While progress has been made in India over the past decade from both public and private sector initiatives, significant challenges persist in providing quality healthcare on an equitable, accessible and affordable basis across all regions and communities, according to a new IMS Institute for Healthcare Informatics study. A 40-45 percent reduction in out-of-pocket expenditures for both outpatient and inpatient treatments can be attained through a holistic approach addressing four critical, interrelated dimensions of healthcare access. Those components are: physical accessibility and the location of healthcare facilities; availability and capacity of needed resources; quality and functionality of service required for patient treatment; and affordability of treatment relative to a patient’s income. The study – Understanding Healthcare Access in India: What is the Current State? – is the most comprehensive assessment of healthcare access undertaken since 2004 and is based on an extensive survey of nearly 15,000 households covering all socio-economic groups in rural and urban areas across 12 states. Information was gathered on more than 30,000 healthcare system interactions, supplemented by interviews with over 1,000 doctors and experts. The full report is available at http://www.theimsinstitute.org for downloading.

1. June 2013
Understanding
Healthcare Access
in India
What is the current state?

2. Expanding healthcare access is a critical priority for India today. Despite numerous efforts made to address this problem
and the progress made to date, the gap between the aspiration - providing quality healthcare on an equitable, accessible
and affordable basis across all regions and communities of the country — and today’s reality still remains.
The inception of National Rural Health Mission (NRHM) and the implementation of other policies over the last decade
have shown a positive improvement in India’s healthcare system. To do more, and at a faster rate, it is important to
understand the current state of healthcare. This understanding will play a pivotal role in determining priorities,
resource allocation and goals for the future, as well as plugging the existing gaps in the system.
This report brings fresh, objective perspective to the status of healthcare in India, and offers the most comprehensive view
of this issue since 2004.
Objectives of the Study
This study has been undertaken for the benefit of all healthcare, including the government; pharmaceutical, payer,
and provider companies; civil society organizations and non-governmental organizations.
The study has the following objectives:
1. Map the current status of healthcare access to gain a comprehensive view on successes and key areas of challenge
2. Prioritize challenges or gaps in terms of their relative impact on healthcare access
3. Provide a roadmap to guide future improvements
This study is intended to help drive the following:
• Educate all relevant stakeholders in the healthcare community about the true status of healthcare access in India
• Clearly establish that healthcare access is multi-dimensional in nature and hence to truly address current gaps,
all dimensions need to be considered and not just one
• Provide clarity on the priorities required to improve healthcare access
• Highlight the need for more effective implementation of existing healthcare policies
Methodology of the Study
At the core of the research is an extensive nationwide survey covering 14,746 households representative of the country
in terms of economic and healthcare parameters, while ensuring proper regional representation. Interviews were also
conducted with over 1,000 doctors and a panel of healthcare experts to provide qualitative inputs.
Household sample distribution split by geographies
Doctor sample distribution split by geographies
19%
50%
30%
35%
All India 1,000
All India 14,746
31%
35%
SEC A
2,802
15%
4,571
15%
7,373
20%
R1
SEC B
25%
25%
25%
R2
SEC C
25%
25%
30%
R3
SEC D
20%
20%
15%
15%
Metro
SEC E
Other
Urban
25%
Rural
TN
R4
MH
WB
UP
Private
Doctors
45% 50% 50% 50%
47% 50% 50%
Govt
Doctors
55% 50% 50% 50%
53% 50% 50%
Regions
Metro Other Rural
Urban
In addition to the primary survey, an extensive review of current healthcare policies, various healthcare schemes (both
at the central and state level), and available data in public domain was taken into consideration to better understand
challenges in India.

3. Defining Healthcare Access
Access is multi-dimensional in nature as it is shown in the illustration below. For a person to have access to healthcare in
India, a healthcare facility must be reachable within a 5 kms and must offer available doctors, drugs and treatment options
that satisfy both acceptable cost and quality-of-care standards.
Even if only one of the components is missing, a patient is unlikely to receive he right treatment in the most appropriate and
efficient manner. It is therefore essential to consider all four dimensions in order to assess the state of healthcare access.
1
Physical
accessibility/
location
Av
ai
la
bi 2
lit
y/
Q
Ca
ua
pa
lit
ci
y/ 3
ty
Fu
nc
tio
na
lit
y
Stages of healthcare access
Location:
Rural vs Urban
IP vs OP
Acute vs Chronic
4
Components:
IP vs OP
Acute vs Chronic
Income levels
Channels:
Private vs Public
Impact on usage
Healthcare Access Study. Findings from Primary and Secondary Research
Key Findings of the study
• The physical accessibility of public or private healthcare facilities is a challenge in rural areas. By contrast, in urban
areas, physical accessibility is less of a challenge due to the overall higher number of available facilities.
Distance travelled to seek OPD treatment
No. of episodes
Less than
5km
19,813
10,112
9,701
68%
80%
92%
Over 5km
32%
20%
8%
All India
Urban
6,498
13,315
83%
79%
17%
21%
Rural
Poor
Source: Household Healthcare Access Survey Conducted by IMS Consulting Group, 2012
• An increasing proportion of the population is using private healthcare facilities for both in-patient and out-patient
treatments.
Choice of in-patient service provider - Rural (% patients)
40
60
56
58
61
44
42
39
Choice of in-patient service provider - Urban (% patients)
40
60
1986-1987
58
62
42
38
1995-1996
Private
2004
Public
69
31
2012
Source: NSSO Data 2004; Household Healthcare Access Survey Conducted by IMS Consulting Group, 2012

4. •
are forced to seek treatment in private care.
Total spend/episode of illness in absolute (INR) and as % of average monthly HH expenditure
Average spend/Event (INR)
247
251
678
728
667 1,096
4.5x
1,481 2,575 13,485 11,605
2,255 2,325
217%
44%
121%
23%
21%
54%
14%
3%
5%
8%
7%
Government
Private
16%
Government
Acute Care
Private
Government
Private
Chronic Care
OPD Treatment
IPD Treatment
Poor
• Long waiting times, lack of available doctors, absence of diagnostic facilities, and lower quality of care are among
the main reasons cited by patients for choosing private treatment over public facilities.
Key reasons cited for selecting private sector for OP treatment
To get
quickly
attended to
56%
Lack of
specialist
in Govt.
14%
13%
Less
waiting2.6
than
Govt Hosp
4.8 62%
29%
All India
11%
3.8
13%
62%
60%
60%
6.2
63%
49%
50%
50%
52%
3.9
Rural
13%
27%
Poor
35%
Acute
30%
27%
32%
Urban
12%
18% 6.4
46%
1.3
26%
22%
13%
16%
6.1
60%
1.4 54%
50%
No free
medicines
in Govt.
imsexecutivesummaryindiae-versionfinal2-130722213510-php
10%
16%
61%
Doctor
availability
in private
sector
15%
13%
56%
56%
56%
57%
56%
56%
Chronic
Source: Household Healthcare Access Survey Conducted by IMS Consulting Group, 2012
• Due to the lack of physical reach, availability of quality treatment and other practices, patients are
00
Channel diversion due to lack of availability of quality healthcare resources
00bn
Government Sector
26%
Doctor
Consultation
Patients
00%
2
ve
Di
n
io
rs
1
More patients are
using high cost
private channel
Diagnostics/
Medicine
00
00bn
3.3%
Doctor
Consultation
Patients
0
5
10
Diagnostics/
Medicine
• The majority of out-of-pocket expenses are incurred title
from medicines purchased from public or private
Key title
Key
healthcare facilities.
% split of OOP spend on OPD treatment (including episodes where free treatment was given)
2,296
Total episode spend (INR)
All other state spending
5%
13%
US Federal Budget 2011
$3.6 Trillion
Medicaid
Social Security
842
Total of State’s Budgets 2011
$1.6 Trillion
Defense
Higher Education
Source: National Association of State Budget O
5%
14%
17%
1%
63%
Elementary & Secondary Education
5%
19%
13%
1%
6%
All India
250
73%
Government
All other spending
941
62%
Private
61%
1%
69%
Government
Acute Diseases
Medicines
20%
1%
, State Expenditure Report, 2010-2012; Congressional Budget O
711
0%
20%
1%
6%
2%
23%
Minor sugeries
Private
Chronic Diseases
Diagnostics
00b
00bn 00bn
00bn
Further diversion when Govt.
doctors send patients for
diagnostics to private
facilities or when patients have
to purchase essential medicines
from private channels
Private Sector
74%
00bn
00
Consultation
Source: Household Healthcare Access Survey Conducted by IMS Consulting Group, 2012
Others
15
20
25
30
35

5. •
exist for the Indian population across all dimensions of access, especially in rural areas.
Urban
Poor
HC services
Availability of HC services;
Rural
Physical reach, availability, quality
Poor
Physical reach
Availability
Quality
No concern
Some concern
Large gaps in access
Concern areas
No gaps in access
• When asked, patients in our study claimed they would readily switch to public healthcare centres if these issues
were addressed.
• From a patient cost of treatment perspective, by improving each of the dimensions of access, there could be a
potential cumulative reduction in out-of-pocket expenditure by ~40% for out-patient treatments and ~45%
for in-patient treatments.
100
4
11
51
Expected change in OOP expenditure on OP ailments
97
Assumption:
OOP on
diagnostics
can be
brought
down by 75%
in Govt. HC
facilities
11
51
1
88
Assumption:
OOP on
drugs can be
brought down
by 90% in Govt.
HC facilities
through
disbursement
of subsidized
essential
medicines
51
1
2
Assumption:
Additional 15%
patients shift
to Govt. HC
facilities due
to A and B
78
43
34
34
34
29
Current
status
A: Diagnostic facilities
available in
public HC facilities
B: Subsidized essential
medicines available in
public HC facilities
Impact of
A+B
Private others
Private medicine
4
2
Government medicine
Assumption:
40% Private
HC patients
shift to Govt.
facilities due to
improvement
in availability
and quality of
healthcare
resources
61
7
3
30
21
Improvement in
quality of
public HC Facilities
Government others
• The largest impact possible can come from improvements in the availability and quality of public facilities, as
demonstrated above.
RECOMMENDATIONS
Recent progress and commitments by the public and private sectors suggest the willingness exists to invest in and
operationalize the changes needed to broaden healthcare access across the entire Indian population. However,
active collaboration between the public and private sectors is necessary in order to truly improve the quality of care
and healthcare services.
Overcoming barriers needs a sustainable, policy-level strategy involving a coordinated approach with the following
three priorities:
• Improve availability
• Raise performance levels by improving availability of healthcare services and augmenting the governance system
to drive higher performance
•
by improving the penetration of health insurance at an accelerated pace
Recognizing that not everything can be changed at once and that the timescale is long, a roadmap is essential to
ensuring gaps are prioritized, interconnections and dependencies recognized, resources directed to the right areas,
Visit our website to download the full report: www.theimsinstitute.org

6. IMS HEALTH®
IMS INSTITUTE FOR HEALTHCARE INFORMATICS INDIA
24 Barakhamba Road,
New Delhi 110001
India
Contact us for more information:
Dr. Raghavan Gopa Kumar,
Head of IMS Institute for Healthcare Information, India
graghavan@in.imshealth.com
Tlf: +91-11-33 58-25-50
www.theimsinstitute.org
IMS Health is present in over 100 markets.
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ABOUT THE IMS INSTITUTE FOR HEALTHCARE INFORMATICS
The IMS Institute for Healthcare Informatics provides key policy setters and decision makers in the global health sector
with unique and transformational insights into healthcare dynamics derived from granular analysis of information.
It is a research-driven entity with a worldwide reach that collaborates with external healthcare experts from across
academia and the public and private sectors to objectively apply IMS’s proprietary global information and analytical
assets. More information about the IMS Institute can be found at: http://www.theimsinstitute.org.