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Will a Wealthier India be a Healthier India?. Jishnu Das, Shanta Devarajan, Jeff Hammer, Lant Pritchett. India has been growing rapidly since the 1980s…. And increases in income have translated into. Higher life-expectancy (population sized circles, India is big blue, China big red.

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will a wealthier india be a healthier india

Will a Wealthier India be a Healthier India?

Jishnu Das, Shanta Devarajan, Jeff Hammer, Lant Pritchett

slide9
Reason 1: Improving health outcomes further may require substantially higher investments in public health services…
reason 2 morbidity is taking a toll on india s productive capabilities

50th %tile

90th %tile

75th %tile

90th %tile

50th %tile

75th %tile

25th %tile

25th %tile

Reason 2: Morbidity is taking a toll on India’s productive capabilities
reason 3 and the poorest 20 are not doing that well at all worse than bgd

Vietnam (poorest 20%)

Bangladesh (poorest 20%)

India (poorest 20%)

Reason 3: and the poorest 20% are not doing that well at all (worse than BGD)…
but we have known this for 60 years
But we have known this for 60 years
  • “If it were possible to evaluate the loss, which this country annually suffers through the avoidable waste of valuable human material and the lowering of human efficiency through malnutrition and preventable morbidity, we feel that the results would be so startling that the whole country would be aroused and would not rest until a radical change has been brought about.”
  • Bhore Committee Report 1946
a roadmap
A Roadmap
  • Three things you should know about the Indian health system (and are fairly well known by now)
  • Four more things you should know about the Indian health system (and are fairly new)
  • What doesn’t work (but is often done)
  • What might work
the indian health system according to the mindset at least on record
The Indian health system according to “The Mindset” (at least on record)

The system is “Pyramidal”

Basic Care is universally given by the state

  • Most people use public facilities
  • The private sector is just “quackery and crookery”
  • Sub center for every 5,000 people
  • PHC for every 30,000 people etc. etc.
  • Integrated referral chain
mindset at least on record
Mindset (at least on record)

Poor people rely on the public system & the benefits of public care mostly accrue to them

slide19

IF we spend the equivalent of one box on Population based public health….

We spend 3 on Preventive Health care

Hospitals

Public Curative Care is 20 boxes

8 on PHC’s

And….

12 on Hospitals

PHC’s

Private Care

“Public health” is 4 boxes

Preventive/Promotive Public Health

Population based public health

and its becoming even more private
And its becoming even more private
  • The public share of institutional deliveries (of babies) fell from 57.3 to 48.2% between 1992 and 1998 (NFHS I, II)
  • The public share of all deliveries fell between 1998 and 2001 (RCH I, II) as the private sector’s share rose from 9.4 to 21.5%
  • Recall: Pay commission raises of 1997 makes this unlikely to be due to lack of money – health ministries are very labor intensive
slide27
Fact #3: More public money on health goes to the rich than the poor (because hospital use is regressive)
one reason that is often given to explain why the poor have worse health outcomes

Poor people don’t use doctors and health facilities…that’s why they have worse health outcomes

One Reason that is often given to explain why the poor have worse health outcomes
recent data show that
Recent data show that…
  • Households in Rajasthan visit doctors more than in the U.S.
    • And the differences between rich and poor in visits to health providers is small
  • In Delhi, the poor go to doctors more than the rich
  • Click here to see a table looking at doctor visits from Delhi
despite the frequent use of health care providers

Distribution of t-tests of the variable “any public facility in village” on rural infant and child mortality. All states, various specifications, NFHS 1998 (propensity score matching*)

Despite the frequent use of health care providers
  • There is no relationship between the presence of health facilities and health outcomes
reason 1 public doctors in india are among the most absent in the world
Reason 1: Public Doctors in India are among the most absent in the world

Absenteeism among health workers

reason 2 when public doctors do show up for work the exert very little effort
Reason 2: When public doctors do show up for work, the exert very little effort

What they

do

What they know

“Effort deficit”

reason 4 and you still have to bribe public doctors to do their work

Money value of “donation” payments

Health 27%

Ration Shops 4%

Education 12%

Taxation& Land Admn. 17%

Police & Judiciary 15%

Telecom & Rail 5%

Power 20%

Reason 4: And you still have to bribe public doctors to do their work
a summary of why poor people may not be using the phc system
A summary of why poor people may not be using the PHC system
  • The doctors are low on competence
  • They don’t show up for work
  • When they do show up, they don’t work to the level of their knowledge
  • And patients have to pay bribes anyway
one oft advocated solution
One oft-advocated solution
  • That probably does not work
  • Training Doctors
training and the invisible hand
Training and the Invisible Hand
  • With public doctors, problem is NOT that they don’t know what to do, its that they don’t do it!
  • No public doctor needs training to know that he/she should come to work!
  • Yet…
training and the invisible hand ii
Training and the invisible hand (II)
  • The percentage of essential care given by a doctor with 6 months training in the private sector = the percentage of essential care given by a doctor with 5 years training in the public sector…
the losses from low effort

Lost Training: Private

Additional Lost Training: Public

The losses from low effort
training and the invisible hand iii
Training and the invisible hand (III)
  • If we train doctors in the private sector, what guarantees that they will practice in ways commensurate with their training?
approaches to a solution
Approaches to a solution

India’s public health system bundles five potentially separate components:

  • Hospital-based curative care
  • Ambulatory curative care
  • Prevention and health promotion
  • Health-sector-based public health (disease surveillance, etc.)
  • Non-health-sector based public health (safe water, sanitation)
the solution is the problem
“The solution” is the problem
  • The “mindset” of universal, hierarchical, poor oriented public production of health care is now only the planner’s fantasy
  • “Deer in the headlights” of reform
  • “System” reform cannot work as there is no coherent system
  • Must be broken to be reset.