Chettinad Health City Medical Journal

Volume 12, Issue 1 - 2023, Pg. No. 54-64

Peer Reviewed & Open Access Journal
Research Article

Utilisation and Out-of-Pocket Expenditure for

AYUSH Outpatient Care among Older Adults
in India
Roopali Goyanka1, Jeetendra Yadav2, Manoj Kumar3, Surendra Kumar Sagar4
1
Associate Professor, Department of Economics, Indraprastha College for Women, University of Delhi, Delhi-110054, India.
2
Technical Officer, ICMR-National Institute of Medical Statistics, Ansari Nagar, New Delhi-110029, India.
3
Assistant Professor & Biostatistician, ACentre for Economic Studies & Planning, School of Social Science, B School of Life Science,
Jawaharlal Nehru University, New Delhi, India.
4
Department of Zoology, Swami Shraddhanand College (University of Delhi), Delhi, India.
DOI: https://doi.org/10.24321/2278.2044.202310

I N F O A B S T R A C T

Corresponding Author: Background: Traditional, complementary, and alternative medicine

Manoj Kumar, ACentre for Economic Studies & are known to be used across the world for many types of diseases.
Planning, School of Social Science, B School of In India, they are referred to as AYUSH and are known to be used for
Life Science, Jawaharlal Nehru University, New promotive, preventive, and curative purposes for healthy living and
Delhi, India. well-being. This study looks at the levels, patterns, and determinants
E-mail Id: of utilisation and out-of-pocket expenditure for AYUSH outpatient care
manojdiwakarstat@gmail.com among older adults in India.
Orcid Id:
Method: Descriptive analysis, data visualisation, and bivariate and
https://orcid.org/0000-0001-6444-8160
multivariate logistic regression analysis have been used.
How to cite this article:
Goyanka R, Yadav J, Kumar M, Sagar SK. Utilisation Results: The utilisation for AYUSH care is found to be quite low at 8.2%
and Out-of-Pocket Expenditure for AYUSH among 52% of respondents in the sample who sought outpatient care
Outpatient Care among Older Adults in India. during the reference period. The study found the mean OOPE for AYUSH
Chettinad Health City Med J. 2023;12(1):54-64. to be ₹ 687 per episode, in comparison with the overall mean OOPE
of ₹ 1239 per episode for all types (allopathic and AYUSH combined)
Date of Submission: 2023-02-27 of outpatient care.
Date of Acceptance: 2023-03-24
Conclusions: Despite the policy support for the promotion of AYUSH by
the Government of India for a long time, and the common knowledge
about the affordability and low cost of AYUSH care, utilisation of
AYUSH healthcare remains low. Evidence-based studies on the efficacy
and safety of AYUSH treatment, promotion of cross-referral between
different streams of medicine, and standardisation of AYUSH medicines
can help to build trust and boost utilisation of AYUSH care.
Keywords: AYUSH, Traditional, Complementary, and Alternative
Medicine, Outpatient Care, Healthcare Utilisation, Out of Pocket
Expenditure, Older Adults

Chettinad Health City Medical Journal (P-ISSN: 2277-8845 & E-ISSN: 2278-2044)
Copyright (c) 2023: Author(s). Published by Advanced Research Publications
 Goyanka R et al.
55 Chettinad Health City Med. J. 2023; 12(1)

Introduction incurred on these services by the users, socioeconomic and

demographic profile of the users, and the types of ailments
In spite of the stupendous success of modern allopathic
for which use of AYUSH care is more prevalent. The role of
medicine in treating diseases and improving longevity, it is
insurance and preventive care on the magnitude of out-
unable to fully cope with the growing epidemics of chronic
of-pocket expenditure is also not known.21,15
illnesses and is also known to have toxic side effects and
iatrogenic disorders in some cases.1,2 When allopathy fails This paper aims to fill this gap in knowledge by looking
to deal with the disease burden and unmet needs of the at the level and pattern of utilisation and out-of-pocket
patients, they take recourse to traditional medicine for expenditure (OOPE) on AYUSH healthcare among the elderly
managing their health conditions.3 Traditional medicine, population of India using a nationally representative sample.
described as the sum total of indigenous knowledge and The study also analyses the types of diseases, the purpose,
practices used in the maintenance of health, is used by a the demographic and socio-economic profile of users, and
large number of the global population. the factors that determine the choice of AYUSH care.
In the United States, 33% of adults suffering from painful This study is important because AYUSH is said to provide
conditions like arthritis were found to make use of natural, low-cost healthcare, and serve as a system of
acupuncture and herbal medicines,4 15% of Canadians primary healthcare by providing culturally acceptable care
suffering from asthma and migraine were estimated to have to the under-served population.22 Its use is found to be
visited a complementary/ traditional medical practitioner,5 quite prevalent among the elderly population as it helps
during the 2015-16 dengue epidemic in Malaysia, a high in promoting well-being and managing chronic conditions,
prevalence of traditional medicine usage was observed,6 the hence the study of utilisation of AYUSH healthcare among
prevalence of complementary medicine utilisation among elderly adults has a special significance.
adults and children has been reported in Korea,7 and use Methodology
of alternative medicine has been found to be important
in the management of diabetes mellitus among Nigerian Data Source
patients.8 This study was based on the nationally representative
India is the cradle of the most ancient system of traditional cross-sectional survey data of 72,250 adults who are 45
medicine – Ayurveda, in the world. It is known to be used years or older across all states and union territories of
in India and many other countries to foster health and India. These subjects were chosen from 42,949 households
well-being.9,10 Besides Ayurveda, Indian people use five during 2017-18 from the first wave of the Longitudinal
other traditional methods of healthcare and promotion: Ageing Study in India (LASI). LASI is an ongoing study in India
Yoga, Naturopathy, Unani, Siddha, and Homeopathy. The that involves the collection of data regarding the health,
Indian policy documents consider all of them under one economic, psychological, and social well-being of people
umbrella and refer to them as AYUSH,11 but not much is aged 45 years and more. At present, data are available only
known about the extent, pattern, and costs associated with for the first wave. The sample was collected from all over
their usage. A study of cancer patients in Kerala found the the country using a multistage stratified area probability
use of AYUSH treatment along with allopathic treatment cluster sampling design.23 India-level weights were used
by patients;12 another study looked at the utilisation of hence the estimates are nationally representative. The
services and client satisfaction by patients attending a public inclusion criterion for the sample was the individuals who
AYUSH hospital in Delhi.13 Even during the recent COVID-19 chose AYUSH care for outpatient healthcare.
pandemic, studies found the use of yoga and self-care by Outcome Variables
respondents an effective strategy for mental and physical
AYUSH Utilisation (AU)
well-being.14-16 Such studies are, however, few in number
and lack population-based descriptions. The respondents were treated as utilising AYUSH care if they
consulted an AYUSH practitioner for seeking outpatient care
The Government of India has also been promoting AYUSH
during the reference period of the last 30 days.
care through various policy measures such as the National
AYUSH Mission,17 budgetary support for the Ministry of Out-of-pocket Expenditure on AYUSH for
AYUSH,18 and mainstreaming of AYUSH care at public Outpatient Care
healthcare facilities.19 Recently, the Government of India, For outpatient care, information was available for
in collaboration with the World Health Organization, also expenditure on consultation fees for doctors, medicines
established the WHO Global Centre for Traditional Medicine and diagnostic tests, medical items like blood, oxygen etc.,
in Gujarat, India with budgetary support of USD 250 transportation, and expenses incurred by the attendant.
million.20 Not much is known about the outcome of these Out-of-Pocket expenditure (OOPE) on AYUSH was estimated
policies in terms of utilisation of AYUSH care, expenditure

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as the total expenditure on these items for using outpatient determined the choice of outpatient healthcare between
care while visiting an AYUSH practitioner. allopathic and AYUSH care. All analyses were carried out
Consent to Participate and Ethics Approval on STATA 13.1.24 Figure 1 shows the flowchart for selection
of the sample for the study.
The present study used data from LASI (2017-2018). Firstly,
the LASI obtained ethical consent from the Institutional Results
Review Committee before the survey. Secondly, the LASI Sociodemographic Characteristics and OOPE for
study was approved by the Indian Council of Medical Patients using AYUSH Healthcare
Research (ICMR) Ethics Committee. Thirdly, during the Table 1 describes the socio-demographic characteristics of
survey, usually written consent had been taken by the patients using AYUSH healthcare for outpatient care. AU
respondent once they agreed to take part in the study. was higher (62.7%) among females compared to males
Therefore, no ethical approval is required separately for (37.3%). Almost two-thirds of all the individuals having AU
the current study. had low levels of education (primary or below) and lived in
Statistical Methods rural areas. The largest number of AYUSH users lived in the
Descriptive analysis was used to look at the socio-economic Western states, followed by Central and Eastern states in the
and demographic profile of individuals using AU, types of country. Among all the users seeking care from an AYUSH
ailments, and types of healthcare facilities for which AYUSH practitioner, about 86% visited private health facilities. The
care was being utilised. Mean OOPE on AYUSH was also mean OOPE for AYUSH care was ₹ 686 per episode. Mean
estimated for different socio-economic groups of people OOPE was found to be increasing across MPCE quintiles.
and across types of ailments and healthcare facilities. The mean OOPE per episode at private facilities (₹ 721) was
Logistic regression was used to analyse the factors that 1.6 times than that at public hospitals (₹ 448).

Figure 1.Analytical Sample

Table 1.AU and OOPE for Outpatient AYUSH Care - Socioeconomic Profile

Sample Utilisation of AYUSH Healthcare (AU) OOPE (₹)

Socio-economic Characteristics
n %, [95% CI] Mean, [95% CI]
Age group (years)
≤ 60 1,233 53.9, [53.8-54.0] 641, [563-719]
61- 80 806 42.2, [42.1-42.3] 757, [612-902]
≥ 81 80 3.90, [3.89-3.92] 537, [362-712]
Gender
Male 791 37.3, [35.3-39.4] 638, [518-759]

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Female 1,328 62.7, [60.6-64.7] 713, [621-804]

Marital status
Single 489 25.2, [25.1-25.2] 812, [627-997]
Married 1,630 74.8, [74.7-74.9] 645, [569-722]
Education
Illiterate 969 45.7, [43.6-47.9] 687, [580-793]
Primary completed 527 24.9, [23.1-26.8] 672, [540-805]
Middle completed 193 9.1, [8.0-10.4] 770, [487-1052]
Secondary completed 223 10.5, [9.3-11.9] 742, [413-1071]
Higher secondary and above 207 9.8, [8.6-11.1] 594, [477-712]
MPCE quintile
Poorest 357 16.8, [15.3-18.5] 454, [391-517]
Poorer 467 22.0, [20.3-23.9] 886, [670-1101]
Middle 501 23.6, [21.9-25.5] 576, [502-650]
Richer 448 21.1, [19.5-22.9] 627, [510-743]
Richest 346 16.3, [14.8-18.0] 908, [634-1182]
Place of residence
Rural 1,511 71.3, [69.3-73.2] 680, [594-765]
Urban 608 28.7, [26.8-30.7] 710, [572-849]
Geographic region
North 157 2.98, [2.97-2.99] 773, [596-950]
Central 603 32.41, [32.38-32.43] 590, [495-686]
East 460 21.74, [21.72-21.76] 560, [431-690]
Northeast 55 0.60, [0.60-0.61] 839, [565-1113]
West 481 33.21, [33.19-33.24] 731, [600-862]
South 293 8.84, [8.83-8.86] 888, [551-1226]
Union territories 70 0.21, [0.21-0.22] 2973, [1312-4634]
Type of healthcare facility
Public 270 8.16, [8.14-8.18] 448, [294-603]
Private 1,713 85.98, [85.97-86.01] 721, [637-805]
Pharmacy 48 1.98, [1.98-1.99] 513, [299-727]
Others 88 3.87, [3.86-3.88] 438, [291-586]
Payment support
Reimbursement from
- - -
insurance/ employer
Total 2119 100 686, [613-758]

Types of Healthcare Facilities for Utilisation of as demonstrated by regular check-ups and immunisation
AYUSH for OPD (the percentage adds up to more than 100% because
individuals may be visiting the AYUSH practitioner for more
Figure 2 shows that most persons (86%) visited a private
than one purpose).
healthcare facility for AU and 1.98% used a pharmacy for
a healthcare facility for utilisation of AYUSH. AU and OOPE by Types of Ailments
Figure 3 shows that most persons (84%) used AYUSH care for Among all those who used outpatient care in the reference
curative care as they see the provider when sick. Utilisation period of the last 30 days, 8% used AU (Table 2). The greatest
for promotive and preventive care was undertaken by 13% utilisation was by those suffering from fever (33%), chronic

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pain of the joints or muscles (20%), and generalised pain diabetes (Figures 4(a) and 4(b)). The mean OOPE per
of the stomach or head (14%), among those choosing AU. episode for AYUSH care was ₹ 461 for fever, ₹ 1085 for
Among those suffering from fever, gastroenteritis and vector-borne diseases, and ₹ 1135 for depression, anxiety
chronic communicable diseases, and vector-borne diseases, and sleep disorders, while OOPE for both allopathic and
about 9-10% of individuals chose AU over allopathic care AYUSH care for these diseases were ₹ 594, ₹ 1595 and ₹
in each type of disease category. The lowest utilisation 1708 respectively (Table 2).
was for diseases like cancer, cardiovascular diseases and

Figure 2.Types of Healthcare Facilities for Utilisation of AYUSH for OPD

Figure 3.Purpose of Visit

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Table 2.Utilisation of AYUSH Healthcare and OOPE by Types of Ailments

Outpatient Utilisation
and OOPE for All Types Utilisation (AU) and OOPE for AYUSH
(Allopathic + AYUSH) Care

Types of Diseases Share of

Share in total AU in total Mean
Utilisation Mean OOPE Utilisation
AU outpatient OOPE (₹)
(n1) (₹) [95% CI] (n2)
(%) utilisation [95% CI]
(n2/n1) (%)
Communicable diseases
594 33.14 9.85 461
1. Fever 10,201 664
[564-624] [33.11-33.17] [9.85-9.86] [389-533]
Gastroenteritis
& other
1667 3.85 9.8 629
2. acute/ chronic 1,190 77
[1346-1987] [3.84-3.86] [9.78-9.83] [396-863]
communicable
diseases
1047 2.89 12.26 860
3. Skin diseases 714 58
[899-1195] [2.88-2.9] [12.22-12.3] [395-1325]
Dengue, malaria
1595 1.8 9.32 1085
4. & other vector- 585 36
[1326-1864] [1.79-1.81] [9.28-9.36] [151-2019]
borne diseases
Respiratory tract 1092 0.57 3.98 504
5. 435 11
infection [804-1380] [0.57-0.58] [3.95-4.01] [149-859]
1347
6. Tuberculosis 117 - - - -
[910-1783]
Urinary tract 2704 0.82 8.0 373
7. 312 16
infection [1948-3460] [0.82-0.83] [7.95-8.05] [143-603]
851 43.07 9.64 529
8. Total (1-7) 13,554 863
[802-901] [43.04-43.1] [9.63-9.65] [452-605]
Non-communicable diseases
Chronic pain
1199 19.71 11.69 761
9. (joints, back, 5,117 395
[1094-1305] [19.68-19.73] [11.68-11.71] [580-943]
neck, muscle)
Hypertension,
1347 5.39 4.29 561
10. cardiovascular 3,810 108
[1257-1437] [5.38-5.41] [4.28-4.3] [445-677]
diseases
Ear, eye, mouth 1397 4.17 6.02 724
11. 2,098 83
& teeth diseases [1235-1559] [4.15-4.18] [6-6.04] [308-1140]
Respiratory 1469 3.46 8.86 630
12. 1,187 69
problems [1218-1720] [3.45-3.47] [8.83-8.88] [527-733]
Diabetes,
1613 2.19 3.14 800
13. nutritional 2,119 44
[1469-1757] [2.19-2.2] [3.13-3.15] [499-1101]
malfunctions
1164 1.6 8.48 476
14. Gastritis/ acidity 570 32
[891-1437] [1.59-1.6] [8.45-8.52] [139-812]

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2052 1.19 8.55 870

15. Liver diseases 423 24
[1401-2703] [1.19-1.2] [8.5-8.59] [45-1696]
Depression,
1708 1.15 10.47 1135
16. anxiety & sleep 334 23
[1391-2025] [1.15-1.16] [10.42-10.52] [341-1930]
disorders
3895 0.56 5.86 1824
17. Stroke/ paralysis 291 11
[2894-4895] [0.56-0.57] [5.81-5.9] [110-3757]
3358
13286 0.03 0.85
18. Cancer 103 1 [2960-
[5969-20603] [0.03-0.03] [0.82-0.88]
3756]
39.46
1497 7.46 747
19. Total (9-18) 16,052 791 [39.43-
[1416-1579] [7.45-7.46] [631-864]
39.49]
Injury
1932
2.4 6.62 761
20. Injury, accident 1,100 [1512-2353] 48
[2.4-2.41] [6.6-6.64] [188-1333]
Others
Generalised
837
pain (stomach,
[775-899] 13.69 11.31 900
21. headache, other 3,671 274
[13.67-13.71] [11.29-11.33] [607-1192]
non-specific
pain)
1629 0.98 5.35 772
22. Other diseases 783 136
[1327-1931] [0.98-0.99] [5.33-5.38] [442-1102]
1227 15.07 [15.04- 10.27 870
23. Total (21-22) 4,454 410
[1084-1369] 15.09] [10.25-10.28] [641-1100]
1239 8.20 687
Total 35,160 2,004 100
[1189-1289] [8.19-8.22] [614-760]

Figure 4(a).Top 5 Communicable Diseases (In Terms of Figure 4(b).Bottom 5 Non-communicable Diseases (In
Number of Persons) for AYUSH Care Utilisation Terms of Number of Persons) for AYUSH Care
Utilisation

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Table 3.Factors affecting the Choice of AU

Choice of AU
Socioeconomic Characteristics
Unadjusted OR Adjusted OR
Age group (years)
≤ 60
61-80 1.101 [0.967-1.253] 1.10 [0.95-1.273]
≥ 81 1.057 [0.78-1.433] 1.13 [0.792-1.611]
Gender
Male
Female 1.093 [0.964-1.238] 1.165** [1.013-1.339]
Marital status
Single
Married 0.989 [0.852-1.148] 0.949 [0.799-1.127]
Education
Illiterate
Primary 1.049 [0.903-1.219] 1.162* [0.986-1.369]
Middle 0.964 [0.777-1.197] 1.198 [0.946-1.517]
Secondary 0.996 [0.786-1.264] 1.481** [1.154-1.9]
Higher secondary and above 0.956 [0.756-1.209] 1.446*** [1.123-1.861]
MPCE quintile
Poorest
2nd poorest 1.161 [0.956-1.41] 1.114 [0.906-1.368]
Middle 1.127 [0.936-1.357] 1.082 [0.883-1.325]
2nd richest 0.869 [0.718-1.052] 0.82* [0.664-1.012]
Richest 0.635*** [0.508-0.795] 0.661*** [0.517-0.844]
Place of residence
Rural
Urban 0.59*** [0.512-0.678] 0.469*** [0.398-0.552]
Geographic region
North
Central 8.111*** [6.472-10.164] 7.553*** [5.933-9.615]
East 3.299*** [2.616-4.16] 3.03*** [2.358-3.893]
Northeast 0.875 [0.574-1.333] 0.934 [0.584-1.495]
West 9.275*** [7.366-11.679] 6.932*** [5.428-8.852]
South 1.523*** [1.183-1.961] 1.408*** [1.082-1.833]
Union Territories 0.888 [0.515-1.531] 1.673* [0.93-3.008]
Preventive
No
Yes 0.675 *** [0.585-0.779] 0.839** [0.715-0.983]
Main reason for the last outpatient visit
All other diseases
Chronic pain (arthritis, joint pain, backache) 2.036*** [1.684-2.461] 2.083*** [1.685-2.575]

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Diabetes 0.426*** [0.286-0.634] 0.484*** [0.315-0.744]

Fever 1.723*** [1.458-2.037] 1.423*** [1.186-1.707]
General pain (headache, stomach ache) 1.988*** [1.579-2.504] 1.936*** [1.522-2.463]
Hypertension 0.721**[0.547-0.95] 0.738** [0.55-0.989]
Other acute/ chronic communicable diseases 1.831** [0.989-3.392] 2.037** [0.993-4.179]
Skin diseases 1.816*** [1.142-2.889] 1.674** [1.056-2.655]
Upper respiratory tract infection 1.354* [0.946-1.936] 1.274 [0.884-1.836]
Distance to healthcare facility from
residence
Far (> 1 km)
Near (0-1 km) 1.396*** [1.228-1.587] 1.573*** [1.368-1.808]
Type of healthcare facility
Public
Private 4.079*** [3.292-5.055] 3.393*** [2.739-4.204]
Intercept 0.007*** [0.005-0.01]
Levels of significance: *p < 0.10, **p < 0.05, ***p < 0.01

Factors affecting the Choice of AYUSH Care education levels, and using private facilities have a greater
likelihood of using AYUSH care.
Table 3 shows the various factors that affect the choice
of AYUSH care. The odds of using AYUSH care are 53% The prime attraction of Ayurveda lies in its affordability,
greater for those living in rural areas. Females had 17% low cost, and low level of technological input. Ayurveda’s
greater odds of choosing AU in contrast to males. Those primary focus is on the prevention of diseases and then it
visiting public facilities or using healthcare for preventive looks to cure manifested diseases by avoidance of causative
purposes had lower odds of using AYUSH care at 16% and factors. Several studies have reported the benefits of
65% respectively. Individuals with chronic body pains were Ayurveda in communicable, neurological, and lifestyle
88% more likely to use AYUSH care, those with stomach diseases such as diabetes and obesity and preventive
pain, headache etc. had 70% more chance of using it, while care for holistic well-being. Ayurveda has given a practical
those suffering from diseases like hypertension were 31% explanation of communicable diseases and their prevention
less likely to use it. and cure in day-to-day life.25-29,15
Discussion But in spite of all these factors, utilisation of AYUSH
healthcare remains low. While there is a lot of anecdotal and
This study has used nationally representative data to
oral discussion about the use of herbs and other traditional
estimate the utilisation and OOPE for AYUSH care among
practices for promotive and preventive healthcare, there
older people in the country. For the year 2022-23, the total
is a general perception of distrust about the effectiveness
budgetary allocation by the Union Govt for the Ministry
of AYUSH care in the minds of the people.30 It is essential
of AYUSH is ₹ 3050 cr and there are 3859 hospitals, 29951
to promote the use of evidence-based health practices for
dispensaries, 712132 practitioners, and more than 18
dispelling this distrust. Good clinical practice guidelines,
million patients for AYUSH. Despite the impetus through
clinical safety, and efficacy documentation for AYUSH care
budgetary allocation, creation of service infrastructure, and
are needed, for it to be adopted as a mainstream treatment
mainstreaming of AYUSH in public facilities, this study found
protocol.31 Systematic research for yoga by Dean Ornish has
that utilisation of AYUSH care remains low at 8.2% of the
helped to demonstrate the efficacy of yoga on the reversal
total persons utilising outpatient care in the sample. The
of heart disease and downregulation of oncogenes and has
mean OOPE on AYUSH at ₹ 687 per episode is lower than
made it popular in some societies.30
the mean OOPE on all types of care at ₹ 1239 per episode
for all types of diseases. For a common disease like fever Integration of AYUSH with various cadres of outreach
or acute communicable diseases which have a high share workers like accredited social health activists, promotion
of utilisation in AYUSH care, the mean OOPE for AYUSH is of cross-referral between various streams of medicine,
lower than that for all types of care. People living in rural scientific validation and documentation of AYUSH drugs,
areas, or far away from healthcare facilities, having lower ensuring purity, safety, standardisation, and preventing

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63 Chettinad Health City Med. J. 2023; 12(1)

counterfeiting of AYUSH medicines are needed to build 4. Valiathan MS. Towards ayurvedic biology: a decadal
trust and boost utilisation of AYUSH care.32 A study showed vision document [Internet]. Bangalore, India: Indian
that utilisation of any type of healthcare gets positively Academy of Sciences; 2006 [cited 2023 Feb 19]. Available
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