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Will a Wealthier India be a Healthier India?. Jishnu Das, Shanta Devarajan, Jeff Hammer, Lant Pritchett. India has been growing rapidly since the 1980s…. And increases in income have translated into. Higher life-expectancy (population sized circles, India is big blue, China big red.
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Will a Wealthier India be a Healthier India? Jishnu Das, Shanta Devarajan, Jeff Hammer, Lant Pritchett
Higher life-expectancy (population sized circles, India is big blue, China big red
Reason 1: Improving health outcomes further may require substantially higher investments in public health services…
where our performance is not stellar (not even lunar)… Source: WDI Indicators Database
50th %tile 90th %tile 75th %tile 90th %tile 50th %tile 75th %tile 25th %tile 25th %tile Reason 2: Morbidity is taking a toll on India’s productive capabilities
Vietnam (poorest 20%) Bangladesh (poorest 20%) India (poorest 20%) Reason 3: and the poorest 20% are not doing that well at all (worse than BGD)…
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) 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
Mindset (at least on record) Poor people rely on the public system & the benefits of public care mostly accrue to them
Fact #1: Most spending is private; the fraction on genuine public goods is tiny
IF we spend the equivalent of one box on Population based public health…. We spend 3 on Preventive Health care Hospitals Public Curative Care is 20 boxes 8 on PHC’s And…. 12 on Hospitals PHC’s Private Care “Public health” is 4 boxes Preventive/Promotive Public Health Population based public health
In fact…India is one of the most private systems of health care in the world
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 #3: More public money on health goes to the rich than the poor (because hospital use is regressive)
Poor people don’t use doctors and health facilities…that’s why they have worse health outcomes One Reason that is often given to explain why the poor have worse health outcomes
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
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*) Despite the frequent use of health care providers • There is no relationship between the presence of health facilities and health outcomes
One important question…Why don’t the poor use public health facilities more?
Reason 1: Public Doctors in India are among the most absent in the world Absenteeism among health workers
Absenteeism amongst doctors by state & reasons for absence Reason 1 (cont): Absences are never below 30 percent!
Reason 2: When public doctors do show up for work, the exert very little effort What they do What they know “Effort deficit”
Less than 2 minutes Just one question Almost none! What does “very little effort” mean? 2, 1, 0
Fact #3: And public doctors in PHCs are not particularly competent to begin with
Money value of “donation” payments Health 27% Ration Shops 4% Education 12% Taxation& Land Admn. 17% Police & Judiciary 15% Telecom & Rail 5% Power 20% Reason 4: And you still have to bribe public doctors to do their work
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…
Lost Training: Private Additional Lost Training: Public The losses from low effort
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?
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)
