Journal of Global Resources
Biannual International Peer-Reviewed Journal
ISSN: 2395-3160 (Print)/2455-2445 (Online)

January 2021
Volume 07 (01)
Crossref DOI 10.46587

DOI: 10.46587/JGR.2021.v07i01.013

13
BARRIERS OF FINANCIAL ACCESS TO UTILISATION OF HEALTH CARE SERVICESTO WOMEN IN RURAL AREAS OF WEST BENGAL, INDIA: AN ANALYSIS OF ASAMPLE SURVEY
Yasmin Khatun1 and Shovan Ghosh2
1
Ph.D, Research Scholar, Department of Geography,
Diamond Harbour Women’s University, Sarisha, South 24 Parganas, West Bengal, India
Email: yasminkhatun2093@gmail.com
2
Associate Professor, Department of Geography,
Diamond Harbour Women’s University, Sarisha, South 24 Parganas, West Bengal, India
Email: ghoshshovan80@rediffmail.com
Abstract: Access to health in low and middle income countries shows a lack of proper
evidence on ways to reduce limiting barriers, especially those on the demand and related
to the lack of education and information, the cost of access and cultural issues. These
problems can be attributed directly to women’s lower average incomes to their greater needfor, and use of, health care services. The present paper seeks to explore the barriers offinancial access to utilisation of health care services to women in rural areas of west Bengal,
India. Outline the issues pertaining to distance, time and out-of-pocket expenditure foroutdoor patient and indoor patient department treatment of women. The analysis of
economic class using wealth index of women was the domain of analysis. Face to faceinterview of 200 women were conducted with a structured questionnaire. Average distanceto sub divisional and rural hospital was far and wide, and also travel time was higher to go
health service centre. Heavy reliance was there on rural medical practitioners and local sub
centre for all health services need of the women. Financial burden of out of pocket
expenditure of women was significantly associated with level of poverty.
Key words: Financial Barriers, Health Care Services, Distance, Rural Area Women
Introduction
The socio-economic development of a country, among other things, largely depends on thequality of human resources. The quality of human resources can not only be visualized interms of educational, and technological skills that it possesses, but also by the status of its
health (Rajaswari and Sinha, 1993). Poverty and health care is a common subject of
research and policy, often using different definitions of poverty and health care access(Peter’s et.al 2008). Welfare has focussed its attention on improving the primary healthservices by channelizing adequate financial and manpower resources for making the healthservices more accessible and affordable to the poor people. (De. 2014). The term
affordability, as used in ordinary life, implies that the primary reason someone chooses not
to purchase a good or service is that the person does not have the ability to pay for it (Glied,2009). Factors that prevent women in developing countries from getting the health careinclude; unavailability and/or inaccessibility of health services, un-affordability of theservices because they are too expensive or reaching them is too costly (direct fees as wellas the cost of transportation, drugs, and supplies), multiple demands on the time that willbe spent on health care seeking, low status of women (Akalu et.al 2016). The scarcity ofvehicles, especially in remote areas, and poor road conditions can make it extremely
difficult for women to reach even relatively nearby facilities. Walking is the primary mode of110

transportation, even for women in labour (Olayinka et.al 2013). Most of the patients cannot
pay for basic care they received at government facilities but may not be willing to pay fortreatment they see as effective convenient or accessible than that obtainable fromtraditional healers (Muelaet. et.al 2000). A review on access to health in low and middle
income countries shows a lack of proper evidence on ways to reduces limiting barriers,
especially those on the demand and related to the lack of education and information, thecost of access and cultural issues (Cormick.et.al 2012). Against these backdrops, thepresent paper concentrates on the problem of affordability to health care services of womenin a rural set up of India. The paper has been bifurcated into three sections to unfold the
dynamicity of financial access. Section-I depicts the socio demographic characteristics ofwomen. Section-II outlines the issues pertaining to distance, time and out-of-pocket
expenditure for outdoor patient and indoor patient department treatment of women. The
analysis of economic class using wealth index of women is the domain of analysis in
section-III. All these financial barriers were tried to be intricately woven out in the researchwork.
Study Area
The District of South 24 Parganas (Figure 1) came into existence on March 1, 1986. The
southern part of the district covers dense mangrove forests and the entire district ischaracterized by heterogeneity in terms of physical, socio-economic and cultural profiles
combined with unique geographical location. South 24 Parganas District possesses 5 Subdivisions, 7 municipalities, 29 Blocks, and 312 gram panchayats. Canning I Block (22º12'
N to 22º 24'and 88º30' E to 88º42'E), called the gateway of Sundarban, is the headquartersof the Canning sub-division of South 24 Parganas District. As per 2011 Census of India,
Canning-I CD block (Figure 1) had a total population of 304,724, of which 181,508 wererural and 123,216 were urban. There were 51% males and 49% females. The total literacy
in Canning-I CD block was 71%, with female literacy rate 44% and male literacy rate 56%.
The block possesses 1 rural hospital and 56 Sub centres, spread over various pockets ofthe block.
Figure 01: Location Map of the Study Area

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Methodology
A cross sectional field study was carried out in eleven purposively selected villages ofCanning-I rural Community Development Block. A stratified sampling approach was
adopted to study a total of 200 women for our study. Women were selected from 3 age
groups pertaining to less than 20, 20-40, and 40-60 age groups. The weightage to selection
among age groups were given more on the age groups between 20-60 years, for this groupmainly correspond to the reproductive age of women. Face to face interview with allparticipants were conducted with a structured questionnaire, that considered three majorparts namely:
1. Women’s socio-demographic characteristics included age, education, family structure,and family income.
2. Distance time and out of –pocket – expenditure for outdoor patient department andindoor patient department.
3. Socio- economic class of women with the NFHS wealth index is based on the following
33 assets and housing characteristics.
RESULTS AND DISCUSSIONS
Section-I Socio-Demographic Characteristics of Women
The mean age of women was 32.54 and ± 11.70 SD years (Table 1). Most of the women
were married and belonged to Hindus and Category of SC (Scheduled Caste) community.
Women’s education registered mostly up to primary level. Average number of family
member was found to the tune of 4. Families were mainly engaged in daily labour activities.
The average monthly income was found to be five thousand. The families stayed at theirown house at least for more than 20 years. Most of the area was covered by unmetalled
road. The average distance of railway station was close to 7 km, and the time spent oftravelling to hospital averaged more than 1 hour. Sometime transport facilities after sunset
cease to exist. The average distances sub divisional hospital was close to 5 km. Women
have problems related to distance and access to health care services, for metalled roads
was insufficient. Hospital was far and wide, heavy reliance was there on rural medical
practitioners and local sub centre for all health services need of the women.
Table 01: Socio-Demographic Characteristics of Women
Name of Variables
Mean
Standard Deviation
Age
32.54
11.70
Marital status
2.18
.783
Religion
1.38
.486
Caste
1.600
.951
Education qualification
1.68
.526
No of family members
4.27
1.45
Occupation
2.71
1.70
Monthly income
1.42
2782
Duration of stay
2.07
0.79
Prefer mode of transport
5.08
3.01
Types of road
1.84
0.36
Distance to railway station
6.905
.773
Time spent travelling to health centre
1.35
.641
Transport facility after sunset
2.48
.701
Distance to SD Hospital
4.94
.432
Source: Computation by Author, 2020

Section-II Distance, Time and Out-of-Pocket Expenditure for Outdoor Patient andIndoor Patient Department Treatment of Women
Affordability of women’s health care service will be analysed in terms of distances, time andout of -pocket expenditure for different health service providers. For outpatient treatment,(Table 2) the mean distance to health care providers was lowest both for RMPs and sub
112centres. Average distance to a sub divisional hospital and rural hospital was close to 20
km. Mean time required to travel was also least for the sub centre, the average time to goboth rural and sub divisional hospital was more than one hour. The mean transport
expenditure was also least for visiting sub centre than any other providers. Out of pocket
expenditure (Table 3) for seeking care of sub divisional hospital was double than seeking
care for RMPs. It was also noted that more than 70 percent of OPD care is provided by the
RMPs and only 30 percent by sub divisional hospital.
For hospitalisation episodes (Table 4) of women’s in the last 30 days, the mean
distance required to travel for IPD treatment was also least for the RMP than any otherproviders. The average distance to a sub divisional hospital was almost 1.10 times thanthat of RMPs. Mean time required to travelling for IPD treatment was also least for the
RMPs and time to sub divisional hospital was seven times higher. Average transport
expenditure (Table5) was also least for the RMPs and the highest to the sub divisional
hospital.
Table 02: Distances and Time for Outdoor Patient Department Treatment of
Women’s in Last 30 days
Mean Distances (KM)
Mean Time (Min.)
Provider
Total
Provider
Total
RMP
2
RMP
20
SD Hospital19
SD Hospital
111
Rural Hospital
20
Rural Hospital117
Sub centre
1
Sub centre
16
Source: Computed by Authors, 2020

Table 03: Transport and Total Out of Pocket Expenditure for OPD Treatment of
Women’s in Last 30 days
Mean Transport Expenditure (Rs.)
Mean Total Expenditure (Rs.)
Provider
Total
Provider
Total
RMP
25
RMP
201
SD Hospital104
SD Hospital
403
Rural Hospital
107
Rural Hospital265
Sub centre
10
Sub centre
15
Source: Computed by Authors, 2020

Table 04: Distances and Time for Indoor Patient Department Treatment of Women’sin last 30 days
Mean Distances (km.)
Mean Time (Min.)
Provider
Total
Provider
Total
RMP
2
RMP
15
SD Hospital21
SD Hospital
105
Rural Hospital
23
Rural Hospital110
Sub centre0
Sub centre
0
Source: Computed by Authors, 2020

Table 05: Transport and Total out of Expenditure for IPD Treatment of Women’s in
Last 30 Days
Mean Transport Expenditure (Rs.)
Mean Total Expenditure (Rs.)
Provider
Total
Provider
Total
RMP
50
RMP
310
SD Hospital170
SD Hospital
512
Rural Hospital
190
Rural Hospital565
Sub centre0
Sub centre
0
Source: Computed by Authors, 2020

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The study discussed on affordability of health care services to women for outpatientcare in last 30 days. Average distance to sub divisional and rural hospital was far and wide,
and also travel time was higher to go health service centre. For inpatient care in last 30
days, women’s had problem related to distance and travel time to access health service
centre. Average expenditure was found to be higher for both rural and sub divisional
hospital.
Section-III Socio-Economic Class using Wealth Index
From the quintile index (Table 6) the household can be divided into three zones, i.e. Poorest
Quintile, Poor quintile and middle quintile. Accordingly, fewer no of the households falls in
the poorest quintiles, and large majority are found in the Poor Quintiles. Only 20% of thehouseholds are found to be at middle quintiles. The study included 200 households from
Canning rural Community Development Blocks of South 24 Parganas District. From thesehouseholds 200 women fulfilling the inclusion criteria were interviewed. Sixty women (80%)
were married. The mean age was respondent mothers was 32 years, about 164 (82%) of
the women was illiterate, only 36 (18%) of women have formal education. Most of thewomen were housewives. Daily labourer was the major economic activity of thehouseholds.
Table 06: Socio-Economic Class using Wealth Index
Wealth Index
No. of House hold
Percentage of House hold
Quintile 1 Poorest
28
14
Quintile 2 Poor
132
66
Quintile 3 Middle
40
20
Total
200
100
Source: Computed by Authors, 2020

Among the women included the primary survey (Table 7) regarding affordability
issues, there was large variation in monthly maternal health expenditures and total
household expenditures among those in the lower and upper quintiles. Households of lower
wealth quintiles were found to be paying relatively significant than those found in the higher
quintiles. The median monthly household proportion of expenditures for the first quintile
2650 rupees, while households in the third quintile spend two and half times more thanthose in the first quintile. Similarly, the median maternal out of pocket expenditure acrossthe wealth quintiles had an increasing pattern as the wealth quintiles increased. The
absolute expenditure of third quintile the proportion of their monthly income was found tobe lower for those in the higher income quintile compared to the percentage of expenditure.
The percentage share of maternal health care expenditure decreased as the wealth index
increased. Women from the two lower quintiles on average paid 43.25% of theirexpenditure for maternal care while those in the third quintile paid 13.5 % of theirexpenditure respectively. Still maternal expenditures constitute substantial proportion of
expenditure and this is due to the fact that households do not solely depend on their regularmonthly income to pay unexpected health care costs. To finance the cost, they usuallyborrowed from relatives, neighbours or from local money lenders. In case, the expenditure
was so large that they could not finance by these means they resort to sell their assets.
Table 07: Average Monthly Total and Maternal Health Expenditures across Wealth
Quintiles at Different Health Public and Private Health Facilities of Women
Wealth Quintile

Total
Expenditure
MedianQuintile 1 Poorest
2650
Quintile 2 Poor
4000
Quintile 3 Middle
6000
Source: Computed by Authors, 2020

Monthly HealthExpenditure
Median
200
450
1000

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Maternal healthExpenditure
Median60
300
600Percentage ofMaternal HealthExpenditure
17.5
69
13.5

The main source of finance to the health service of women in the first and second
quintile proportion borrowing from relatives, while for the third quintile proportion sellinghousehold items and animals. Borrowing from money lenders was found to be the lastresort since the households had no capacity to pay the high interest rate. Rather thanborrowing from the money lenders they preferred to sell articles. They did not solely dependon one source of finance rather they were found to use multiple sources.
Table 08: Main Source of Finance for Health Care Services of Women
Source of Finance

Own savings
Out of regular income
Borrowing from relatives
Borrowing from money lenders
Selling household items and animals
Selling land of family
Source: Computed by Author, 2020

Number of Women in each Wealth Quintile
Quintile1
Quintile 2
Quintile 3
Total(Poorest)(Poor)(Middle)N(28)N(132)
N(40)
2
7
7
16
2
19
8
29
9
53
8
70
6
15
6
27
4
27
9
40
5

11

2

18

Utilization of health and family planning service was found to be low among the
respondent households. In addition, there are indirect cost of seeking health even if out of
pocket expenditure at point of service was assumed to be negligible such as travel, distanceand time etc. The opportunity cost of care seeking to the patient or the attendant will besignificant since the economic activity was mainly labour. Thus these costs are among thefactors that are found to discourage utilization. Out – of pocket payments were the common
way of paying for health in developing countries (Akalu. et.al. 2012). These payments havedifferential impact with respect to health outcomes, usually out-of- expenditures results infinancial difficulty by households and these health expenditures poses a major setback to
the proper utilization of health care services for a backward rural area where bulk of thehouseholds are in the poorest quintile.
Findings and Conclusion
The study provides an analytical discussion on the financial barriers to access to healthcare services of women with regard to a Canning-I rural community development blocks inWest Bengal state of India. The distribution of out –of –pocket expenditure across thewealth quintiles shows that households having poor socio-economic pay more than theircounter-parts in absolute terms. Maternal expenditures constitute substantial proportion of
expenditure and this is due to the fact that households do not solely depend on their regularmonthly income to pay unexpected health care costs. The health care cost depends on thesocio-economic status of the population. However, the proportion of out of pocket
expenditure from their total consumption expenditure is higher for the worse-off implying
out-of-pocket expenditure regressive. Thus the poor are the most vulnerable as they areless able to recover from financial consequences of out-of-expenditure. The financing
system of health care should be based on the principle of cost sharing so that there will beresource pooling among poor and the rich. The government should work the private sector
to increase the availability of health services and health care resources including the humanresources through private wing and out-sourcing.
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