health-care reform in india
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Health-care reform in India. Abhijit Vinayak Banerjee. Child health. 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 - PowerPoint PPT PresentationTRANSCRIPT
Abhijit Vinayak Banerjee
Health-care reform in India
Child health 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 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
Usage of the government health system 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
Cheaper (client side reports)
One problem is demand People wants shots and drips
The government nurses can only give tablets Huge demand for curative rather than
preventive services The government rightly emphasizes preventive
One problem is quality Udaipur Continuous facility survey: facility survey
that cover all the sub-centers and PHC serving 100 villages, weekly, over a year. In 2003 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.
Das-Hammer provide data on patient-provider interaction in Delhi: 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 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? Were sanctions not applied?
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
Register Records
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Half dayAbsent
Casual Leave
Exempted days
Machine problems
The government’s response: Spending money 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”.
Why would that help?
The government’s theory that beneficiary control will do it. User’s group Making it justiciable
Under NRHM there are supposed to be beneficiary committees modeled on SSA
SSA The Village Education Committees (VECs) were
supposed to play a key role in SSA implementation (e.g in spending SSA funds).
In Uttar Pradesh the VEC is responsible for: Monitoring the performance of the schools; complaining about teacher performance to the higher ups if necessary.
Applying for and getting additional teachers for their schools, wherever needed.
Learning? 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? 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
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?
Might work for some things Lot of work going on the efficacy of private health
insurance for in-patient care Not much demand so far What about Out-patient?
How will it generate behavior change? 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
Lots of spillovers, including within the family Boys get breast-fed longer.
Both these are also reasons why beneficiary control has limited effectiveness.
How about a “right to health”? 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 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 Public health:
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 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:
Remember details matter and most things can be improved