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It’s broken: Health policy in India. Jeff Hammer Princeton University and NCAER Jishnu Das World Bank and Centre for Policy Research Delhi, 8 November, 2012. Problem #1. Problem #2: No one raised problem #1.

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It s broken health policy in india

It’s broken: Health policy in India

Jeff Hammer

Princeton University and NCAER

Jishnu Das

World Bank and Centre for Policy Research

Delhi, 8 November, 2012



Problem 2 no one raised problem 1
Problem #2: No one raised problem #1

  • Bhore committee 1946: Recommended integration of curative and preventive medicine at all levels with seamless referrals. Specific staffing per capita requirements for each level.

  • Mudaliar Committee 1962: noted PHC’s weren’t working but advised spending more on them anyway

  • Jungalwalla 1967: A service with a unified approach for all problems

  • Singh (1973), Shrivastav (1975), Bajaj(1986), plus four other reports all the same

  • Mid-term review 10th plan 2005: Sub center for every 5,000 people, PHC for every 30,000 people etc. etc., Integrated referral chain (virtually identical to Bhore on).

  • NRHM mission statement 2005: not much different but does mention water and sanitation (which may not have happened but a new line of health workers did)

  • Lancet (January 2011): “The time is right” for universal health care – which lead to:

  • High Level Expert Group (November 2011): ”Develop a National Health Package that offers, as part of the entitlement of every citizen, essential health services at different levels of the health care delivery system.” Oh, and “Reorient health care provision to focus significantly on primary health care.” while we “Ensure equitable access to functional beds for guaranteeing secondary and tertiary care.” By “increasing HRH density to achieve WHO norms of at least 23 health workers per 10,000 population” (i.e., Bhore if Xerox machines existed in 1946)

  • Einstein 1925 (possibly apocryphal, though true):“Insanity is doing the same thing over and over and expecting different results”


The big picture
The Big Picture

d(742 other things)

∂(Traditional (19th century) public health spending) ∂health spending

d(health status)

d(health spending)

×

∂(primary care spending) ∂health spending

d(financial protection)

∂(Hospital spending)

∂health spending


The big picture1
The Big Picture

d(742 other things)

∂(Traditional (19th century) public health spending) ∂health spending

d(health status)

d(health spending)

×

∂(primary care spending) ∂health spending

d(financial protection)

∂(Hospital spending)

∂health spending

A very long chain


Today s picture
Today’s Picture

∂Traditional (19th century) public health spending

d(health status)

d(health spending)

×

∂primary care spending


Pathway 1 most important very brief
Pathway 1: Most important (very brief)

∂(Traditional (19th century) public health spending)

d(health status)

d(health spending)

×

∂(primary care spending)


Health and sh stuff
Health and Sh... stuff

Open sewers

Garbage dumps


Pathway 2 old and new research
Pathway 2: Old and new research

∂(Traditional (19th century) public health spending)

d(health status)

d(health spending)

×

∂(primary care spending)




Unpacking primary care chain1
Unpacking Primary Care Chain

“Medicine” (even if ‘cost-effective’)


Working backwards1
Working backwards

  • One, of many, proximate cause of improved health may well be some medical intervention – mini-micro, “cost effective” components of “accurate advice”. But, as you’ll see, this pales to insignificance compared to all the other problems. So, I’m ignoring them.


Unpacking primary care chain2
Unpacking Primary Care Chain

Does increasing publicly supplied care increase total supply available to people?


Working backwards2
Working backwards

  • One, of many, proximate cause of improved health may well be some medical intervention – mini-micro, “cost effective” components of “accurate advice”. But, as you’ll see, this pales to insignificance compared to all the other problems. So, I’m ignoring them.

  • A “problem” repeated endlessly is that people have no “access” to medical care so there must be X public providers per Y inhabitants

  • Maybe we should ask:

    • Does this “ratio” policy make any sense? Even theoretically?

      • No. There is a very large literature on optimal number of firms in an industry. Ratios of suppliers to consumers have nothing to do with it.

    • Does this preoccupation have anything to do with reality?

      • No. Perhaps cause for mild embarrassment: In NO country can we answer the simple question “how many health care providers are there in an average village?”

  • It turns out that all these questions matter!


Mindset of ministry since bhore committee and of who to this day
Mindset of Ministry since Bhore committee (and of WHO to this day)

Health Centre

Everyone goes to the public health centre


The mindset continued
The mindset, continued

AIIMS

With a “seamless web of referral” through primary, more primary, secondary, tertiary, teaching



But what if1
But what if…

we look at the real world and find…


(results from MAQARI project)


With this sort of access to health care providers
With this sort of “access” to health care providers

Public providers

Private MBBS

households


But there s a larger village two miles away that most people go to when sick
But there’s a larger village two miles away that most people go to when sick

2 miles

With roads


And it has 1 public and 11 private real doctors
…and it has 1 public and 11 private “real” doctors people go to when sick

Public providers

Private MBBS


Plus 8 homeopaths 15 ayurveds a bunch of unani electro homeopaths integrated medics pharmacists
…plus 8 homeopaths, 15 people go to when sickAyurveds, a bunch of Unani, electro-homeopaths, “integrated” medics, pharmacists

Public providers

Private MBBS

Homeopaths

Ayurvedic / Unani


And a larger number altogether of people with no training at all
…and a larger number altogether of people with no training at all

Public providers

Private MBBS

Homeopaths

Ayurvedic / Unani

No degree or qualification at all


If we do the right counts
If we do the right counts at all

  • Availability in rural India is high

  • These numbers are providers within the village

    • Across the 100 villages studied in MP, 2.46 providers “in village” vs. 9.39 “in market”


Two things stand out size of market excess capacity
Two at allthings stand out Size of market Excess capacity


Market size the market is much bigger
Market Size: The market is much bigger at all

  • than the immediate village

  • than people trained in allopathy (even if that’s what they all practice)

    • What’s relevant isn’t merely that the public sector is small, it’s whether there is close substitution between them and their alternatives

    • This is hard to find out but people switch regularly, so there is likely a lot of substitution

  • And most people go to the private sector


What do market shares look like
What do market shares look like? at all

Primary Health Care

Doesn’t seem to matter how poor you are. But national average masks some interesting state variations.

Hospitals

Source: Calculations based on Mahal et al (2001)


Excess capacity
Excess Capacity at all

Leading to so many alternatives that public employees work 39 minutes/day – same as private providers (similar results from Tanzania, Senegal where doctor “shortage” is even more acute


We are not in this world anymore
We are not in this world anymore at all

Instead, we are here

Health Centre


Unpacking primary care chain3
Unpacking Primary Care Chain at all

So, this term could be really small. The public sector is just swamped by the private and the two appear to be substitutes


Aha you say but you just told us that many of these providers are quacks

“Aha!” You say. “But you just told us that many of these providers are quacks”

Let’s look at the prior link


Unpacking primary care chain4
Unpacking Primary Care Chain these providers are quacks”


Why don t people go to free public clinics instead of paying for quacks
Why don’t people go to free public clinics instead of paying for “quacks”?

  • In other words: “why can’t we even give this stuff away?”

  • Standard response from people working in public health:

    • People can’t tell good from bad

    • (We shall return to this later)

  • Let’s ask a different question


Phc s what do people find when they get there
PHC’s: What do people find when they get there? paying for “quacks”?

% of staff positions vacant

  • Vacancies


Phc s what do people find when they get there1
PHC’s: What do people find when they get there? paying for “quacks”?

  • Vacancies

  • Absent workers


Absence rates doctors

Absence rates – Doctors paying for “quacks”?

Source: Chaudhuryet al (2004)


Phc s what do people find when they get there2
PHC’s: What do people find when they get there? paying for “quacks”?

  • Vacancies

  • Absenteeism

  • Low capability

Just Delhi!


The competence of providers in delhi is very low in public and private sectors
The paying for “quacks”?competence of providers in Delhi is very low- in public and private sectors


Competence in vignettes rural madhya pradesh
Competence in Vignettes: Rural Madhya Pradesh paying for “quacks”?

MBBS providers (nearly all public sector!) are more competent than providers with other qualifications and provider with no qualifications


Phc s what do people find when they get there3
PHC’s: What do people find when they get there? paying for “quacks”?

  • Vacancies

  • Absenteeism

  • Low capability

  • Very little effort

CGHS facilities are in here


What does very little effort mean in delhi
What does “very little effort” paying for “quacks”?mean (in Delhi)?

Less than 2 minutes

Just one question


Very little effort in mp time spent
Very little effort in MP: time spent paying for “quacks”?



Know do gap in delhi
Know-do paying for “quacks”?gap in Delhi


Know do gap
Know-do gap paying for “quacks”?

  • And in Tanzania

  • And in Rwanda

  • And in Netherlands…..

  • We are beginning to see a pattern


Quality combining competence and effort with standardized patients

  • Standardized case-patient mix paying for “quacks”?

  • Incognito patients (SP) visit health providers

  • Quality can be measured by

    • Process measures

      • Completion of case-specific checklist items (history taking questions and examinations)

    • Diagnosis & Treatment

    • Effort: Time Spent by Providers

  • Harder to implement but provides a better overall measure of providers’ practice

Quality: Combining Competence AND Effort with Standardized Patients

Das and others, 2012.


Quality in mp
Quality in MP paying for “quacks”?

Public MBBS doctors, although most competent, they did the least and so are of the lowest quality in the entire sample.


In rural madhya pradesh unqualified practitioners do better than public phc providers on process
In rural Madhya Pradesh: Unqualified practitioners do better than public PHC providers on process…

Using Standardized Simulated Patients for asthma


D iagnosis and treatment a sthma in madhya pradesh
D than public PHC providers on process…iagnosis and treatment Asthma In Madhya Pradesh

Wrong

Right


Worse look at this for a heart attack
Worse! Look at this for a heart attack! than public PHC providers on process…

Based on 327 SP visits, no diagnosis given in 178 cases


Untrained providers beat the public sector in diagnosis
Untrained providers beat the public sector in diagnosis than public PHC providers on process…


Incentives must be at work somehow
Incentives must be at work somehow: than public PHC providers on process…

Mean


Public sector doctors do much better in their private clinics
Public sector doctors do much better in their private clinics

People have always known this:

“I know Mr. Reddy. He is a government doctor but I go to him in the evening.” (Probe Qualitative Research Team, 2002)


And it s the private sector overprescribing drugs
And it’s the clinicsprivate sector overprescribing drugs?


Phc s what do people find when they get there4
PHC’s: What do people find when they get there? clinics

Money value of “donation” payments

Health 27%

Ration Shops 4%

  • Vacancies

  • Absenteeism

  • Low ability

  • Low effort

  • “Donation” requests

Education 12%

Taxation& Land Admn. 17%

Police & Judiciary 15%

Telecom & Rail 5%

Power 20%

Source: Transparency International


Incentive problems
Incentive problems clinics

  • You are paid by salary

  • You are not monitored by supervisors

  • You will not be fired or have pay reduced under virtually any circumstances

  • You are of much higher social status and have much greater political power than your clients – complaints don’t touch you

  • You have lucrative alternative work in the private sector

    What would you do?


Unpacking primary care chain5
Unpacking Primary Care Chain clinics

Because of the long chain of things that can screw up – this can be a very small number


So why don t people go to free real doctors instead of quacks
So why don’t people go to (free) real doctors instead of quacks?

  • You haven’t been paying attention?

  • Ministry (and international organization) answers: People don’t know any better

  • Really?


Prices willingness to pay for quality
Prices: willingness to pay for quality quacks?

  • In fact, prices are significantly correlated with quality

Higher quality providers charge higher prices – this can’t happen without a demand response

This price-quality relationship is purged of case and patient selection problems


Prices and quality effort
Prices and Quality (effort) quacks?

Average Fees for MBBS

Average Fees for others


Why the divide accountability
Why the divide?: accountability quacks?

  • Private sector whether trained or not: to the patient (possibly “too much”)

  • Public sector hospital physicians (who do pretty well, all things considered, in Delhi)

    • To Supervisors in the same building (career track)

    • To Colleagues?

  • Public sector primary health care center doctors: ???


Summary public provision of primary health care
Summary: Public provision of Primary Health Care quacks?

  • It was never clear what “efficiency” gains, what “market failure”, this was supposed to fix

  • It is not obvious that poor people gain from such public provision of private goods (so what “equity” gains?)

  • It is very clear that this is a devilishly difficult program to implement – a fact that has been known for years decades

  • Why is this still such a high priority?

  • Why doesn’t the government make sure PUBLIC goods (that can’t even exist without government) before it spends a paisa on private goods?

  • Why are we still talking about this?


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