived from the review of literature review.

The Primary Data is collected through Structured Questionnaires which was developed after extensive literature review. The basic structure of the questionnaire was divided into 3 parts, namely preference of hospitals- public or private; reasons for preference; and efficiency assessment of public hospitals by the people. Since the ultimate aim of the paper





was public to study the efficiency of healthcare provision, the respondents were selected on the basis of whether or not they have visited/taken services from, a public hospital or dispensary in the last one year. The respondents, who had not, were excluded from the study.

The age of the respondents has been categorized into 5 categories. This categorization was important and necessary as most individuals visiting the public hospitals were uneducated and had only estimates to present about their age. Thus keeping in mind the estimates presented by these individuals the age brackets have been created. However, where ever possible the actual age of the respondent has been recorded and there after added to the age brackets. The age of respondents is categorized as- 18–25 years, 26–35 years, 36–45 years, 46–55 years, 55 years and above. The respondents under the age of 18 have not been considered as they are not adults.

People, which is the third part of operational efficiency has been studied through the primary survey in order to find out what benefits the people have attained in terms of cost, money, quality and time. It further also tries to check upon their level of information based on the fact that the government does take steps to inform the people about preventive measures and medical first aid and emergency procedures. The respondents were also questioned about the reason for which they may believe that the efficiency is reducing in public healthcare. The reasons mostly listed were lack of trained doctors and staff, low level of technological capital in use, low accessibility to public healthcare, and the high time used in processes and procedures. The respondents were also asked a subjective question for the same through which an even better insight was gained into the problem of low efficiency of public healthcare.

The reliability of the questionnaire is tested by using the Cronbach Alpha formula, given underneath:

Suppose that we measure a quantity which is a sum of K components (K-items): X = Y1 + Y2 +…….YK. Cronbach’s αis defined as

212 1

1

KYii

x

KK

where is the variance of the observed total test scores, and is the variance of components I for the current sample of persons.

The Cronbach alpha was 0.920794511, which indicates that there is very high level of internal consistency.

1.3.1. Demographics of RespondentsIn total there were 162 respondents who filled up the survey for this study on people efficiency, or the outcome of the operational efficiency in healthcare in India. The age distribution of the respondents has been shown in the Table 1. The age distribution of the said respondents is of concern in this paper as this is later used to analyze the outcomes based on the preference of the respondents among choosing a private or public hospital.



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TABLE 1. Age distribution of respondents

Age group No. of respondents

18–25 6326–35 4136–45 3746–55 1255 and above 9

As can be seen from the table above 38.9% of respondents belong in the age group of 18–25 followed by 25.3% in the category of 26–35; 22.8% in 36–45; 7.4% in 46–55 and 5.6% in 56 and above.

2. Technological Efficiency and Healthcare

2.1. Operational EfficiencyOperational Efficiency refers to the capability of an enterprise to deliver products or services to its customers in the most cost-effective manner possible while still ensuring high quality of its products. Operational efficiency can be divided into three parts, namely- Technology, Process and People.

Health care is the organized provision of medical care to individuals or community. There are several things which encompass the healthcare industry. If it had to be divided in order to understand it better, then, there are six components. These components are -

(i) Hospitals – government as well as private hospitals (ii) Pharmaceutical – including manufacturing, extraction, processing, purification

and packaging of chemical materials for use as medications for humans or animals (iii) Diagnostics – comprising businesses and laboratories that offer analytical or diag-

nostic services, including body fluid analysis. (iv) Medical Equipment and Supplies – includes establishments primarily manufac-

turing medical equipment and supplies, e.g. surgical, dental, orthopedics, ophthal-mologic, laboratory instruments, etc.

(v) Medical Insurance – includes health insurance and medical reimbursement facil-ity, covering an individual’s hospitalization expenses incurred due to sickness.

(vi) Telemedicine – Telemedicine has enormous potential in meeting the challenges of healthcare delivery to rural and remote areas besides several other applications in education, training and management in health sector.

For the purpose of this study we shall focus on all these components and list out their operational efficiency.

This studies the three factors of operational efficiency with regard to public healthcare. The study of efficiency is done in regard to the factors of healthcare listed above. Technological efficiency has been studies in section 2.2 followed by Process efficiency in section 3 and people efficiency in section 4 as shown in Figure 1.





2.2. Technological EfficiencyTechnology is a key of operational efficiency. With better technology the healthcare industry has been able to conquer several diseases over the past decades. The use of technology in healthcare helps to collect, store and analyze critical patient data. The use of x-rays, and chemical research has helped achieve cure to several diseases and recognized new diseases which were earlier unknown. Other than that, the Artificial Intelligence is being used as caregivers and in operations and complex procedures. 3D printing and augmented reality are being used for educational purposes. From something as small as a smart watch to a robot performing a surgery healthcare technology has innovated to a great unimaginable extent.

Until the mid-1990s very little was done in order to integrate computers into clinical procedures. The innovative automation of clinical process was not completed due to the four reasons. Firstly, the healthcare industry was new and was beginning to see the extended use of clinical data repositories for advanced studies and application for other purposes as well. The use of technology in healthcare was still a farfetched dream. During the initial stages data collection and analysis was the prime function of technology in order to increase the efficiency of healthcare. The collection of data and its use for clinical process was indeed a starting point for radical technological changes in the field. Repositories helped find unique solutions to the diseases prevalent. The repositories also enabled the doctors to study patterns for massive diseases and outbreaks which later were prevented due to the presence of this vast data set.

Second, most of the vendors, till mid 1990s did not see the acumen in advanced applications and they were still reluctant to switch to technology from the existing system. Innovation in any field takes up time to get absorbed. The technological advancements in terms of machinery and equipment was the second pedestal for growth in healthcare efficiency. The use of x-ray and ultrasounds along with several other equipment to study the proper functioning of the body were introduced in the second phase. The application of these technologies in that scenario was tough. Doctors were accustomed to their knowledge of bones instead of relying on x-rays and so on.

FIGURE 1. Operational efficiency.



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Thirdly, there was a lack of supportive data which could be used in order to show that the clinical application of computer and technology will be effective in terms of effort and cost. Computers and technology were still very new in that era and not a lot of data could support their claims of being effective. Fourthly, the vendors more often than not did not have the funds required to invest in computers and technology at that period of time. The switch to computers, would’ve been cost effective, was expensive.

There are disruptive technologies in healthcare. There are several components to the same- surgical robotic tools, less invasive diagnosis, patient-facing mobile apps, remote monitoring solutions, digital platform integration, ancillary services, connected device for home use, 3D printing, Artificial intelligence, and smaller implants.

All these disruptive technologies have been able to provide better results in the healthcare sector. The use artificial intelligence for instance has enabled humans to count their steps, and maintain a healthy balance. 3D printing, is another radical switch from conventional methods. The 3D printing helps in operations in a very big number.

Technology for healthcare includes machinery/ equipment/ devices or methods for diagnostics as well as for therapeutics that may be used in relation to provision of healthcare services. The technological innovation and advancement in healthcare sector in India came up in the 1990s

Traditionally the healthcare industry did not have any technological support however, with the improvement in the technological industry itself, there has been a rapid increase in the type of technology available in healthcare industry. Artificial Intelligence in healthcare is used in 3 manners: Clinical Decision Support, Population Health, and Disease Management. The percentage of use of AI in these areas is 46%, 33% and 29% respectively. Projected percentage share for 2020 is an increase of 59%, 46% and 42% [1].

The use of technology in the healthcare sector will prove to be highly economically valuable. The use of virtual healthcare practice would save up to $7 billion annually. The use of 3D printing has revolutionized the healthcare industry at large. There are several significant achievements of use of technology in the healthcare sector. India needs to invest more into healthcare technology. The use of the technology will help improve the efficiency.

3. Process EfficiencyIndia has been lacking behind in innovation and advancement in the healthcare industry. The people of India have several problems related to the public healthcare system. These problems range from infrastructure to medicine, in short, everything. When all is not well, it leads to lack of efficiency in the system of public healthcare. The public goods and services are very important for the proper functioning of the economy. The government is liable to provide public goods to the public so as to increase their productivity and their satisfaction as well. Several studies have been done in India and worldwide in order to assess the level and impact of public goods in economic development. In addition to this there is a National Accreditation Board for Hospitals (NABH) which is a self-assessment and external peer assessment process used by healthcare organizations to accurately assess





their level of performance in relation to established standards and to implement ways to continuously improve [2]. As per NABH there are several parameters, which if, satisfied constitute to the hospital having an accreditation. Out of the 79,000 public and private hospitals in India only 1000 hospitals have applied and are in the process of being reviewed on quality parameters, as per NABH website. The data has revealed that the only 1% of the hospitals in India have applied for the NABH Accreditation. In [3] India if the number of hospitals applying for NABH accreditation is low, it is quite evident that the quality of these hospitals is presumably low.

India has been expanding the base of medical facilities it provides as well as the number of hospitals and medical institutes in the last decade. The target population is not only the citizens of the India, it is also targeting towards the patients who travel to India for medical tourism purposes. India has been able to increase its revenue from medical tourism exponentially. It is now a global hub for medical facilities of world class level [4].

3.1. InfrastructureThe structure of healthcare in India is divided into public, private indigenous system of medicine, voluntary health agencies and the national health program. For the purpose of this study, the focus will be on public sector with slight interest in private sector, for slight comparison.

The public sector, is further divided into 4 sub categories- primary health centers (PHCs) which include a PHC center and some sub centers; hospitals and health centers consisting of community, rural, district and specialist hospitals (primary focus of the study for infrastructure); health insurance scheme consisting of employee state insurance and central government health scheme; and other agencies comprising defense and railways. As per regulation there needs to be one PHC for every 30000 population in most areas but one for every 20,000 populations in hilly/tribal/difficult areas [5].

As per the NSSO Health Survey of 2018 it was reported that more than 70% of ailments in rural as well as the urban sector were treated in private hospitals all across India barring Kerala, Tamil Nadu, Odisha and Assam where public sector hospitals were more common [6]. The report also showed that the private hospitals had a major share in treating patients both in rural and urban area at 58% and 68% respectively [7] as shown in Figure 2.

There is very low expenditure on healthcare infrastructure in India, as per IBEF reports on healthcare in November 2018. It states that by 2024 India needs to spend at least USD 200 billion on the medical infrastructure. This high amount which is expected to be spent is all due to the lack of infrastructural development in India.

If we come to the education side of the healthcare sector, it is important to note that the medical colleges in India are very low in supply whereas their demand is sky high. As of February 2018, the total number of medical colleges in India is 479, which consists of 227 government colleges and 252 private colleges. These colleges are not apt for the population in India. The seats at medical colleges are in a state of pity. There are 6 seats available per lakh of populations as noted by the Ministry of Health and Family Welfare in February 2018.



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Figures 3–4 show how the states fare in the provision of medical colleges and seats per lakh of population:

FIGURE 3. Geo-mapping of medical colleges in India state wise.

FIGURE 4. Geo-mapping of medical seats per lakh of population.

FIGURE 2. Division of healthcare industry in India.





Evidently there is very little investment in infrastructure in India in the healthcare market. With the increase in burden of diseases in India, whether communicable or no communicable, there needs to be ample infrastructure to be able to treat these patients. India which is on a path to development should invest enough to not only treat the people but also to be able to prevent such diseases. This lack of infrastructure leads to lower efficiency of health care market [8].

3.2. Proportion of Beds to Number of PatientsThe proportion of beds per 1000 people is very low in India. This leads to lowering the efficiency of the healthcare provision [9]. There have been several initiatives where in millions of rupees have been allotted for building up new hospitals with larger number of beds. However, these projects take up several years to complete.

This lag in allotment of funds and completion is projects is majorly due to the lack of public private partnership in India. The government gives tenders usually for the completion of the project. The level of corruption and delay in the bureaucracy further adds to this problem of lag.

To achieve the required proportion of 3 beds per 1,000 people by 2015, India needs additional 3 million beds. This problem causes sheer wastage of resources and injustice to the people. The cost of being hospitalized in a private hospital in India is on an average 4 times higher than that in a public hospital. And if we consider the urban area or specialty and super specialty hospitals the cost increases to about ten times on average [10]. This high cost is not affordable to majority segments of the society.

The people who are hospitalized in private hospitals, generally take up loan to finance the medical bill. The lack of hospital beds in public hospitals, sometimes, leaves the poor in debt trap. Due to their inability to repay the loan they end up in a debt trap. And in some cases the cost is too high for them to even cover through loans that the patient’s condition gets even worse and there may be an increased risk of death.

3.3. Unethical Practice by DoctorIncrease in instance of medical negligence and unethical practices by doctors clearly indicate that health care is being compromised by doctors as well. There is a very big issue of asymmetric knowledge amongst the patients and doctors. The doctors are well informed of the medicine, procedures, etc. however, more often than not they tend to misguide the patient about the disease at hand in a way to make money.

The problem not only lies in asymmetric information for the doctors at public hospitals. The doctors at public hospitals are generally considered competitive and in majority cases better than the private doctors. However, these doctors decide upon earning more money by opening up private clinics [11]. The government of India has strict regulations that state that a doctor practicing at a public hospital should not open a private clinic for financial gains. The doctors are however allowed to practice for free, as a mode of social service. They are compensated for this in the form of non-practicing allowance. Several states bar doctors from practicing in the evening, including Delhi.



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Doctor is one of the noblest professions globally. However, a study by Lexology showed that some doctors at the public hospitals increase the waiting time for patients in order to lure them into visiting them at the private clinic when public hospital timing is off. This only helps the doctors to increase their income and reputation. Some doctors use reserve of this, they end up quickly freeing the patient with the argument that he/she has to attend several patients that are waiting. And if the patient’s wishes to get more time with the doctor, they must visit the doctor at his/her private clinic [12]. Time spent in private practice deprives Indian government the resources, thereby making the public health care system lack efficiency.

Apart from this the doctors may advice the patients to undergo several unnecessary tests, which may not (majorly) be available in the public hospital. Thereby, the doctors recommend some private diagnostic center which turns out to be costly. Upon doing this the doctors are paid a commission for every patient they refer to a particular diagnostic center with which they have a tie. The procedure is simple- the doctors write down several test which are of two categories- sink test and marked tests [13]. The sink test are the unnecessary tests, for which samples are collected by the diagnostic center, but are only thrown into the sink, and a fake normal report is sent to the patient. Only the marked tests are the ones which are actually conducted ethically. This helps in making money, as the patient is charged for both the sink test and the medical test. Furthermore, this is also done with various medicines, injections and devices.

More often than not pharmaceutical companies provide with expensive gifts and medical equipment to lure the doctors into prescribing their drug for treatment. The doctors generally fall prey to this and inform the patient that even though the same drug is available in the public dispensary free of cost but it would be better to procure it from private dispensary under the brand same of the pharmaceutical company. The doctors claim that the medicine of a particular pharmaceutical company will bring better and timely results, or the dosage is better for intake, or it is available in syrup/tablet form.

The doctors also some time perform clinical trials on the poor patients. These patients unknowingly become guinea pigs for the doctors [14]. All this happens due to the lack of information available to the patients. The lack of knowledge is a very big loophole which doctors use to their advantage.

3.4. Staff and DoctorsIndia needs an additional 1.54 million doctors and 2.4 million nurses to meet the growing demand for healthcare [15]. The healthcare sector has grown exponentially in the past decade, however, its growth has not been able to maintain or even reach the prescribed minimum ratio of staff and doctors per thousand populations.

This leads to lowering the efficiency of the public healthcare system. Public healthcare’s incapability at providing the basic doctor to population ratio has not been achieved which leads to several spillover effects. The lack of doctors and nursing staff more often than not leads to higher waiting time, higher cases where patients are unable to get required medical attention, higher cost for treatment, poor nursing care, and several others. This leads the patients to undergo a massive problem.





4. People Efficiency: Primary AnalysisPeople efficiency is the last and one of the most basic outcomes of operational efficiency. Public healthcare provisions are made in order to prevent outbreaks of diseases, and to cure the diseases present in the country. To keep the population healthy both physically and mentally is the responsibility of the government, which it completes by providing public healthcare.

India, as can be seen in the previous sections, does not fulfill the generic guidelines which would make it have an efficient public healthcare system. However, it is still possible that these fewer number of hospitals, nurses, doctors, paramedics, etc. are able to provide for the population in a manner which makes the system efficient given the circumstances. This section is based on a primary survey conducted in the month of March in 2019. The aim of the survey was to find out how many respondents visited/ preferred visiting a public hospital when need be instead of visiting a private hospital. The outcome of the survey did not result in favor of the efficiency of public healthcare provisions made by the government of India.

4.1. Age Groups and ChoiceThe primary survey showed that the respondents preferred private hospitals to public hospitals when they were younger. The proportion of respondents who fall in the age group of 18–25 chose private hospitals over public hospitals which was followed by the respondents in the next age category as well but not with as big of a gap as in 18–25. Respondents in age bracket 26–35 chose private hospitals to public hospitals but only with a difference of 2%. After the age of 35 most of the respondents chose the public hospitals over private hospitals.

(Table 2) regression table a regression analysis has been done on the question of public versus private provision of healthcare. The independent variable is age and the dependent variable is choice of provision.

For the same Public hospitals, dispensary and doctors have been given a score of one whereas the choice of private hospitals Dispensary and doctors has been given a value of zero.

By running regression it was found that P value= 0.0004 which means that the independent variable (age) and the dependent variable (choice of provision- public or private) have significant relationship

TABLE 2. Regression table

CoefficientsStandard error t Stat P-value

Intercept 29.90909091 1.377843926 21.70716896 0Which hospital or healthcare service do you use? Public = 1, Private = 0 5.502673797 1.902164493 2.892848551 0.004349744315



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Further it was also found that Coefficient = 5.502, which shows there is a positive relationship between the two variables.

This shows that age affects the choice that an individual make. Thereby making it a relevant factor for the study.

The Table 3 has elucidates the age distribution and the choice of provision that people make. The percentage of youth consisting of people in 18–25 chooses private to public hospitals, and when it comes to dispensaries 79% prefer private dispensaries to public ones, the doctors preferred by this age group is also 57% private and 42% public. Similarly, the people falling in age group 26–35 prefer more of private provision, in terms of all three- hospitals, dispensaries and doctor. The proportion of respondents choosing private hospitals is higher in this age group than in the one preceding it. In the next age bracket, it is found that the respondents prefer public hospitals, and public doctors, however 67% of respondents in this age bracket prefer public dispensary to private. Further in the age bracket 46–55 the trend is even higher. A higher proportion of people prefer public hospitals and private doctors. However, recorded 100 % respondents prefer private dispensaries. In the last age bracket it is found that only 11 % respondents prefer private hospitals, and 11 % prefer public dispensaries whereas 67 % prefer private doctors.

The certain features highlighted by the above table are that when the age rises the respondents prefer to shift towards public hospitals. This can also be that the new generation is more inclined towards the use of private hospitals rather than public ones, which has been a habitual go to place for the elder generation. There might be a trust factor involved which makes the elder people chose public hospitals. Apart from this, the other reason can be that when the respondents’ age, the savings decline and thus they have a limited amount to spend for themselves. The younger people have higher income and some are dependents. There can be several reasons for the same which have been identified through literature review and respondents have been questioned upon the certain factors which may make them chose public hospitals over private hospitals. Given the fact that older people who have limited source of income and have to spend wisely chose public hospitals instead of private ones. Income and cost is one factor, several other factors have been identified and talked about in the following section of this paper.

4.2. Reasons for ChoiceThe pilot survey and other several surveys conducted over time by institutions, along with the literature review helped identify the most common factors which indeed become

TABLE 3. Age and choice of provision (in percentage)

Age group Hospital Dispensary Doctor

Private Public Private Public Private Public

18–25 52.38 47.61 79.36 20.63 57.14 42.8526–35 60.97 39.02 78.04 21.95 63.41 36.5836–45 40.54 59.45 83.78 16.21 62.16 37.8346–55 25.00 75.00 100 0 75.00 25.0055 and above 11.12 88.88 88.88 11.12 66.67 33.33





reasons for which the people prefer a specific type of hospital. For private hospitals it was found that people had reason varying from specialized doctors, vicinity, consideration of quality equipment, early diagnosis, less wait time, in house laboratories, clean and green area, better skilled staff and nurses, in house chemist, etc. Whereas for public hospitals majority of the reasons were listed on which the top reason was that the cost of public hospitals is zero, there is no doctors’ fees, the medicine prescribed were available at public dispensaries for free, vicinity, specialization, etc.

The top factors have been chosen for this study only for the choice of public hospitals, without comparison to the choice of private hospitals. The sole purpose of choosing these factors has been to understand in completely independence why the people chose public hospitals over private hospitals, without the comparative factor at play. The factors presented to the respondents were only three close vicinity, specialized hospitals or zero cost.

The analysis done below will show the only the respondents who chose public provision over private ones and their reason for doing so based on their age.

The respondents falling in the age bracket 18–25 solely chose public provision for the close vicinity factor, 70% respondents who used public healthcare provision was due to its accessibility and no other reason. The other two reason of zero cost and specialization were cited by 26% and 3.35 % respectively. This means they are not enticed by the zero cost and specialization factor. On further questioning it was found that this was attributed to the fact that these youngsters would rarely ever need specialist and the cost was incurred by them or in case of people under 21 it was majorly incurred by their parents. The respondents in this age bracket use public dispensaries majorly due to the zero cost factor and 15 % use it as public dispensaries are in close vicinity and 23 % use it as it has some specialized drug, otherwise unavailable. The same respondents use public doctors when needed, based on the reason that they are close in vicinity (25 %), zero cost (41 %) and specialty (34 %)

The second bracket of age 26–35. It can be easily accessed from the Table 4 that people on the age group od 26–35 are the ones who use public hospitals the most and those in age group 18–25 use it the least. The respondents in this age category use it for two reasons that is 62.5 % use it as it is in close vicinity and the rest 37.5 % use it due to the zero cost associated. 44 % use public dispensaries due to its close proximity, 22 % use it as its affordable owing to zero cost and 33 % use public dispensaries due to their specialization. The respondents in this age bracket use the services of public doctors majorly due to the specialization provided by them (60 %) the rest use it due to proximity (26 %) and zero cost (14 %).

The third age bracket has near equal proportion for both reasons of close vicinity and zero cost. 42 % use public hospitals because these are in close vicinity and 57 % use these as they have zero costs. The public dispensaries are only used in this bracket by people for two reasons, 50 % use it due to close vicinity and 50 % due to the specialized drugs available. The public doctors are used by this age bracket due to specialization possessed majorly (56 %), followed by the close proximity of public doctors (25 %) and the rest use the services of public doctors due to the zero cost factor.

The next age bracket has respondents using it for specialist as well. 12.5 % respondents use public hospitals provision as it has some specialty. The rest 50 % use it for the zero



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cost associated and 37.5 use it due to the close vicinity factor. People falling in this age bracket do not use public dispensaries at all. This is also noted in Table 3. These age bracket respondents use public doctors’ services when they need a specialist (66 %) or when they have close vicinity to the public doctors (33 %). Clearly, it may be noted here that people in this age bracket are not lured by the zero cost factor.

The elder people falling in the age bracket 56 and above use it for all three factors, 37.5 % respondents each use public hospital as it is in close vicinity and associated zero cost, in addition to which 25 % use it due to the specialty factor. The elder people in this bracket use the public dispensaries for one sole reason which is the zero cost factors. They may have to travel distance for public dispensaries but they use public dispensaries due to the zero cost factor. The public doctors’ services are availed by this age group due to the close vicinity (66 %) and zero cost (34 %). It may be noted here that the respondents in this age do not visit public doctors for specialization but only the other two reasons.

4.3. Reason for Low Efficiency in Public HospitalsIn another question, the respondents were further asked, if need be which healthcare provision were they more likely to use - public, private or were they indifferent between both. The respondents were distributed as such- 41 said public hospitals, 37 said indifferent between both and 84 said private hospitals.

This shows the dismay amongst the people. After listing out the factors for proper input efficiency at healthcare service it was found that the most important variables affecting the efficiency of public healthcare provision were- timely conduct of procedure and processes, technological adequacy, accessibility, vacancy of doctors and staff, were the top factors which help analyze the level of efficiency. The respondents were questioned about the efficiency of public healthcare provisions based on these four variables.

TABLE 4. Age and reason for choice (in percentage)

Reason for choice Close vicinity Zero cost SpecializationA

ge g

roup

18–25

Hospital 70 26.66 3.34Dispensary 15.38 61.53 23.07Doctor 25.92 40.74 33.33

26–35

Hospital 62.5 37.5 0Dispensary 44.44 22.22 33.34Doctor 26.66 13.34 60

36–45

Hospital 42.85 57.15 0Dispensary 50 0 50Doctor 25 18.75 56.25

46–55

Hospital 37.5 50 12.5Dispensary 0 0 0Doctor 33.34 0 66.66

56 and above

Hospital 37.5 37.5 25Dispensary 0 100 0Doctor 66.66 33.34 0





They were required to rate these four factors on a Likert scale ranging from 1–5. 1 being least and 5 being the highest quality. Upon analyzing it was found that nearly 19.75 % respondents said there was a lack in efficiency of public healthcare services due to the lack of trained doctors and staff, that is, they believe that there is a high vacancy in public provision of healthcare, which if filled would owe to higher efficiency. 25.31 % of the respondents responded that the inaccessibility to public healthcare provision was the prime reason for its low efficiency. These respondents felt that the private hospitals have cropped up in all small districts as well, however, even PHC is unavailable in several districts in India. The problem of unethical practices by doctors discussed earlier in Section 3.3 leads to lack of public doctors in small towns and districts in India, therefore making accessibility to public healthcare a very big concern regarding efficiency. 16.67 % of the respondents blamed the inadequacy of technological capital in public healthcare as the major reason for its falling efficiency. These respondents upon further questioning revealed that they believe if artificial intelligence is used in India, and then there would be no need for doctors to be present in small towns and villages. Therefore, as per these respondents, the increase in technology would lead to solving the accessibility problem as well. They further felt that the lack of technology sometimes compels the patient to travel several kilometers for x-ray, CT scan, etc. who are unavailable at some PHC, SHC and THC in some villages and towns, thereby acting as deterrent for public to avail the public healthcare provision services. 24.69 % respondents believe that efficiency of public healthcare provision is low as the time consumed for processes and procedures is too high. These respondents revealed that the time taken in queues at OPD, at dispensaries, and even for operations and surgeries is very high. Some patients have to wait for months to get the date to meet and consult a particular physician for special treatments. The wait period for some surgeries and operations ranges from months to years as well. The most prevalent problem shared by the respondents was the waiting time period for OPD. The OPD patients first queue up receive a token number which is then translated to an even longer queue to the doctor. These patients sometimes spend entire day in queue and leave the OPD section without consulting the doctor. The lack of doctors and staff usually leads to this problem. On the positive side, 13.58 % respondents felt that the public healthcare system was efficient.

The respondents were also asked to give a subjective answer. The respondents pointed out the lack of cleanliness, specialized doctors, consideration of quality equipment, early diagnosis, more wait time, lack of in house laboratories, low skilled staff and nurses, lack of in house chemist, etc. to be other leading factors for lower efficiency of public healthcare provisions.

4.4. Case Study from HaryanaThe case is conducted with the aim of analyzing the status of migrant population. This case study is only mentioned in this paper to elaborate on the fact that conditions for migrants are worse than what it may seem from afar. Several inter-state migrants come to Delhi and other metropolitan cities in India with hopes of better quality of life, higher income,



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better education and better healthcare facilities. But when it comes to healthcare services, the public healthcare services in India are not efficient enough to cater to the needs of the migrant population.

This case study is based in Haryana, which is considered to be the agrarian backbone of India. This state houses more than a million migrants who come with the aim of earning higher money than their home state. Majority of migrants are employed in the agricultural sector as unskilled or skilled labor. The agriculture land does not belong to these migrants, they only help produce the output and earn wages in return. Some migrants who have been working on the same field for a long time are sometimes promoted to share cropping. These migrants are a major source of capital for land owners and farmers alike.

The burden of healthcare of these migrants falls on the public hospitals in Haryana. The state is not well equipped to cater to the needs of an addition million people. The surveyor used a questionnaire similar to the one used throughout the study and an interview method was followed so as to understand the personal stories of people and have a thorough understanding for a broader study on migrants and healthcare.

There were several interviews conducted on field. The questionnaire designed for the same was based on two parts- household demographics (including variables like land holding, employment status and source of income, education and expenditure, healthcare and expenditure, loan history); and Healthcare Awareness.

Upon interviewing several migrants, it was found that most of them had ailments due to unfortunate incidents at work. Naresh Mandal, a 55-year migrant, working on the fields had a mishap in 2015 and broke his right arm. As told by him, “I didn’t know that government hospitals could fix it. I thought they did not have ample machinery to fix the arm. So, I went to a private hospital and they charged me ₹. 2500”. Out of fear of being unemployed, Naresh did not tell the landowner about his arm and made his children do the field work. His monthly income is of ₹9000 (₹300 daily) out of which he sends money to his hometown in Bihar for his family and little is left for his children and wife living with him on the field. So, he was inquired about how he covered up the hospital bill, Naresh financed it by taking up a loan from a money lender. The loan so attained was on monthly 6% rate of interest and till date Naresh has only managed to repay 48% of the principal amount (₹1200).

Sometimes getting treatment from the touts present in the healthcare services also lead to several other complications. To cite the case of Mahesh Ram, a 34-year-old man, who is handicapped with his right leg in 2007; the cause of being handicapped was when he went to a tout to cure his fever. The tout gave him incorrect medication for quick recovery which led to severe iron deficiency. “I didn’t know I would take the medicine every time I was in pain, as was prescribed, and in one month although my fever was gone, somehow my right leg was always shaking. I did not pay attention to it then but a couple of months later I noticed my leg had started shrinking and now after 6 years my leg is almost 2 inches shorter than what it was earlier” as told by Mahesh. Currently, he has to take medication daily and visits a doctor about once or twice in the month. The monthly expenditure for the same turns out to be ₹1,000. Mahesh has to take a loan for not only his medical expenses but also for consumption purposes as it is hard for him to feed 8 mouths with





a monthly was of ₹10,000. However, Mahesh did share that he satisfied in general with the private healthcare provided in Haryana than the public one and even the private and public healthcare facilities in his hometown in Bihar.

Just like Mahesh, Ram Kant Paswan, a migrant worker in Haryana for the last 10 years, has other woes. Paswan got a hip prosthesis done in 2015. Paswan shared his story and mentioned that earlier he did visit a government hospital but there he was “not paid attention to for 2 days” when he was in “severe pain”. So as to get treated early and not complicate things, Paswan decided to get hip prosthesis from a private hospital. The cost of the operation was ₹32,000 and other expenditure including hospital bills, doctor’s fee, medication, travel, etc. amounted to a sum of ₹1,60,000. He had to take a credit of ₹2,00,000 in order to pay up for these medical bills. The amount was taken on an interest rate of 5% monthly and he has only paid ₹3,00,000 till now. Currently, Paswan has an average monthly expenditure of ₹. 400 on medicines and doctor visits (if any). Upon being suggested that he visits a public hospital at least now, he said “in government hospital, the doctors charge us about ₹600 per visit even in OPD”.

To ensure that the migrants weren’t biased and to check whether locals got the correct treatment at the public hospitals the same questions were asked to the locals as well. Upon interviewing the locals, it was found that most of the locals did not face any disability or chronic ailment. Majority of the locals of the village were engaged in agricultural sector. One of the local, Vijender Antil, shared an incidence of healthcare woes in his family. His mother, 72 years of age, is diabetic. The monthly expense of medication for his mother is of ₹9000 to 10,000 on an average. He also shared that she was hospitalized a couple of months prior to the survey for 4 days, and the bill of the treatment for the same was of ₹20,000. Vijender had enough finance to pay for the costs himself.

Upon doing a field survey of the area it was evident that the migrant labour had low nutritional intake whereas the locals were fit and healthy (majorly). The locals of Khewra are jaats, who are genetically fit and have a strong build. They also shared their experience about the rising number of migrant labour in their district. The big farmers were happy to have cheap labour present in abundance. They felt that having a migrant worker live on the farm was very practical “he could take care of the land 24x7, I don’t have to check on the land every day. The wage or share is mostly fixed on the output he produces. So, he also has an incentive to produce better quantity of output so that he may receive a bonus and not lose his job in the next seasons” shared Monu Singh. When asked about the problems with the increase in migrant population, the locals stated that there has been a decrease in the sanitation condition of the village and district at large. This may lead to several sanitation related diseases.

Several cases were found which clearly indicated that even though pubic hospitals are present in the district they are about 15 kilometers away. The migrant population was aggrieved by the lack of attention they face at public hospitals due to which they have to opt for private hospitals. Further it was found that due to lack of awareness about the correct ways to use fertilizers and pesticides several migrant labor was beginning to face skin diseases, breathing problem, etc. They were also found to be taking up credit for overcoming the medical bills they had to pay for.



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5. ResultsThe outcome of this study indicates to the direction that several steps have been taken, whereas several are yet to be taken. The efficiency of healthcare is a primitive issue of concern, especially for a country like India, which is second highest populated country in the world. The country has reduced its mortality rate and increased its life expectancy, which in a layman term means that healthcare sector in India, is better than what it was, even, a decade ago.

However, when studied in details, it was found out that the healthcare sector, at large, might have grown, but the growth in the sector was attributed majorly to the rise of private provision of healthcare services and slightly to the rise in public provision of healthcare services. The role of insurance is not yet explained in this study, but it must be mentioned that the public healthcare insurance being provided by Modi government is a step forward in ensuring that human capital is taken care of.

In the first section, the technological efficiency was highlighted. It is noted that the rise in technological use has led the country’s public healthcare system to become more developed and advanced. Not only in terms of curing diseases, but also in terms of preventing and identifying (yet unknown) diseases. The use of technology in Indian healthcare system was started by data collection and use of data to analyze outbreaks and recommend steps in order to prevent such outbreaks. Later, the use of technology advanced to such significant levels that Artificial Intelligence is handy now. However, it must be pointed out here that the use of artificial intelligence in public hospitals in India, is almost negligible. Only few public hospitals, situated in the metropolitan cities in the country use such technology. It may come as a surprise but there are several villages and districts in India where people still have to travel kilometers to get a simple x-ray done, and in some cases to even find a doctor or hospital.

Therefore, it is correct to infer that technological advancement has not been increased at a rate which is required for efficient use of resources for better output and outcome. The technological advancement needs to be adapted into the public healthcare services provision as well, for better efficiency so as to help increase the capacity of human capital, which is plenty in India. The cost of production and use of technologically advanced tools and capital may be high, but the reward attached with the use is in turn aimed at increasing economies of scale thereby, increasing the efficiency of public healthcare provisions. The government must invest in educating the staff about technological advancements available; also it must invest in procuring and producing technologically advanced capital for achieving higher efficiency.

The next section based on the process efficiency measured the efficiency in terms of several factors. The infrastructure, proportion of beds to number of patients, unethical practices by doctors and; staff and doctors. The rate of growth of infrastructure in India is very slow as compared to the rate of growth of population. The country needs several thousands of more hospitals and dispensaries. The second requirement is medical institutions in order to train and educate students and doctors. India has a high number of aspiring students but the number of seats at medical colleges is too low to accommodate





all the students. Therefore, there is a very high demand for the medical colleges and institutions. The proportion of beds for patients is again very low, which will be improved hand-in-hand with increase in infrastructure. The unethical practices by doctors and the lack of trained doctors and nurses are other factors which lead to lower efficiency in public healthcare system.

The most important factor to measure outcome efficiency is people. The people were dissatisfied with the outcome of public healthcare provision and therefore clearly indicated to a low efficiency in public healthcare. The results showed that the people would prefer private healthcare provision to public healthcare provision whenever it was possible for them. The specialist in public healthcare provisions were low in number, or their specialty was already being provided by the private healthcare institutions. The other factor was accessibility; there is very low accessibility to public hospitals and dispensaries, even in National Capital Territory region of India, Delhi. The lack of accessibility translates into a huge question mark about efficiency of public healthcare facilities. It is important here to see that the people considered zero cost as an important factor in choosing public healthcare facilities to private ones. This could indicate to the fact that either insurance of people is low in the country, or the people cannot afford private healthcare for either of the two reasons- low income, high cost. The government is doing a remarkable job by providing free healthcare; however in order to actually transfer the entire benefit to the ultimate consumer, the government must shoulder the responsibility of higher accessibility, higher efficiency and higher quality of services in public healthcare.

The lack of efficiency in public healthcare was attributed to several factors, out of which four major factors were questioned upon. The respondents felt that the reason which was most important out of the four was inaccessibility to public hospitals, followed by high time consumed in processes and procedures, lack of trained doctors and staff and finally the low level of technological capital used. The respondents also shared several other factor which they felt would help increase the efficiency of public healthcare provision in India.

6. ConclusionHealthcare is one of the most primitive concerns for development globally. Poor health is an indication towards suffering and deprivation which are of the most fundamental kind. The significance of life expectancy and other common killers has been stressed upon in the past, leading to higher life expectancy and lower mortality rates, etc. The Government should take effective steps to ensure increase in the affordability to the health insurance schemes, especially amongst the rural population. With higher insurance penetration in the country, the accessibility to quality healthcare services would greatly improve. Globally, there has been decline in the infectious diseases since 2000, including malaria, TB and HIV/AIDS.

The better picture of healthcare is still shadowed by several problems and new pandemics keep arising and affecting regions of the world. There is a need to improve the treatments, vaccines and technologies for healthcare provision at affordable rates.

It is important to focus on healthcare as it impacts the basic welfare and wellbeing of an individual. It burdens the public resources and hampers sustainable development. The



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aim should be to have a healthy population, which can be used as a healthy workforce in all industries, where ever needed. Government should provide advantages to the private sector in terms of long term tax benefits for establishing hospitals in the rural areas. The people of all ages, from infant to old age, should be healthy and protected from disease. The fundamental of a good life is a good health, which becomes a responsibility of the government as people are a state subject and their welfare is a key concern of government. The better healthcare promises opportunities for everyone, while providing impetus for economic development and growth.

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