It’s broken: Health policy in India

IT’S BROKEN: HEALTH POLICY IN INDIA

Jeff Hammer

Princeton University and NCAER

Jishnu DasWorld Bank and Centre for Policy Research

Delhi, 8 November, 2012

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

d(health spending)

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

∂(primary care spending) ∂health spending

∂(Hospital spending)∂health spending

d(health status)

d(financial protection)

d(742 other things)

×

𝜕health

𝜕 public go

ods×𝜕 pub

lic goods

𝜕 spending

×

The Big Picture

d(health spending)

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

∂(primary care spending) ∂health spending

∂(Hospital spending)∂health spending

d(health status)

d(financial protection)

d(742 other things)

×

A very long chain

𝜕health

𝜕 public go

ods×𝜕 pub

lic goods

𝜕 spending

×

Today’s Picture

d(health spending)

∂Traditional (19th century) public health spending

∂primary care spending

d(health status)

×

𝜕health

𝜕 public go

ods

Pathway 1: Most important (very brief)

d(health spending)

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

∂(primary care spending)

d(health status)

×

Health and Sh... stuff

Garbage dumps

Open sewers

Pathway 2: Old and new research

d(health spending)

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

∂(primary care spending)

d(health status)

×

Unpacking Primary Care Chain

∂ health status𝜕Government Spending on primary care

=¿

Working backwards



=¿ “Medicine” (even if ‘cost-effective’)

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.



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

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)

Health CentreEveryone

goes to the public health centre

The mindset, continued

District Hospital

CHC CHC CHC

PHC

S-C S-C S-C

PHC

S-C S-C

PHC

S-C S-C

PHC

S-C S-C S-C

District Hospital

Bigger Hospital

Even Bigger Hospital

AIIMS

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

But what if…

But what if…

we look at the real world and find…

• A Village looks like this (in Eastern Madhya Pradesh)• 2,315 persons in 457 households

(results from MAQARI project)

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

2 miles

With roads

…and it has 1 public and 11 private “real” doctors

Public providers

Private MBBS

…plus 8 homeopaths, 15 Ayurveds, 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

Public providers

Private MBBS

Homeopaths

Ayurvedic / Unani

No degree or qualification at all

If we do the right counts• 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”

0.0

10.0

20.0

30.0

40.0

50.0

60.0

34

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27

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26

.7

14

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.9

7.7

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.43

12

79

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69

33

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82

81

97

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89

78

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58

05

84

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85

8

6.0

23

28

95

24

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92

2

2.3

85

81

94

79

58

07

6

18

.64

41

61

09

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52

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15

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63

82

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63

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98

88

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51

7

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98

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28

53

75

51

7

Number of providers per 10,000 persons

Global

India

Country/State

Nu

mb

er

or

pro

vid

ers

Source: Countries; WHO 2011; MP, India: in progress

•Two things stand outSize of marketExcess capacity

Market Size: The market is much bigger

• 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?Primary Health Care

Share of the private sector in number of visits for primary care services - rural areas

0

20

40

60

80

100

Karnataka Kerala Rajasthan WestBengal

All India

poorest

2

3

4

richest

Share of the private sector in hospital in-patient days - rural areas

010203040506070

Karnataka Kerala Rajasthan WestBengal

All India

poorest

2

3

4

richest

Hospitals

Source: Calculations based on Mahal et al (2001)

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

Excess Capacity

Public, less busy

Public, very busy

Private, less busy

Private, very busy

8:00am 9:00am 10:00am 11:00am 12:00pm 1:00pm 2:00pm 3:00pm 4:00pm 5:00pm 6:00pm 7:00pm 8:00pm

Offi ce hours Occupied

Provider Work Load

Time

Work hours Attending to a patient

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

Instead, we are here

Health Centre



=¿

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”

Let’s look at the prior link



=¿

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?

• Vacancies

0

5

10

15

20

25

30

35

Doctors

Nurses

% of staff positions vacant


• Vacancies• Absent workers

ABSENCE RATES – DOCTORS

Reasons for absence among doctors by state

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

Bihar

Jhar

khan

d

Oris

sa

Uttran

acha

l

Uttar P

rade

sh

Assam

Rajas

than

Mad

hya P

rades

h

Chhat

tisgar

h

West

Bengal

Andhr

a Pra

desh

Karna

taka

Keral

a

Tamil N

adu

Mah

arash

tra

Guja

rat

Harya

na

Punjab

Per

cen

t

OfficialDutyLeave

ClosedFacilityNoReason

Source: Chaudhury et al (2004)


• Vacancies• Absenteeism• Low capability

Just Delhi!

The competence of providers in Delhi is very low- in public and private sectors

0.1

.2.3

.4.5

Den

sity

-2 -1 0 1 2Competence

Histogram Kernel Density

Publ ic--A l l MBBS

0.1

.2.3

.4.5

Den

sity



Private--M BBS

0.1

.2.3

.4.5

Den

sity



Private--Non-M BBS

0.1

.2.3

.4.5

Den

sity

/Per

cent


Public Providers Private--MBBS

Private--Non-MBBS

Al l Providers

Distribution of Competence by Qualification

Competence in Vignettes: Rural Madhya Pradesh

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


• Vacancies• Absenteeism• Low capability• Very little effort

-2-1

01

2S

tand

ardi

zed

Effo

rt

-2 -1 0 1 2Competence:IRT Score

Private, No MBBS Private, MBBSPublic (Non-Hosp) Public Sector (Hosp. Only)

Effort and Competence

CGHS facilities are in here

What does “very little effort” mean (in Delhi)?

0

1

2

3

4

5

6

7

time questions exams

low effortmediumhigh

Less than 2 minutes Just one question

Very little effort in MP: time spent

Public Private trained Private untrained0

1

2

3

4

5

3.1

3.9 3.9

2.6

4.13.8

Time spent by providers

Physician Observa-tions

Standardized Pa-tients

Type of provider

Tim

e sp

ent

(in

min

ute

s)

The “know – do” gap in Madhya Pradesh

Public Private trained Private untrained0%

10%

20%

30%

40%

50%

60%55.9%

45.0%

22.2%

0.0%

18.2%

3.7%

What providers know, what providers do? Madhya Pradesh

What they know

What they do

Type of providerPe

rce

nta

ge

of

ca

se

s w

he

re d

iag

no

sis

g

ive

n w

as

co

rre

ct

Know-do gap in Delhi0

.1.2

.3.4

% W

ho a

sked

the

rele

vant

que

stio

n

Private MBBS Private, No MBBS Public

...And What They DoWhat They Know

% Asked (DCO) % Asked (Vignettes)

Know-do gap

• 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

• 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

Das and others, 2012.

Quality in MP

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…

Using Standardized Simulated Patients for asthma

2.4 2.7

0.5

6.4

4.1

1.4

5.6

3.8

1.1

5.5

3.7

1.4

PublicPrivateQualifiedUnqualified

Min

ute

s, q

ue

sti

on

s, e

xa

ms

Diagnosis and treatment Asthma In Madhya Pradesh

0.13

0.20

0.01

0.07

0.320.41

0.23

0.03

0.23

0.310.31

0.25

0.040.11

0.30

0.39

0.21

0.01

0.27

0.32

PublicPrivateQualifiedUnqualified

Pe

rce

nt

of

inte

rac

tio

ns

wit

h it

em

c

om

ple

ted

Right

Wrong

Worse! Look at this for a heart attack!

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

0%

10%

20%

30%

40%

0.134

0.336000000000001

0.060.074 0.087

0.208

0.101

Diagnosis for heart attack

Per

cen

tag

e o

f C

ases

Untrained providers beat the public sector in diagnosis

Public Private trained Private untrained0%

10%

20%

30%

40%

0.00%

13.79%

8.47%

Likelihood of correct diagnosis in heart attack

Type of provider

Pe

rce

nta

ge

of

ca

se

s w

he

re d

iag

no

sis

wa

s g

ive

n

Public MBBS in public Public MBBS in private Private trained Private untrained-0.50

-0.25

0.00

0.25

0.50

-0.325770000000001

-0.0458971

0.43

0.32

Effort Index by provider type

Type of provider

Sta

nd

ard

ized

eff

ort

sco

re

Mean

Incentives must be at work somehow:

Public sector doctors do much better in their private clinics

38%

62%

Likelihood of correct treatment for a heart at-tack: Public MBBS in public clinics

Correct

Incorrect

60%

40%

Likelihood of correct treatment for a heart at-tack: Public MBBS in private clinics

Correct

Incorrect

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)

0%

10%

20%

30%

40%

30.9%

17.5%

14.0%17.1%

Likelihood of prescribing antibiotic(s) for heart at-tack

Per

cen

tag

e o

f ca

ses

And it’s the private sector overprescribing drugs?


• Vacancies• Absenteeism• Low ability• Low effort• “Donation” requests

Health 27%

Police & Judiciary 15%

Power 20%

Telecom & Rail 5%

Taxation& Land Admn. 17%

Education 12%

Ration Shops 4%

Money value of “donation” payments

Source: Transparency International

Incentive problems

• 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?



=¿

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?

• You haven’t been paying attention?• Ministry (and international organization) answers: People

don’t know any better• Really?

Prices: willingness to pay for quality• 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) 0

50

100

150

Pri

ce in

Rs.

-2 0 2 4Effort

No Qualification Some QualificationMBBS

Prices and Effort in Provider-Patient Interactions

Average Fees for MBBS

Average Fees for others

Why the divide?: accountability • 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 • 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?

It’s broken: Health policy in India

Documents

primary health care

health care provision

universal health care

health policy

health care delivery

essential health services

national health package

supplied care