Health-care reform in India
Abhijit Vinayak Banerjee
Child health
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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
Child nutrition
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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%
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
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Usage of the government health system
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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
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Cheaper (client side reports)
One problem is demand
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People wants shots and drips
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The government nurses can only give tablets
Huge demand for curative rather than
preventive services
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The government rightly emphasizes preventive
One problem is quality
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Udaipur Continuous facility survey: facility survey
that cover all the sub-centers and PHC serving
100 villages, weekly, over a year. In 2003
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Das-Hammer provide data on patient-provider
interaction in Delhi:
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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.
In half the visits public doctors don’t touch the patient
More recent work by Das and others
Why is quality so low: Results from an
incentive experiment
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The government of Rajasthan allowed to let an NGO, Seva
Mandir, 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%
What happened?
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Were sanctions not applied?
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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
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Register Records
100%
Machine problems
80%
Exempted days
60%
Casual Leave
40%
Absent
Half day
20%
Present
0%
Feb06
Mar06
Apr06
May06
Jun06
Jul06
Aug06
Sep06
Oct06
M onth
Nov06
Dec06
Jan07
Feb07
Mar07
Apr07
May07
The government’s response: Spending
money
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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”.
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Why would that help?
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The government’s theory that beneficiary
control will do it.
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User’s group
Making it justiciable
Under NRHM there are supposed to be
beneficiary committees modeled on SSA
SSA
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The Village Education Committees (VECs) were
supposed to play a key role in SSA
implementation (e.g in spending SSA funds).
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In Uttar Pradesh the VEC is responsible for:
Monitoring the performance of the schools;
complaining about teacher performance to the
higher ups if necessary.
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Applying for and getting additional teachers for
their schools, wherever needed.
Learning?
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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%
People’s power?
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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
A randomized experiment on
community action
 In 130 randomly chosen villages Pratham, an
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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
How about using the market?
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Might work for some things
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Lot of work going on the efficacy of private health
insurance for in-patient care
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Not much demand so far
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What about Out-patient?
How will it generate behavior change?
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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
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Lots of spillovers, including within the family
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Boys get breast-fed longer.
Both these are also reasons why beneficiary control has
limited effectiveness.
How about a “right to health”?
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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
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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.
What else: some thoughts for the future
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Public health:
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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
And more
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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:
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Remember details matter and most things can
be improved