Health ‘seeking’ behavior
As health systems become more and more complex, navigating the system becomes challenging for people. It becomes critical to understand the health seeking behavior of people, while making any strategic plans to strengthen health systems. People tend to fall back on their family, near relatives, neighbors, self-help groups or friends for guidance, more so if they are from medical profession. People in villages seek out informal practitioners (RMPs) for guidance. Increasingly people are seeking help from community health workers such as ASHA workers and ANMs. People in urban areas reach out to general practitioners (GPs) in their neighborhood. There is a growing trend towards online search, especially amongst youth. Many organizations have started engaging medical officers in their dispensaries or clinics to their employees and their dependents for guidance.
The experience people have in their encounter with a doctor or hospital or pharmacy or diagnostic center is the most powerful determinant of whether they go back to them again or they refer someone to them. Like many other service industries, private healthcare providers are focusing more and more on the experience of their customers. As stories of inappropriate tests, drugs, and procedures become common knowledge amongst people, the trust in provider systems has been gradually declining over time. As people become more aware of widely prevalent referral practices in private practices, their trust in both informal and formal first responders is diminishing. Increasingly, people are seeking out providers whom they can trust.
People seek healthcare to get relief from their suffering and to save them from serious illnesses. They need to have the confidence in their doctor or hospital to provide safe and effective care. The reputation of a doctor or a hospital is based on the outcomes that they give and is built over a period of time through word of mouth. People do not mind travelling long distances just to see a doctor whom they trust and have confidence in. This aspect of health seeking behavior has to be kept in mind in any health system design effort.
Another important criterion is the ease of access, especially during emergencies. People are gradually getting used to the convenience of getting various online services wherever and whenever they need them. The Covid-19 pandemic has further accelerated the already growing trend of seeking healthcare online. Online platforms are also playing the role of a navigator, thereby widening the choices available to patients.
The cost of services is increasingly influencing people’s health seeking behavior. While trust and confidence in a provider to give safe and effective care dominates the behavior, people do look for high quality services for the lowest possible cost (so called value for money). Even though public healthcare services are free, people have gradually lost trust in them over time. The expectations of people are constantly rising with increasing exposure to higher quality of services. Public health insurance schemes like Arogyashree and PMJAY are exposing people from economically weaker sections to five-star corporate hospitals, thereby changing their perception of the quality of care. Even slight improvement in the quality of public healthcare services can change people’s behavior as they realize a higher value in improved public healthcare.
People with health insurance are obligated to seek services from empaneled hospitals, doctors, and diagnostic centers. People tend to opt for insurers who have their preferred providers in their empaneled list. People continue to take the opinion of the doctor whom they trust before they go through the recommended tests and procedures if it is not an emergency. Sometimes they are even willing to forego the insurance cover if they do not have trust in the empaneled providers. This might explain high underutilization rates witnessed in certain public or social health insurance schemes.
As the awareness on wellness and prevention is growing steadily and as market competition is driving the cost of these services lower and lower, more and more people are seeking wellness and preventive services. Master health checks, whole body scans, and genome patris are becoming highly popular. The advent of point of care tests and monitoring devices, wearable devices, and various self-care apps is inducing new health seeking behaviors in people. Google and social media are disrupting the information asymmetry between patient and provider, bringing in another dimension to health seeking behavior. Self-monitoring and self-medication are rising rapidly in recent years, more so after Covid pandemic.
Poor people at the bottom quintile do not have the luxury of free choice. Essentially, they have no choice! They forego seeking care lest they lose their daily wage. They may even lack the money to travel to a free facility. Their only recourse is to go to informal providers or quacks in their village or ward or to a functioning subcenter or PHC or to a mobile clinic. The middle class avoids public health because of crowding by those who cannot afford private healthcare. For the richest, it is the status symbol that they seek. They will have their whole genome sequenced because that is the new “in” thing. Thus, socio-economic status plays an important role in the health seeking behavior of people.
Health ‘purchasing’ behavior
People either purchase healthcare services or purchase health insurance products. If they can afford, people in general prefer to purchase services directly. It gives them the freedom of choice of a provider. As they witness catastrophic health expenses themselves or in the case of someone they know, they tend to hedge against the future risk by opting to purchase an insurance product. Over time people tend to make intelligent choices that give them the best value for the money spent. As healthcare markets move towards being a buyer’s market than a dominantly seller market and with the information to make choices becoming available online, people are having wider choices.
The health insurance market has been witnessing a double digit growth since its entry in the new millennium. It has been slowly adapting to the dynamic behaviors of both the beneficiaries and the providers. People have been adapting slowly to the evolving private health insurance market. They are slowly becoming discerning in choosing a policy. Just as in health seeking behavior, it is the collective experience of people with an insurer or a product that will determine their purchasing behavior. In early days, people learnt to conceal their preexisting diseases to avoid denial of a policy. However, as the regulations stipulated insurers not to deny service to such people, disclosure norms are improving.
Health financing behavior
It is also interesting to understand how people finance their healthcare needs. Traditionally, gold has been the hedge against emergency financial needs in India and continues to be so. In the absence of a public social security net, family, friends, relatives, and their community, form the main social net for a majority of people. The chit system is a unique financial safety net for small groups, acting both as a saving and borrowing instrument. It bypasses the formal banking system. People who do not have recourse to the above means end up borrowing money at very high interest rates or by mortgaging their land and dwellings. These are the people who are most likely to get into the debt trap. While consumer financing has matured for the purchase of vehicles, housing, education etc., health consumer financing is just beginning to take roots. With growing activity in the fintech space, more innovative health financing solutions may be available for people in future. In the near future, people may have many more choices of financing than what exists today. Government can also come up with programs to finance the unprotected needs of poor people.
In summary, any student of health systems should begin their study by understanding the dynamically evolving health seeking, purchasing and financing behavior of people. Health systems either evolve in response to the changing behavior or induce a change in people’s behavior.
Dr Krishna Reddy Nallamalla
President, InOrder,
Country Director, ACCESS Health International.
Photo Credits: USAID