will a wealthier india be a healthier india? jishnu das, shanta devarajan, jeff hammer, lant...

Will a Wealthier India be a Healthier India?

Jishnu Das, Shanta Devarajan, Jeff Hammer, Lant Pritchett

India has been growing rapidly since the 1980s…

Chart 1. Economic Performance in India 1960-2000(log scale, 1960=1)

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GDP/capita

GDP/worker

TFP

And increases in income have translated into

Higher life-expectancy (population sized circles, India is big blue, China

big red

Lower child-mortality

And lower fertility

And yet…

There are three good reasons to worry

Reason 1: Improving health outcomes further may require substantially higher investments in public

health services…Trend of IMR by Selected States in India

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1994 1995 1996 1997 1998 1999 2000 2001 2002

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IMR

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Karnataka Kerala RajasthanTamil Nadu Utter Pradesh West BengalOverall India

where our performance is not stellar (not even lunar)…

Measles Immunization: 12-23 Months

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90

2000 2001 2002 2003 2004

Year

% Im

mu

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ChinaIndiaIndonesiaKenya

Source: WDI Indicators Database

Reason 2: Morbidity is taking a toll on India’s productive capabilities

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0 .2 .4 .6 .8 1% W eeks Sick with an Acute Illness

Men

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0 .2 .4 .6 .8 1% Weeks Sick with an Acute I llness

Women

Source: Author's Calculations based on ISERDD Data

Labor and Health in Delhi

90th %tile

25th %tile

50th %tile

75th %tile

90th %tile

75th %tile

50th %tile

25th %tile

Reason 3: and the poorest 20% are not doing that well at all (worse

than BGD)…

India (poorest 20%)

Bangladesh (poorest 20%)

Vietnam (poorest 20%)

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

• 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)

Basic Care is universally given

by the state

The system is “Pyramidal”

• 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)

Poor people rely on the public system & the

benefits of public care

mostly accrue to them

In Reality(and this is well known)

Fact #1: Most spending is private; the fraction on genuine public goods is tiny

“Public health” is 4 boxes

Population based public health

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

Preventive/Promotive Public Health

We spend 3 on Preventive Health care

Public Curative Care is 20 boxes

PHC’s

8 on PHC’s

Hospitals

12 on Hospitals

Private Care

And….

75 Boxes on Private Care!

In fact…India is one of the most private systems of health care in the world

Public Health Spending (% of Total)

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2000 2001 2002 2003

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China

United States

Source: WDI Database

The Heartless Capitalists

People Power

Public Health Spending (% of Total)

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Source: WDI Database

The Heartless Capitalists

People Power

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

Fact #2: The poor use private care as much as the rich

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

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Karnataka Kerala Rajasthan WestBengal

All India

poorest

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richest

Fact #3: More public money on health goes to the rich than the poor (because hospital use is

regressive)

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Poorest II III IV Richest

Hospitals

Primary HealthCenters

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

But this perceived wisdom is wrong

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

• There is no relationship between the presence of health facilities and health outcomes

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Significant, rightsign

Not Significant,right sign

Not significant,wrong sign

Significant,wrong sign

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*)

One important question…

Why don’t the poor use public health facilities more?

4 Reasons based on 4 lesser known facts

Reason 1: Public Doctors in India are among the most absent in the world

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Uganda

Bangladesh

IndiaIndonesia

Peru

Absenteeism among health workers

Reason 1 (cont): Absences are never below 30 percent!

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Official Duty

Leave

No reason

Absenteeism amongst doctors by state & reasons for absence

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

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Hospitals

PHC's

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Hospitals

PHC's

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Hospitals

PHC's

Private

Locality-Income and InstitutionCompetence and Effort

Clinical Competence Effort-in-Practice

What they knowWhat theydo

“Effort deficit”

What does “very little effort” mean? 2, 1, 0

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time questions exams

low effortmediumhigh

Less than 2 minutes Just one question

Almost none!

Fact #3: And public doctors in PHCs are not particularly competent to begin with

PHC Doctors are substantially less competent than in TZA(!) or IDN

Reason 4: And you still have to bribe public doctors to do their work

Health 27%

Police & Judiciary 15%

Power 20%

Telecom & Rail 5%

Taxation& Land Admn. 17%

Education 12%

Ration Shops 4%

Money value of “donation” payments

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

• That probably does not work

• Training Doctors

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)

• 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…

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Private MBBS Private, No MBBS Public

...And What They DoWhat They Know

% Asked (DCO) % Asked (Vignettes)

The losses from low effort0

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What they know W hat they Do: PrivateWhat they do: Public

Rotating The Curve

Lost Training: Private

Additional Lost Training: Public

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?

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Practitioner Qualifications and Drug Use

Medicines per patient Antibiotics per patientAlternative Medicines per patient

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)

Each of these is subject to a different market failure

Sub-system Market failure

Hospital-based curative care Insurance-market failure

Ambulatory curative care

Prevention and health promotion

Merit goods, some externality

Health-sector based public health

Pure public goods

Non-health-sector based public health

Externalities

…and to a different government failure

Sub-system Government failure

Hospital-based curative care Political capture by elites

Ambulatory curative care Monitoring of effort/quality, asymmetric information


Monitoring of effort/quality, logistics



No middle-class support for reforms

Matching the sub-system to the market and government failure

Sub-system Institutional arrangement

Hospital-based curative care Health insurance with autonomous hospitals

Ambulatory curative care “Money follows the patient”


Devolve to local governments



“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.

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