October 08, 2010
If you build it, he will come, whispered an unseen voice to the protagonist in the movie Field of Dreams. Of course that was about building a baseball field, but it turns out that the same principle applies to healthcare delivery in developing countries. The voice talking to Kevin Costner was an advocate of supply-side intervention, much in the way public healthcare has operated in developing countries until recently. But after years of capacity expansion through building new hospitals and recruiting medical staff, some governments still find it difficult to break the socioeconomic barriers that prevent the poor from utilizing these services. To nudge the sleeping leviathan and to reduce the elite capture of public healthcare many are turning to a pro-demand policy response by providing direct incentives, often monetary, to poor patrons. With strong economic growth and more public funds to spend than ever before, a two-prong strategy involving both supply and demand is increasingly affordable, and desirable. Here I will discuss the paradigm shifts that are bringing forth a new era of targeted service delivery in India.
Although some primary care policies had dotted the healthcare scene since the 1970s, the first milestone in India’s public health history was a comprehensive National Health Policy (NHP) of 1983. Following the Alma-Ata approach of Health for All, the key objective of this policy was very straightforward a goal-oriented growth in capacity by building primary healthcare facilities and creating a network of providers. The Rural Health Policy (1977) provided a foundation with an innovative component for information dissemination community level semi-volunteers, called village health workers, who were deployed in rural areas. The NHP was followed by two busy decades of supply-side policymaking, often supported by multilateral donors such as the World Bank and UNICEF. Policymakers took a multidimensional approach in which the core elements of primary care, and maternal and child health were frequently nested across policies for horizontal expansion, and newer policies subsumed older ones for the sake of vertical integration. A separate policy was designed for virtually every aspect of human health and disease, ranging from sanitation and malnutrition to malaria and leprosy, and the piecemeal approach continues to this day. The prominent fruits of this era were the Universal Immunization Policy (1986), the Reproductive and Child Health Program (1997, followed from a similar program in 1992), and the National Population Policy (2000).
Before refurbishing the all-encompassing National Health Policy in 2002, Indian policymakers reviewed the recent history. They lauded the achievements of the previous decades, such as lower mortality rates and decreased prevalence of diseases. They lamented the inadequate density of services, and made the almost rhetorical push for further capacity. True, expansion was needed. Thankfully, the new policy also did not fail to identify two other problems regional variation in coverage and the need to improve existing facilities. A greater decentralization of service delivery was prescribed to include ill-served areas. For example, the National Rural Health Mission (2005) focused on poorer states, symbolizing the common proverb, If the mountain will not come to Mahomet, Mahomet must go to the mountain.
The praise showered upon supply-side health policies in India is well-deserved. Healthcare delivery does not suffer from a chicken-egg problem and capacity building is universally recognized as the first step for any country. However, surprisingly little systematic research has been conducted on the public healthcare sector in India, even in the presence of a labyrinth of spatially and chronologically varying policies. Expansionary policies have definitely had their share of impacts on health outcomes, but very few researchers have been able to separate the impact of health infrastructure from the confounding effects from economic growth and social changes.
Research that does exist documents problems in both quality and access to care. A famous study by the MIT Poverty Action Lab illustrates the dismal state of service delivery in Rajasthan, one the poorest Indian states. Another study finds that the incompetence of doctors in Delhi leads to waste of resources in both the public and private sectors. Doctor absenteeism is a severe problem in other low-income countries such as Bangladesh. These, and many other studies (e.g. the Demographic and Health Surveys in India) also document the inequality in healthcare access. Emily Oster argues that increased access does not have any impact on gender inequality, and preliminary findings from a 2009 survey reveal that the poor in India still depend on expensive private healthcare. The rock-and-a-hard-place combination of low quality public care and expensive private care often leaves the poor stranded with no treatment altogether.
Given the concerns about access and quality, demand-side policies could help alleviate some shortcomings. Many conditional cash transfer (CCT) programs, as the name suggests, are designed to navigate the needy to a nearest healthcare facility. The most well-known of these programs globally is probably the Progresa (1997) or Opportunidades (2002) in Mexico. The scheme provides monetary incentives to families for accessing preventive healthcare (and also for sending children to school). The Bolsa Fam lia program in Brazil, a similar cash incentive scheme, is among the largest in the world, covering 12 million families. Research has found a significantly positive impact of the Mexican program on healthcare access (an official evaluation was conducted by IFPRI, among others). Some other South American and Asian countries have implemented their own CCTs. The evidence of the impact of these CCTs on health outcomes is generally favorable (e.g. positive results in Nicaragua, and in Mexico), with a few exceptions.
India is no stranger to CCTs either. For example, the National Old Age Pension Scheme was launched in 1995 to help ease the economic hardship of the poor elderly (although the program is notorious for its small outlays). I mentioned the Girl Child Empowerment Scheme (Balika Samridhi Yojana, 1997), an initiative for reducing gender inequality in India, in a previous blog post. For families living below the poverty line, this program provides a one-time monetary incentive of Rs. 500 ($1 = Rs. 45, approximately) for every female child birth. In addition, annual scholarships ranging from Rs. 300 to Rs. 1000 are provided after the child s completion of grades 1 through 10 in school. Parts of the birth-grant and the annual scholarship are deposited in a special insurance scheme in the name of the girl child, recoverable at adulthood.
In 2005, India launched its first major healthcare-related CCT. The Safe Motherhood Scheme (Janani Suraksha Yojana (JSY)) is an attempt to address the maternal and neonatal health problems arising at childbirth. The scheme provides Rs. 700 to pregnant women living below the poverty line to seek institutional childbirths (at home deliveries are associated with much higher mortality risks). Women in urban areas are not covered (except for some few low-performance states), as institutional deliveries are more common. The program is implemented through an army of health workers who identify the pregnant women and form a health-partnership with them. These workers educate expecting mothers about antenatal and postnatal care, and usher them to a nearest health facility for delivery. In low-performance states, the health worker also earns an incentive (Rs. 600 in rural and Rs. 200 in urban areas) for each institutional delivery.
How is the JSY faring? A recent study evaluated the program and finds that although it did not sufficiently cover the poorest segment of the society and regional variation is still a major concern, its impacts on health outcomes are encouraging. JSY is associated with a rise in institutional childbirths. Also, estimated perinatal deaths have reduced by 3.7-4.1 and neonatal deaths have fallen in the range of 2.3-2.4 for every 1000 live births, depending upon the evaluation methodology.
CCTs are certainly not the silver bullet. They are infamous for high overhead cost, as precise targeting requires a heavy dose of administrative prowess. At one point, more than 90% of Progresa outlay was spent in organizational expenditure. In addition, there is a debate on whether the incentives are too small. Greatest number is prioritized over greatest good, often rightly so, leaving the beneficiaries with a pittance. However, reciprocating supply-side economics with demand-side policies is certainly a refreshing and welcome change.
Image Credit: Flickr: deepay
