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
• 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(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 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
∂Traditional (19th century)
public health spending
d(health status)
d(health spending)
∂primary care spending
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
Open
sewers
Garbage
dumps
Pathway 2: Old and new research
∂(Traditional (19th
century) public health
spending)
d(health status)
d(health
spending)
∂(primary care spending)
Unpacking Primary Care Chain
∂health status
=
𝜕Government Spending on primary care
∂health status
∂Effective medical care in market
×
∂Effective medical care in market ∂Effectively delivered care in PHC′s
𝜕Effectively delivered care in PHC′s
𝜕Public PHC′s
×
×
𝜕Public PHC′ s
𝜕Public Spending on primary care
Working backwards
Unpacking Primary Care Chain
∂health status
=
𝜕Government Spending on primary care
“Medicine” (even
if ‘cost-effective’)
∂health status
∂Effective medical care in market
×
∂Effective medical care in market ∂Effectively delivered care in PHC′s
𝜕Effectively delivered care in PHC′s
𝜕Public PHC′s
×
×
𝜕Public PHC′ s
𝜕Public Spending on primary care
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 Chain
∂health status
=
𝜕Government Spending on primary care
Does increasing
publicly supplied care
increase total supply
available to people?
∂health status
∂Effective medical care in market
×
∂Effective medical care in market ∂Effectively delivered care in PHC′s
𝜕Effectively delivered care in PHC′s
𝜕Public PHC′s
×
×
𝜕Public PHC′ s
𝜕Public Spending on primary care
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)
Everyone
goes to
the public
health
centre
Health
Centre
The mindset, continued
With a “seamless web of
referral” through primary,
more primary, secondary,
tertiary, teaching
AIIMS
Even Bigger Hospital
Bigger
Hospital
District
Hospital
CHC
CHC
PHC
S-C
S-C
District
Hospital
CHC
PHC
S-C
S-C
PHC
S-C
S-C
PHC
S-C
S-C
S-C
S-C
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
52.1
Number of providers per 10,000 persons
26.3
15.3
16.3
0.0
Country/State
•
Global
India
3.1
18.7
12.7
7.7
16.2
18.6
2.4
6.0
18.0
15.9
18.1
4.8
17.4
10.9
6.7
19.4
7.7
10.0
10.9
20.0
14.2
30.0
26.7
40.0
27.4
50.0
34.2
Number or providers
60.0
Source: Countries; WHO 2011; MP, India: in progress
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
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
100
poorest
80
Doesn’t seem to matter
how poor you are. But
national average masks
some interesting state
variations.
2
60
3
40
4
20
richest
0
Karnataka
Kerala
Rajasthan
West
Bengal
All India
Hospitals
Share of the private sector in hospital in-patient
days - rural areas
70
60
50
40
30
20
10
0
poorest
2
3
4
richest
Karnataka
Kerala
Rajasthan
Source: Calculations based on Mahal et al (2001)
West
Bengal
All India
Excess Capacity
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
Provider Work Load
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
Time
Office
hours
Work hours
Occupied
Attending to a patient
5:00pm
6:00pm
7:00pm
8:00pm
We are not in this world
anymore
Health
Centre
Instead, we are here
Unpacking Primary Care Chain
∂health status
=
𝜕Government Spending on primary care
So, this term could be
really small. The public
sector is just swamped
by the private and the
two appear to be
substitutes
∂health status
∂Effective medical care in market
×
∂Effective medical care in market ∂Effectively delivered care in PHC′s
𝜕Effectively delivered care in PHC′s
𝜕Public PHC′s
×
×
𝜕Public PHC′ s
𝜕Public Spending on primary care
“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 Chain
∂health status
=
𝜕Government Spending on primary care
∂health status
∂Effective medical care in market
×
∂Effective medical care in market ∂Effectively delivered care in PHC′s
𝜕Effectively delivered care in PHC′s
𝜕Public PHC′s
×
×
𝜕Public PHC′ s
𝜕Public Spending on primary care
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?
% of staff positions vacant
35
• Vacancies
30
25
20
Doctors
Nurses
15
10
5
0
b
nja
Pu na
a
ry
Ha at
jar
tra
Gu ra sh
ha du
a
Ma
il N
m
Ta tak a es h
a
d
a
rn
r
Ka ra P
l
dh
ga
An Ben
t
h
ar
es
W tis g
sh
de
ha
ra
Ch ya P
dh n
Ma tha
ja s
Ra
h
m
sa des
As Pra
tar hal
c
Ut
an
tar
Ut a
iss d
Or han
k
ar
Jh
ar
h
Bi
PHC’s: What do people find when they get there?
• Vacancies
• Absent workers
B
J h i ha
r
ar
kh
an
d
O
r
is
U
sa
ttr
a
n
U
tta ac
r P ha
ra l
de
s
As h
sa
R
m
M
a
ad
ja
h y sth
an
a
P
r
a
C
hh d es
at
h
t
W i sg
ar
e
h
An st
d h Be
ng
ra
Pr al
ad
Ka esh
rn
at
ak
a
Ke
Ta ral
a
m
i
l
M
ah Na
a r du
as
ht
ra
G
uj
a
H rat
ar
ya
na
Pu
nj
ab
Percent
ABSENCE RATES – DOCTORS
Reasons for absence among doctors by state
80.0
70.0
60.0
Official
Duty
Leave
50.0
40.0
30.0
20.0
Closed
Facility
No
Reason
10.0
0.0
Source: Chaudhury et al (2004)
PHC’s: What do people find when they get there?
• Vacancies
• Absenteeism
• Low capability
Just Delhi!
The competence of providers in Delhi is very lowin public and private sectors
Distribution of Competence by Qualification
Public--All MBBS
.2
.3
Density
.3
.2
0
0
.1
.1
Density
.4
.4
.5
.5
Private--MBBS
-2
-1
0
Competence
Histogram
1
2
-2
-1
Kernel Density
0
Competence
Histogram
Private--Non-MBBS
2
Kernel Density
.4
.3
.2
.1
0
.1
.2
.3
.4
Density/Percent
.5
.5
All Providers
0
Density
1
-2
-2
-1
0
Competence
Histogram
1
2
-1
0
Competence
Public Providers
Kernel Density
Private--Non-MBBS
1
2
Private--MBBS
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
PHC’s: What do people find when they get there?
Standardized Effort
• Absenteeism
2
1
• Vacancies
Effort and Competence
-1
CGHS facilities are in here
-2
• Very little effort
0
• Low capability
-2
-1
0
Competence:IRT Score
Private, No MBBS
Public (Non-Hosp)
1
Private, MBBS
Public Sector (Hosp. Only)
2
What does “very little effort” mean (in Delhi)?
7
6
5
4
low effort
medium
high
3
2
1
0
time
Less than 2 minutes
questions
Just one question
exams
Very little effort in MP: time spent
Time spent by providers
Time spent (in minutes)
5
3.9
4
4.1
3.9
3.8
3.1
3
2.6
Physician
Observations
2
Standardized
Patients
1
0
Public
Private trained
Type of provider
Private untrained
The “know – do” gap in Madhya Pradesh
Percentage of cases where diagnosis
given was correct
What providers know, what providers do? Madhya
Pradesh
60%
55.9%
50%
45.0%
40%
30%
What they know
22.2%
What they do
18.2%
20%
10%
3.7%
0.0%
0%
Public
Private trained
Type of provider
Private untrained
Know-do gap in Delhi
What They Know
0
.1
.2
.3
.4
...And What They Do
Private MBBS
Private, No MBBS
% Asked (DCO)
Public
% 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.
Minutes, questions, exams
In rural Madhya Pradesh: Unqualified practitioners do
better than public PHC providers on process…
6.4
5.6 5.5
4.1 3.8
3.7
2.4
2.7
0.5
Visit length (mins)
Number of
recommended
questions
1.4 1.1 1.4
Number of
recommended exams
Using Standardized Simulated Patients for asthma
Public
Private
Qualified
Unqualified
Diagnosis and treatment
Percent of interactions with item
completed
Asthma In Madhya Pradesh
0.41
0.39
0.31
0.25
0.20
0.23 0.21
0.27
0.31 0.32
0.32
0.30
0.23
Public
Private
Qualified
Unqualified
0.13
0.11
0.04
0.03
0.01
0.01
Articulated
diagnosis
Correct
diagnosis (if
articulated)
0.07
Prescribed
inhaler
Prescribed
steroids
Prescribed
antibiotics
Wrong
Right
Worse! Look at this for a heart attack!
Diagnosis for heart attack
40%
Percentage of Cases
33.6%
30%
20.8%
20%
13.4%
10%
6.0%
7.4%
8.7%
10.1%
0%
Heart
attack
Heart
Blood Muscle Weather Stomach Other
problem pressure pain
problem/
Gas
Based on 327 SP visits, no diagnosis given in 178 cases
Untrained providers beat the public sector
in diagnosis
Likelihood of correct diagnosis in heart attack
Percentage of cases where diagnosis was given
40%
30%
20%
13.79%
8.47%
10%
0%
0%
Public
Private trained
Type of provider
Private untrained
Incentives must be at work somehow:
Effort Index by provider type
Standardized effort score
0.50
0.43
0.32
0.25
Mean0.00
-0.05
-0.25
-0.33
-0.50
Public MBBS in public
Public MBBS in private
Type of provider
Private trained
Private untrained
Public sector doctors do much better in their
private clinics
Likelihood of correct treatment for a heart
attack: Public MBBS in public clinics
38%
62%
Likelihood of correct treatment for a heart
attack: Public MBBS in private clinics
40%
Correct
Correct
Incorrect
Incorrect
60%
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?
Likelihood of prescribing antibiotic(s) for heart
attack
40%
Percentage of cases
30.9%
30%
20%
17.5%
17.1%
14.0%
10%
0%
Public MBBS
in public
Public MBBS Private trained
in private
Private
untrained
PHC’s: What do people find when they get there?
Money value of “donation” payments
Ration Shops
4%
• Vacancies
Health
27%
Education
12%
• Absenteeism
• Low ability
• Low effort
Taxation& Land
Admn. 17%
• “Donation” requests
Police & Judiciary
15%
Telecom & Rail 5%
Power 20%
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?
Unpacking Primary Care Chain
∂health status
=
𝜕Government Spending on primary care
Because of the long
chain of things that
can screw up – this
can be a very small
number
∂health status
∂Effective medical care in market
×
∂Effective medical care in market ∂Effectively delivered care in PHC′s
𝜕Effectively delivered care in PHC′s
𝜕Public PHC′s
×
×
𝜕Public PHC′ s
𝜕Public Spending on primary care
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)
150
Prices and Effort in Provider-Patient Interactions
100
Average Fees
for others
0
50
Price in Rs.
Average Fees
for MBBS
-2
0
2
Effort
No Qualification
MBBS
Some Qualification
4
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?