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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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