Health-care reform in India

1. Health-care reform in India Abhijit Vinayak Banerjee

2. Child health • 48% of children under 5 are stunted • 24% are severely stunted • 43% are underweight • 20% are wasted. • More than twice the rate in SSA • Worse than Pakistan • These numbers are more less representative of the middle wealth people • Under-5 mortality rate of 74: roughly twice that in China: recently surpassed by Bangladesh

3. Child nutrition • Less than a quarter of the women took iron pills for more than 90 days during pregnancy • Despite anemia rates of 50% or more • Only a quarter breast-fed the child within an hour of birth (lost colostrum) • Only 2 months of exclusive breast-feeding (six months recommended) • Late transitions to solid foods • Full immunization rates are still less than 45% for the country as a whole • 27% for Rajasthan: self-reported • In rural Udaipur district our estimate: 4.5%

4. What is the government doing? • ICDS and RCH • Anganwadi and the sub-center are the point of delivery. • 81% of children live near an anganwadi • 33% of children less than six received any services from an Anganwadi • 26% received some food supplements • 20% were weighed. Of those half were counseled after the weighing

5. Usage of the government health system • Out of 0.51 visit to a health provider, 0.12 are to a public facility, the rest to private doctors or traditional healers (Banerjee et al.) • Despite the fact that • Public practitioners are: • Closer • Better trained: • In private facilities 17% of primary doctors and 62% of secondary doctors in private facility have no medical training • 37% of primary doctors do not claim to have a college degree • Cheaper (client side reports)

6. One problem is demand • People wants shots and drips • The government nurses can only give tablets • Huge demand for curative rather than preventive services • The government rightly emphasizes preventive

7. One problem is quality • Udaipur Continuous facility survey: facility survey that cover all the sub-centers and PHC serving 100 villages, weekly, over a year. In 2003 • 56% of sub-centers are closed • 45% of nurses in sub-centers are absent… • 36% of medical personnel in CHC/PHC is absent • No predictability. • Das-Hammer provide data on patient-provider interaction in Delhi: • In half the visits public doctors don’t touch the patient • More recent work by Das and others

8. Why is quality so low: Results from an incentive experiment • The government of Rajasthan allowed to let an NGO, SevaMandir, to monitor nurses for presence and send them the results • Announced that nurses who are present less than 50% of the time will be suspended after the second month • Initial jump up in presence to over 60%

10. What happened? • Were sanctions not applied? • Initially they were applied. Some ANMs were given deduction. In one zone, deductions were more severe than what is imposed by the boss • Then the system was undermined from inside • In one sense the system is not meant to work: Employees are the top priority of the system

11. Register Records Machine problems Exempted days Casual Leave Absent Half day Present

12. The government’s response: Spending money • Huge expansion of health expenditure: extra expenditure of 1% of GDP under NRHM. • Now there is another very large expansion proposed in ICDS. • Also talk of “right to health”.

13. Why would that help? • The government’s theory that beneficiary control will do it. • User’s group • Making it justiciable • Under NRHM there are supposed to be beneficiary committees modeled on SSA

14. SSA • The Village Education Committees (VECs) were supposed to play a key role in SSA implementation (e.g in spending SSA funds). • In Uttar Pradesh the VEC is responsible for: Monitoring the performance of the schools; complaining about teacher performance to the higher ups if necessary. • Applying for and getting additional teachers for their schools, wherever needed.

15. Learning? • Learning is a huge problem • In Jaunpur district in UP in 2004… • 15 percent of children age 7 to 14 could not recognize a letter; • Only 39 percent could read and understand a simple story (of grade 1 level); • 38 percent could not recognize numbers. • Worse but comparable to all India ASER numbers. • Child attendance is 50%

16. People’s power? • The VEC is supposed to be the primary instrument through which parents can affect children’s education. • In UP it has 3 parent members + the head teacher + sarpanch (typically). Every village has a VEC • In 2005, 4 years after SSA was launched, a survey of more than a 1000 households found that 92% of parents in Jaunpur district have not heard of the SSA • 8% knew about the VEC • 2% could name a VEC member • ¼ of all VEC members do not know that they are SSA members • 3/4 of VEC members have not heard of SSA; 4/5 do not know that they can get money from the SSA; very few know that they can hire an extra Shikshamitra

17. A randomized experiment on community action • In 130 randomly chosen villages Pratham, an educational NGO, provided results (mostly dismal) about the state of education in the village and rights of villagers to complain/act under SSA • Knowledge of rights went up • No effect on any other outcome, neither grades nor any parental actions • In 65 more villages they recruited several volunteers through discussion of learning levels. • Given one week training on how to teach reading • Improved test scores very substantially

18. How about using the market? • Might work for some things • Lot of work going on the efficacy of private health insurance for in-patient care • Not much demand so far • What about Out-patient? • How will it generate behavior change? • The private market wants change in the opposite direction • Instead of ORS they want the diarrhea patients to get another antibiotic shot: already 60% go to a doctor • Lots of spillovers, including within the family • Boys get breast-fed longer. • Both these are also reasons why beneficiary control has limited effectiveness.

19. How about a “right to health”? • Guaranteed access to healthcare • Supplied by whom? • If it is the government can we deal with quality? • If it is the market (through insurance), how do we measure delivery • What people want is not always good for them • How do we deal with demand for unnecessary care • How we deal with fraud: Especially given the culture of cynicism around health care • Possibly a very limited right-built around IPD and catastrophic care.

20. What else: some thoughts for the future • Public health: • Sanitation and water quality • Food fortification for things like anemia • Designing new foods: For weaning for example • Reward pro-social behaviors • A simple gift of a kilo of dal for each immunization visit raised immunization rates from 4.5 to 45% in rural Udaipur Progresa • Be much more aggressive in creating demand: • Use the media more • Glamorize pro-social behaviors • Can be done by a centralized agency

21. And more • Build credibility: people do not believe what the govt says which is why public messages fail • Abandon programs that create suspicion (“cases”) • Deliver: that’s what creates the most cynicism • Focus: every budget starts a new program (often barely funded) • Remember that government capacity is very limited • Experiment before you go to scale: • Remember details matter and most things can be improved