Health Care System in India: Towards Measuring Efficiency
in Delivery of Services, Brijesh C. Purohit (Gayatri Publications:
Delhi), 2010; pp XI+187, Rs. 600.
All over the world, concern is growing about efficiency of
the health care system. The concern is severe in case of developing
countries with different socio-economic backgrounds wherein citizens
face distressingly different prospects of living a healthy life. There
is widespread disparity in various measures of health between the
privileged and the deprived despite the long-term tendency towards
convergence of a healthier society. In industrial countries, there is a
shift in the health care system from the principle of universal access to
a more market-oriented system that is causing growing disparities. The
rise in income inequality is another potential problem creator. Policy
makers worldwide talk about efficient delivery of essential health care,
but disagree on what counts as essential and on the optimal mix of
private and government components of service. In Indian context, the
current book has the answer to this short of pertinent questions.
It is properly mentioned in the book that the health care system
performance could be monitored with either in terms of efficiency,
effectiveness, or economy. Efficiency indicator is rightly defined as
“the extent to which a health agency or health system maximizes the
output produced from a given set of inputs or minimizes the input cost
of producing a given set of outputs”. This has been accurately estimated
by deploying ‘frontier efficiency measurement techniques’. Some of the
techniques discussed are capable of making sensible analysis on health
care system at national and sub-national level. The secondary sources
of statistics provided in the book relating to health care system ranges
from the First Plan period to the current decades is amazingly great. The
study under the aegis of the National Commission on Macroeconomics
and Health of the Government of India compared 14 major states as its
focus as well as all-India and a sub-State level analysis of five States
(Punjab, Maharashtra, Karnataka, Madhya Pradesh and West Bengal).
The whole gamut of questions are addressed with appropriate statistical
techniques and having contemporary relevance.
In recent years, with growing public attention to the problem of
health inequalities, a huge literature has accumulated regarding the
link between socio-economic factors and health. Effectiveness is the
extent to which programs and services (outputs) of a system achieve
the desired outcomes. “Economy refers to buying appropriate quality
resources or inputs in the most economic manner (or at least cost)”.
Among various lines of recent research, the influence of income
inequality on health is perhaps the most popular area. Over the last
decade, a series of studies have provided evidence that the extent of
income inequality in society is negatively associated with the health
status of citizens, based on cross-sectional comparisons between and
within countries and at sub-national level.
Statistical Measurements
Three broad approaches to economic performance measurement
are generally used. These are (i) index number technique; (ii) statistical
programming approach; and (iii) mathematical programming. These
empirical testing led to a controversy over the pathway through which
income inequality affects individual health status. Some of the researchers
have largely focus on the negative effects of psycho-social stress resulting
from the perceptions of relative deprivation and the disruption in social
cohesion that are more prevalent in unequal societies. This hypothesis is
substantiated by the finding that more egalitarian societies exhibit more
cohesion, less violence, lower homicide rates, more trust, lower hostility
scores, and more involvement in community life.
The ‘stochastic frontier analysis’ and ‘data envelope analysis’
hypothesize the fact that: “States differ in their technical efficiency
pertaining to health system due to the factors which requires emphasis in
health facility planning”. It is also hypothesized that these factors differ
from State to State according to their level of development. A number
of studies have raised concerns about the validity of the empirical
relationship between income inequality and health. It is the level of a
country’s income, rather than the degree of inequality, that is crucial. An
interesting exception to these usual patterns of health care disparities is
New Zealand, where the poor were found to receive either appropriate
or slightly excessive use of services given their estimated health needs.
This may be explained by the effects of a continued restructuring of the
New Zealand public health system that focuses on providing decent
minimum care.
As the review of the literature on healthcare reveals in this book,
economists and epidemiologists are primarily focused on empirical
issues: establishing the facts on differences in health care by socioeconomic
status, and measuring the impact of inequality on health
outcomes. Discussions of such normative issues as how much of national
resources ought to be devoted to health care or how these resources ought
to be distributed within the population are left largely to legislatures and
to various socio-economic organizations and think-tanks. International
institutions, such as, the World Health Organization (WHO) and
International Labour Organization (ILO) have called on all countries to
guarantee delivery of “high-quality essential care to all persons, defined
mostly by criteria of effectiveness, cost and social acceptability”.
Major Findings
As incomes rose, the public demand for health services increased
much more rapidly than income (because of the high income elasticity of
the demand for health care), making the cost of operating such systems
unsustainable. In Indian case, as the book reveals, there is widespread
disparity prevalent across rural and urban areas, poor and rich states
and a notable neglect of some of the emerging needs of the society.
Public sector investment has rather come up as a less efficient system
thus providing a major impetus to the private sector for an investment
which is more inequitable and less regulated. It has been rightly pointed
out that inefficiency in public sector health care services has been a
propelling factor for the private sector services (NRIs, Industrialists
and Pharmaceutical companies played pivotal role) to expand more to
compensate for inadequacy in care.
There is no clear agreement currently on the optimal mix of private
and government components of health care services. There is not much
of a literature on this question, nor is there a consensus on the criteria
that should be invoked to resolve the issue. Moreover, conditions vary
so much from country to country that the optimal mix cannot be the
same for all countries.
Since deaths due to infectious diseases are now a small proportion
of total deaths, it might seem that environmental improvements that
were so important in reducing health risks have been exhausted. Such
a conclusion is premature. A series of recent studies has reported a
connection between exposure to stress (biological and social) in early
life, with the onset of chronic diseases at middle and late ages, and more
so with reduced life expectancy. The strongest evidence for such links
that has emerged thus far is with respect to hypertension, coronary heart
disease, and type II diabetes.
The urgent needs include the distribution of drugs to combat
tuberculosis, malaria, and acute gastrointestinal and respiratory infections;
vaccines to prevent measles, tetanus and diphtheria; and improved
nutrition in order to revitalize immune systems, reduce pre-natal and neonatal
deaths, lower death rates from a wide range of infectious diseases,
and improve the functioning of the central nervous system.
It is likely that past public health reforms, improvements in nutrition
and other living standards, and the democratization of education have
done much more to increase longevity than has clinical medicine.
The main thing that physicians do is to make life more bearable: to
relieve pain, to reduce the severity of chronic conditions, to postpone
disabilities or even overcome some of them, to mend broken limbs,
to prescribe drugs, and to reduce anxiety, overcome depression, and
instruct individuals on how to take care of themselves.
Missing Priorities
Although the access to health care matters, insurance does not
guarantee adequate access. An important but poorly addressed issue in
this book is how different attitudes toward risk influence the insured and
the uninsured in deciding when and where to seek health care. This issue
is important when considering solutions to those who are under-served
in health care, since under-service of the poor also exists in countries
with universal health insurance. If the poor and the young are willing
to accept higher health risks than are the rich and the elderly, merely
extending entitlements may not be adequate. An aggressive outreach program, targeted at those who fail to take advantage of entitlements,
may be required.
The most effective way to improve the health system for the poor
is by identifying their most urgent needs and designing an effective
way of administering to those specific needs. This goal will not be met
merely by equalizing the annual number of visits to doctors (since the
rich often waste medical services) or the annual expenditures on drugs
(since the rich often overmedicate). Focusing on the specific needs of
the poor may not save money but it will insure that whatever is spent is
properly targeted.
A second priority that is missing is improved health education and
mentoring to enable poorly educated people, both young and old, to
identify their health problems: (i) to be able to follow instructions for
health care, (ii) to properly use medication, and (iii) to involve them in
social networks conducive to good health. It is not enough to wait for
such individuals to seek out available services. Outreach programs can
be developed to identify the needy individuals and this can be done
in the most cost-effective way by organizations already experienced
in outreach, so that they can include health screening and counseling
among their services. Systems for monitoring the effectiveness of such
community organizations also need to be established.
Another point that needs prioritized attention in the study is the
reintroduction of health care education into public schools, particularly
those in poor neighbourhoods, from nursery school through the twelfth
standard of periodic health screening programs using physicians and
nurses on a contract basis. Personnel could be employed to ensure that
parents understand the nature of their children’s problems and who can
direct the parents to public health facilities that can provide appropriate
health care services.
Narayan Chandra Pradhan*
* Narayan Chandra Pradhan is Research Officer, Department of Economic Analysis
and Policy, Reserve Bank of India. |