Will a Wealthier India be a Healthier India?

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Will a Wealthier India be a Healthier India?

• Jishnu Das, Shanta Devarajan, Jeff Hammer, Lant
  Pritchett

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India has been growing rapidly since the 1980s
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And increases in income have translated into
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Higher life-expectancy (population sized circles,
India is big blue, China big red
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Lower child-mortality
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And lower fertility
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And yet
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There are three good reasons to worry
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Reason 1 Improving health outcomes further may
require substantially higher investments in
public health services
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where our performance is not stellar (not even
lunar)
Source WDI Indicators Database
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Reason 2 Morbidity is taking a toll on Indias
productive capabilities
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Reason 3 and the poorest 20 are not doing that
well at all (worse than BGD)
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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

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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 doesnt work (but is often done)
• What might work

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The Indian health system according to The
Mindset (at least on record)
The system is Pyramidal
Basic Care is universally given by the state

• 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

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Mindset (at least on record)
Poor people rely on the public system the
benefits of public care mostly accrue to them
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In Reality(and this is well known)
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Fact 1 Most spending is private the fraction
on genuine public goods is tiny
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75 Boxes on Private Care!
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In factIndia is one of the most private systems
of health care in the world
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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
  sectors 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

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Fact 2 The poor use private care as much as the
rich
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Fact 2 The poor use the private system as much
as the richeven of hospitals there is
substantial private use
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Fact 3 More public money on health goes to the
rich than the poor (because hospital use is
regressive)
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One Reason that is often given to explain why the
poor have worse health outcomes
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But this perceived wisdom is wrong
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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

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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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One important questionWhy dont the poor use
public health facilities more?
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4 Reasons based on 4 lesser known facts
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Reason 1 Public Doctors in India are among the
most absent in the world
Absenteeism among health workers
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Reason 1 (cont) Absences are never below 30
percent!
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Reason 2 When public doctors do show up for
work, the exert very little effort
What they do
What they know
Effort deficit
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What does very little effort mean? 2, 1, 0
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Fact 3 And public doctors in PHCs are not
particularly competent to begin with
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Reason 4 And you still have to bribe public
doctors to do their work
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A summary of why poor people may not be using the
PHC system

• The doctors are low on competence
• They dont show up for work
• When they do show up, they dont work to the
  level of their knowledge
• And patients have to pay bribes anyway

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The visible hand Example 1

• Public Doctors are
• paid by salary
• not monitored by supervisors
• cannot be fired or have pay reduced under
  virtually any circumstances
• have higher social status and have much greater
  political power than your clients complaints
  dont touch you
• have lucrative alternative work in the private
  sector
• What would you do?

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One oft-advocated solution

• That probably does not work
• Training Doctors

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Training and the Invisible Hand

• With public doctors, problem is NOT that they
  dont know what to do, its that they dont do it!
• No public doctor needs training to know that
  he/she should come to work!
• Yet

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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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The losses from low effort
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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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Approaches to a solution

• Indias 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)

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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
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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
Prevention and health promotion Monitoring of effort/quality, logistics
Health-sector based public health
Non-health-sector based public health No middle-class support for reforms
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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
Prevention and health promotion Devolve to local governments
Health-sector based public health
Non-health-sector based public health
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The solution is the problem

• The mindset of universal, hierarchical, poor
  oriented public production of health care is now
  only the planners 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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Indias drugs are cheap(Example 1)
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Indias drugs are cheap(Example 2)
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Training and the Invisible Hand (IV)

• And what guarantees that they will remain in the
  place they were trained?
• (Invisible hand will allocate better private
  doctors to richer areas)

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Doesnt matter what data or method

• NFHS I no regression effect (nothing)
• NFHS II (kucch bhi nahin)
• Reproductive and Child Health survey (kicchu na)
  1998
• RCH 2001 ditto
• Torture the data as much as you like and it still
  wont talk (in contrast education, income
  proxies, water source, sanitation habits, pucca
  roads, etc., etc. all squeal at the slightest
  provocation samples are very large)

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Delhi doctor visits
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