It’s broken: Health policy in India

1. 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

2. Problem #1

3. 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”

4. 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

5. 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

6. Today’s Picture ∂Traditional (19th century) public health spending d(health status) d(health spending) × ∂primary care spending

7. Pathway 1: Most important (very brief) ∂(Traditional (19th century) public health spending) d(health status) d(health spending) × ∂(primary care spending)

8. Health and Sh... stuff Open sewers Garbage dumps

9. Pathway 2: Old and new research ∂(Traditional (19th century) public health spending) d(health status) d(health spending) × ∂(primary care spending)

10. Unpacking Primary Care Chain

11. Working backwards

12. Unpacking Primary Care Chain “Medicine” (even if ‘cost-effective’)

13. 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.

14. Unpacking Primary Care Chain Does increasing publicly supplied care increase total supply available to people?

15. 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!

16. Mindset of Ministry since Bhore committee (and of WHO to this day) Health Centre Everyone goes to the public health centre

17. The mindset, continued AIIMS With a “seamless web of referral” through primary, more primary, secondary, tertiary, teaching

18. But what if…

19. But what if… we look at the real world and find…

20. A Village looks like this (in Eastern Madhya Pradesh) • 2,315 persons in 457 households (results from MAQARI project)

21. With this sort of “access” to health care providers Public providers Private MBBS households

22. But there’s a larger village two miles away that most people go to when sick 2 miles With roads

23. …and it has 1 public and 11 private “real” doctors Public providers Private MBBS

24. …plus 8 homeopaths, 15 Ayurveds, a bunch of Unani, electro-homeopaths, “integrated” medics, pharmacists Public providers Private MBBS Homeopaths Ayurvedic / Unani

25. …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

26. 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”

27. Two things stand out Size of market Excess capacity

28. 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

29. What do market shares look like? Primary Health Care Doesn’t seem to matter how poor you are. But national average masks some interesting state variations. Hospitals Source: Calculations based on Mahal et al (2001)

30. 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

31. We are not in this world anymore Instead, we are here Health Centre

32. Unpacking Primary Care Chain So, this term could be really small. The public sector is just swamped by the private and the two appear to be substitutes

33. “Aha!” You say. “But you just told us that many of these providers are quacks” Let’s look at the prior link

34. Unpacking Primary Care Chain

35. 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

36. PHC’s: What do people find when they get there? % of staff positions vacant • Vacancies

37. PHC’s: What do people find when they get there? • Vacancies • Absent workers

38. Absence rates – Doctors Source: Chaudhuryet al (2004)

39. PHC’s: What do people find when they get there? • Vacancies • Absenteeism • Low capability Just Delhi!

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

41. 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

42. PHC’s: What do people find when they get there? • Vacancies • Absenteeism • Low capability • Very little effort CGHS facilities are in here

43. What does “very little effort” mean (in Delhi)? Less than 2 minutes Just one question

44. Very little effort in MP: time spent

45. The “know – do” gap in Madhya Pradesh

46. Know-do gap in Delhi

47. Know-do gap • And in Tanzania • And in Rwanda • And in Netherlands….. • We are beginning to see a pattern

48. 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 Quality: Combining Competence AND Effort with Standardized Patients Das and others, 2012.

49. Quality in MP Public MBBS doctors, although most competent, they did the least and so are of the lowest quality in the entire sample.

50. In rural Madhya Pradesh: Unqualified practitioners do better than public PHC providers on process… Using Standardized Simulated Patients for asthma