When it comes to the health of its 1.5 million people, sunny, sylvan Goa–India’s smallest state by area and the fourth-least populous–does better than most Indian states and best among the five heading into elections, according to an analysis by the Observer Research Foundation.
With health increasingly important to economic progress, this is the fourth of a six-part series that uses the latest available data to discuss the state of health and nutrition in Uttar Pradesh, Manipur, Goa, Punjab and Uttarakhand.
Goa has a lot going for it: It is India’s fifth-most literate state (93% men, 82% women are literate) according to 2011 Census; 94% of women in the state participate in household decisions, according to National Family Health Survey, 2015-16 (NFHS-4) data; 99.5% of births take place in a hospital as against all-India average of 79%, according to Rapid Survey on Children 2013-14 data; public-health expenditure is four times the Indian average; medical facilities abound, and they have no shortage of health professionals; the sex ratio is among India’s best and getting better; and the infant mortality rate is India’s best, the same as Saudi Arabia and better than Brazil.
Yet, as we parsed these data, we found prosperity has brought new worries:
- Despite having one of India’s best public healthcare systems, Goans are using household savings or borrowing money to pay for private healthcare.
- While large swathes of rural Goa have India’s best sex ratios, urban areas are now reporting sex ratios that are among India’s worst.
- Although Goan babies have among the best chances of surviving, the proportion of wasted–low weight for height–children is growing, as are anaemic women.
- Obesity is a growing problem and is bringing with it a rise in lifestyle diseases.
As we delved into the details, some answers emerged.
The government is spending money, but so are citizens
Public health expenditure in Goa, at Rs 2,439 per capita, is almost four times the national average, five times that of Uttar Pradesh and twice that of Uttarakhand, according to a health and family welfare ministry report.
Even in rural Goa, the average medical expenditure per hospitalisation is twice the average for all states and union territories (UTs) in India. For a state with no shortfall of nursing staff at public health centres (PHCs) and sub-health centres (SHCs), as data from Rural Health Statistics 2016 show, the high average medical expenditure in Goa begs an explanation.
Health Spending In Goa
Public health infrastructure among India’s best, but there aren’t enough specialists
Since the public per capita expenditure on health is quite high, health infrastructure at PHCs and CHCs in Goa appears to be better than most states: 94% of Goan villages surveyed had a SHC within 3 km and 82% had a PHC within 10 km.
Apart from a surplus of nursing staff at these centres, no PHC was short of a doctor, lab technician or pharmacist, according to the Rural Health Statistics 2016.
There is, however, a shortfall of specialists–surgeons, obstetricians, gynaecologists, physicians & paediatricians–at the CHCs. This is why Goans may be flocking to private healthcare facilities, despite the high premia they charge.
So, Goans flock to private healthcare, borrowing or dipping into savings
Roughly 45% and 60% of hospitalisation cases in urban and rural Goa, respectively, use public healthcare and is generally free. However, using private healthcare, which is largely paid for with household savings or loans, drives up private health expenditure.
While 16% of Goan households have at least one member covered by a health scheme or health insurance, according to NFHS-4 data released in 2016, there is a difference of almost 14 percentage points in insurance coverage between the two districts in Goa.
The average treatment cost per person for an ailing Goan was roughly Rs 50 over/under the Indian average, for both rural and urban India. However, in rural Goa, the average total medical expenditure (TME) per ailing person for an acute illness was 17 times the average expenditure at a public hospital; in urban Goa, it was four times higher. This reflects the premium Goans pay to private hospitals, even for acute “non-hospitalised treatment”–meaning, treatment for illnesses or ailments which did not require admission of patients into hospitals as in-patients–in the private sector.
This affinity for private healthcare begins when a baby is born.
The high costs of having a baby: The Caesarean explanation
The average total medical expenditure for delivery care in rural Goa is Rs 16,351, almost three times the average for rural India. The corresponding figure for urban Goa is Rs 19,477, or 70% more than the average for urban India.
Average Medical Expenditure On Childbirth
The breakup of expenditure on delivery care, by public and private sector expenditure, makes it clear that the high expenditure on deliveries is because many Goans tend to frequent private healthcare. Even so, why is childbirth at a private hospital so expensive?
Two words: Caesarean section.
Caesarean births increased by 22% in Goa over the last decade, according to NFHS-4 data, the latest available. About 40% of institutional births take place in the private sector, but of those 40%, around half are caesarean births. While public-sector caesarean deliveries are lower (19%), this is still higher than the ideal rate for these types of deliveries, which should be between 10% and 15%–beyond which there is no evidence of gains in mortality rates–according to this World Health Organization statement.
In urban North Goa, 62% of all births in private-sector healthcare institutions were delivered by a caesarean section, while the comparable figure for urban South Goa was 54%.
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