The India Health Systems Project team will present several areas of work at the upcoming 2021 Congress of the International Health Economics Association (iHEA), July 12-15, 2021.
Organized Session on Odisha Health System Assessment
Health System Performance Assessment: Implications for Health Reform in the State of Odisha, India
CHAIR: Prof. William Hsiao
PRESENTERS: Annie Haakenstad, Anuska Kalita, Bijetri Bose, and Jan Cooper
DISCUSSANT: Rahul Reddy
Health systems are comprised of interlocking pieces that work together to produce outcomes. Yet, the many components of health systems are rarely assessed simultaneously or comprehensively. This leads to policies that fail to address systemic, deep-rooted problems, and achieve policy goals. In this session, we will present analyses from a comprehensive health system assessment that documents performance and analyzes the underlying drivers of poor outcomes, demonstrating the potential for using health system analysis to support the design of policies and programs.
The health system assessment presented in this session focuses on the state of Odisha, India. Home to more than 40 million people, Odisha is one of the poorest and most rural states in India, with 36% of the population living below the poverty line, 84% of the population residing in rural areas, and 39% belonging to disadvantaged caste and tribal groups. We will present four studies assessing the performance of Odisha’s health system, focusing on: financial risk protection, access to services, quality of care, and the connection between the organization of health facilities and efficiency.
The analyses presented in this session employ a rich dataset collected from households, health facilities, providers, and patients in Odisha over 2019-2020. Data include clinical vignettes, outpatient and inpatient exit interviews, interviews and clinical vignettes with the public and private sectors, including solo providers, health facilities and private pharmacies, and in-depth interviews with households about spending on health and their experience using health care. The dataset is rare in collecting information from the often-used but poorly understood private sector in India. Furthermore, these data allow us to link information about facilities with household and patients’ reports about their care and health care costs. Finally, geocoding of datasets allows us to characterize localized health care markets, assess variation in these markets, and map the ecosystem of providers in a region.
Four studies will be presented using these data. First, an assessment of Odisha’s performance in the area of financial risk protection will be presented. We investigate the drivers of catastrophic health expenditure, including why out-of-pocket (OOP) payments for drugs are high when care is pursued in the public sector, where the policy is to provide pharmaceuticals for free, and whether the market for private sector pharmaceuticals plays a role in high OOP drug spending. Second, we unpack access issues, showing that while the majority of respondents report access to health services, there is significant variability in the availability and use of public versus private providers. Third, we explore the competency of providers using clinical vignettes, assessing whether correct diagnoses are made, and the extent to which public and private providers prescribe unnecessary and harmful drugs and fail to make proper referrals for necessary care. Fourth, we investigate whether the inefficient use of labor in the form of healthcare worker shortage, absenteeism, and low productivity can be explained by the failure to account for the incentives inherent in the organizational structure of healthcare facilities.
One discussant and the chair will synthesize the four presentations and connect them to policy options in the state of Odisha, demonstrating how health systems analysis can foster effective policies. Presentation length will be kept to a minimum to ensure ample time for interaction with the audience and discussion of policy options. Overall, this session will present a model of how comprehensive health system analysis enables a unified approach to policy reforms.
Presentation 1: Private sector pharmaceuticals and poor financial risk protection in the state of Odisha, India
Presenter: Annie Haakenstad
Financial risk protection in the Indian state of Odisha is poor. The rate of catastrophic heath expenditure (CHE) was 24% in 2018, the second-highest across India. Nearly 70% of health spending was sourced from out-of-pocket (OOP) payments, of which 66% was disbursed on drugs alone, despite government policy that drugs be provided free-of-charge at public facilities. Furthermore, India is the third-largest producer by volume of pharmaceuticals worldwide, potentially making drug prices lower than countries that need to import them but also increasing the potential impact of supplier-induced demand and other shaping of consumer preferences. The question, thus, is whether the problem of high drug OOP spending in Odisha is due to lack of supply in the public sector or, alternatively, whether consumers bypass public sector drugs because they prefer to purchase brand name drugs in the private sector.
We collected data from 7,550 households and 30,654 individuals, oversampling households in which individuals used health care or had chronic conditions. We use Shapley decomposition to analyze variation in OOP as a share of consumption expenditure according to why and where care was sought, what OOP was disbursed for, and underlying sociodemographic characteristics. We link users of healthcare with a health facility survey in which we collected information about the drugs in stock and other health facility characteristics. Using the linked data, we assess whether government health facility users with substantial OOP spending on drugs faced drug stock-outs or whether users instead bypassed the free drugs in stock at public pharmacies for private pharmaceuticals. Finally, we assess whether high OOP drug costs and public sector stock outs were associated with the market for private sector drugs, measured by the number of private pharmacies surrounding government health facilities.
At each visit in the 15 days prior to the survey, individuals obtained 2.6 drugs, 86% of which were obtained in the private sector. At visits to government facilities, 2.9 drugs were obtained, 72% of which were purchased in the private sector with 51% of OOP spending disbursed to purchase drugs. More than half of all CHE among government health care users was due to OOP drug spending alone. Among public health care users, 62% of all variation in OOP as a share of consumption expenditure was explained by whether drugs were purchased in the private sector, and 14% was explained by the number of drugs obtained. Users of health care at public facilities were more likely to obtain drugs from the private sector when overall drug stocks were low. Average stocks were lower where the density of private sector pharmacies was higher.
Spending on drugs in private sector pharmacies is a major contributor to the poor financial risk protection observed in the state of Odisha. Public health facilities may be relying on the private sector to fill gaps in supply of drugs. To reduce CHE, the government must consider the market for private sector drugs and the supply of drugs in the public sector, including whether patients prefer the private sector to the public sector for obtaining pharmaceuticals.
Presentation 2: Who goes where, and why?
Presenter: Jan Cooper
One goal of health systems reform is to ensure that access to care will generated improved population health outcomes while reducing the financial risks associated with using health services. Yet the interrelated and complex dynamics of a health system make it challenging to pinpoint which reforms will ensure that health care is well organized and delivered effectively, and that scarce resources are distributed efficiently and fairly. How, and how effectively, citizens access care provides important insights for reforming a health system.
Access to care is shaped by the demand for health services and how these services are supplied by the health sector. Interventions (for example, information campaigns or incentives programs) have had some success at improving the uptake of health services. However, access to care is only effective at improving a health system’s end goals (i.e. good health outcomes among satisfied citizen who are protected from the financial risks of health care) if it takes place in a context of high-quality care by providers in facilities that work efficiently. Here, we analyze how citizen’s access to care is situated within the broader ecosystem of health providers. Looking at access to care in the context of the mix of public and private providers, organizational efficiency and quality can highlight the types of reform options needed for a more effective health system.
Our analysis is based on a cross-sectional household survey conducted in six districts of Odisha. We link household surveys to surveys of facilities where respondents sought care, and map the ecosystem of providers in a region. We use descriptive analyses of health seeking among key demographic subgroups of the population. We situate these patterns of health seeking within the mix of public, private and informal providers within a region and draw on analyses of how efficiently facilities provide care and the quality of care provided.
Preliminary analyses indicate that while the majority of respondents report access to health services, there is significant variability in availability and use of public versus private providers. Our analysis will explore over-use or foregone care across demographic subgroups and within the landscape of private and public providers in each region.
Linking care-seeking patterns to analyses of provider quality and efficiency provides insights on new ways the health system can achieve its end goals. Furthermore, analyzing the relationship between access to care and provider characteristics in the context of a region’s mix of public and private providers can help disentangle the complex dynamics within the health system, and point to new opportunities for reform.
Presentation 3: Quality for primary care in India: an assessment of competence among public and private sector providers in Odisha, India
Presenter: Anuska Kalita
Evidence confirms that health systems with strong primary care are more likely to achieve better health outcomes, more equity in health, and greater efficiency. India’s health system faces many challenges in achieving these goals. As an effort to address gaps in primary care, the government’s Ayushman Bharat program (2018) aims to build Health and Wellness Centers (HWCs) – public sector facilities that are envisioned to deliver primary care. While this is an ambitious endeavor, it is important to examine this program in the context of the quality of healthcare services in India. For primary care programs to successfully improve the population’s health outcomes and achieve health system goals, timely and correct treatment delivered by providers is critical. Poor competence of primary care providers to correctly diagnose and treat patients could lead to delayed care that results in preventable complications, often requiring several healthcare visits, expensive hospitalizations, and wasted spending on unnecessary treatments.
In this paper, we assess the competence of primary care providers in both public and private sectors in the state of Odisha in India; and examine differences between these two types of providers on three parameters: competence to make a correct diagnosis, knowledge of the diagnostic process, and competence to provide correct treatment.
We use data from a survey of 110 providers in public and private sectors who were administered clinical vignettes on five illness conditions. The survey was undertaken in six districts of Odisha, one of the poorest states in India. The public sector providers included physicians at government-run primary health centers, and the private sector providers included those engaged in solo-practice, irrespective of medical qualifications.
We find that competence of both public and private providers is poor. Overall, only around half the providers could correctly diagnose the conditions presented in our vignettes. Public sector providers showed poorer competence to both correctly diagnose and treat most common conditions, compared to private sector providers. A majority of providers from both sectors prescribed a high number of incorrect and unnecessary drugs, with public sector providers prescribing more number of drugs for each condition. Further, providers, especially those in the public sector, did not refer patients even for conditions that mandatorily require referrals for appropriate care. The widespread misdiagnosis of common conditions, the prescription of a high number of unnecessary drugs, and a lack of referrals raise concerns for meaningful access and health expenses in a context where primary care is uninsured.
Most programs in India have focused on expanding coverage and access. Given the abysmally low competence of primary care providers in general and public sector providers in particular, India’s policy efforts towards improving access to primary care need to be re-examined. It is time that these programs go beyond access to include access with quality. Our findings have relevance for health systems like India’s with healthcare markets with little de facto regulation and significant market failures arising out of information asymmetry.
Presentation 4: Understanding the organizational structure of healthcare facilities in Odisha, India
Presenter: Bijetri Bose
Health systems in many low- and middle-income countries suffer from the inefficient use of labor in the form of shortage, absenteeism, and low productivity of healthcare workers. A standard solution has been to implement monitoring and reward schemes for providers. However, such reforms are often met with limited success because they fail to address the insufficient incentives inherent in the organization of healthcare facilities. For example, in an experimental study in India where nurses’ absence in government health facilities was recorded and punished, the authors found that the administration undermined the scheme. Such experiences have led to the increasing acknowledgment of organizational reforms as an essential part of health systems reforms. Therefore, it is crucial to examine the organizational structure of healthcare facilities as a significant determinant of their behavior.
In this paper, we seek to study the organizational structure of public healthcare facilities and examine whether these are associated with the indicators of provider efficiency. We follow the framework developed by Preker and Harding, in which five elements of hospitals’ organizational structure have been identified. These are the allocation of decision rights, distribution of residual claims, degree of market exposure, the structure of accountability mechanisms, and provision for social functions. The framework also highlights the importance of considering three factors that are external to the facilities – the relationship between the government and facilities, input and output market environments, and funding and payment systems – when examining the organization structure.
Using organizational level data from a survey of health care facilities conducted in six districts of Odisha, India, we provide a descriptive analysis of each of the five elements. Officers-in-charge at government hospitals at all levels of care were asked detailed questions on the facilities’ internal administration, management, finances, decision-making autonomy, accountability mechanisms, market exposure, and others. These questions allow us to measure the degree to which the five organizational elements in public facilities depart from the private sector’s incentive regime. A review of government documents and the literature is used to supplement the survey data and provide information on externals environments. Further, we exploit detailed provider-level data to assess the relationship between the elements and the efficiency outcomes.
Results & Conclusion
Our analysis highlights the inconsistencies in the five organizational elements in public healthcare facilities, We also find that the provider-related problems observed in the health system are associated with some of the organizational elements. An analysis of each element is necessary to formulate an appropriate reform package that corresponds to the internal and external environment of facilities. Although specific aspects of each organizational element have been explored individually, this study takes a comprehensive approach to study the role of organization structure in healthcare providers’ underperformance. In doing so, it contributes to the understanding of provider efficiency and productivity.
Individual Session, related to Odisha Assessment
Political economy of health reform in India – unpacking agenda-setting for the world’s largest health insurance program
Presenter: Anuska Kalita
The Indian government announced its flagship health insurance program – the Pradhan Mantri Jan Arogya Yojana (PMJAY) in August 2018. A government-sponsored health insurance scheme, PMJAY aims to cover ~500 million people, making it the world’s largest health insurance program. Although India has had several health reforms before this, the distinction of the PMJAY has been the high media attention, political and electoral interest that it has received, including being an issue in national elections. In a country where health and health insurance have been historically absent from political agendas and public discourse, the interest in the PMJAY is thought-provoking.
This study analyzes the political economy of the agenda-setting process for the PMJAY and examines how it has sustained public and political interest.
Data and Methods
The study uses a unique set of data from three categories of material: (i) media articles published between 2014-19 in leading national dailies, (ii) election manifestos of the two main contesting political parties (the Bharatiya Janata Party or BJP and the Indian National Congress) during the two legislative elections in 2014 and 2019, and (iii) the debates and questions in the Indian parliament (the two legislative houses) between 1999 and 2017 on topics of health, health insurance, and the PMJAY. The study uses content analysis and applies Kingdon’s Multiple Streams Framework to examine the data.
Our analysis shows how Kingdon’s separate streams of problems, politics and policies came together at a critical time in India, leading to the announcement of the PMJAY and sustained it as a politically salient issue. The problem stream had two sets of problems – one, the issues of corruption and policy-paralysis (associated with the pre-2014 Congress rule), and two, high out-of-pocket expenditures faced by a majority of the Indian population. The political stream included the change in the status quo, with the BJP coming to power in 2014 after decades of Congress-rule. The absolute majority won by the BJP in 2014, and 2019 reduced the role of legislative veto-players to either question or oppose the PMJAY. Together with policy entrepreneurs, political leaders acted in the policy stream to design and roll-out the PMJAY with unprecedented speed and newly set-up unconventional institutions. The choice of its name and branding of the program contributed to the sustained public and political interest in the PMJAY.
Research on the political economy of health reforms in India is scarce. Most research has focused on either description of health policies or their evaluation. Studies on the political economy of a program of the size and scale of PMJAY are even scarcer. This study attempts to address this gap in the literature. The paper throws light on the importance of the role of political economy factors in health reforms. It underscores the importance of conducting such analyses to inform better policy design as well as increase the chances of better policy-adoption by political leaders.
Individual Session, other
Reproductive Autonomy in Modern Family Planning Care: A Critical Assessment Using Data from 68 Low- and Middle-Income Countries
Author: Liana Woskie
Background & Objectives: Improving women’s autonomy is a key policy goal globally. Access to, and uptake of, modern family planning (mFP) services can facilitate autonomy through increased labor force participation, social mobility and economic freedom. However, the extent to which women are able to exercise reproductive autonomy in their choice of mFP care is not well understood and is often assumed in global accounting of reproductive care coverage. As we celebrate the recent conclusion of the Family Planning 2020 (FP2020) Agenda, we require a critical re-examination of progress focusing on women’s ability to exercise free choice within mFP.
Methods: We use data from the Family Planning Estimation Tool compiling country data from the Demographic and Health Surveys (DHS), Performance Monitoring and Accountability 2020 (PMA2020) surveys, Multiple Indicator Cluster Surveys, and Reproductive Health Surveys. We examined progress on Family Planning 2020 using a subset of available variables from an reproductive autonomy framework developed by Senderowicz et al and the WHO InteragencyStatement on Eliminating Forced, Coercive and Otherwise Involuntary Sterilization. We also look at methods available at the point of purchase and calculate a Herfindahl-Hirschman Index (HHI)of concentration to examine the distribution of mFP methods in use; an indirect measure of available choice. The study population was surveyed women across 68 low-and middle-income countries targeted by FP2020 between the ages of 15 and 49 years.
Results: We find that approximately 53 million women gained access to mFP in study countries between 2012 and 2019. However, of these women 10.1% reported they did not make the decision to use their current mFP method; the choice was made by someone else e.g. a spouse or healthcare worker. In almost every country, autonomous choice of mFP method was lower within the poorest wealth quintile. In addition, even if a decision was made autonomously, 39.7% of women lacked the information required for informed consent, such as: knowledge of alternative mFP methods or known side-effects of a given method. We observed wide between-country variation: 83.9% of women lacked this information in Pakistan, while only 27.3% did inSenegal. Method availability at the point of purchase was better, though this also varied significantly by country with an all-country mean of 75.7% (primary care facilities with 3 or more methods available) and a number of countries falling below 30%. Concentration of mFP methods ranged with HHI-scores from 1,768 in Bolivia (relatively low concentration) to 9,040 inDPR Korea (highly concentrated), where as many as 95.1% of women were using an IUD.
Conclusions: While the 1990s marked a shift towards women’s empowerment and away from population control in mFP, an assessment of available data raises concern. Taken together these results suggest that the continued practice of centering mFP success on the volume of women covered may mask issues of low autonomy and empowerment. This is of particular relevance given the renewed focus on mFP in the face of climate change, higher rates of compromised autonomy amongst poor women and the prominence of permanent mFP methods.