VR Muraleedharan, Umakant Dash, and Lucy GilsonPresented at NHSRC, New Delhi, 13 December 2013

Good Health at Low Cost 25 years on. What makes an effective health system?Dina Balabanova & GHLC project teamhttp://ghlc.lshtm.ac.in

Primary Question?

.the Good health at low cost report sought to describe how some developing countries were able to achieve better health outcomes than others with similar incomes

New countries: Bangladesh, Ethiopia, Kyrgyzstan, Tamil Nadu, India, Thailand

Original countries reviewed: China, Costa Rica, Kerala, Sri Lanka

.the Good health at low cost report sought to describe how some developing countries were able to achieve better health outcomes than others with similar incomesCountry Selection: Preston Curve (Income vs Life Expectancy)Countries/Regions with significant improvement in MCH/RCH indicators Countries/Regions not known to have spent lavishly on healthcare low public spending compared to many others in similar income levelCountries/Regions known to have implemented reforms, large scale

VR Muraleedharan, Umakant Dash, and Lucy GilsonNHSRC, New Delhi

ObjectivesQuestion: how certain factors, individually and combined, contributed to improvements in health and access to key services (beyond what could be expected at their income level):Factors related to the health system;Factors related to living conditions and public services (policies in other sectors);Factors related to the institutional environment (political, economic, social);Factors related to the context (geography, climate etc.)

Conceptual framework: Good health at low cost 2011

Historical approachHistorical approach chosen aiming to:construct rich analytical case studies tracing pathways to good health, by which good health at low cost is achieved over long periods of timeanalysis reflecting interplay of different factorsrecognise path dependency of health systems development establish temporal and plausible relationships

pattern recognition within and between countries

MethodsHistorical case studies mix of quantitative and qualitative methods: Secondary analyses/synthesis of existing dataAnalysis of documentsSemi-structured interviews (policy-makers, providers, managers etc.)Qualitative survey25 in-depth interviews and 2 focus groupsNational/State level: MOHFW, MOH (Tamil Nadu), NGOs etc.District level: health facilities, Social Departments under local authorities(Dharmapuri, Madurai, Salem, Coimbatore)Experts from International organizations: WHO, WB, UNICEF

MCH Indicators

Utilization of public out-patient and maternal delivery services: Quintile wise analysis (Source: Girija Vaidyanathan, Debashis Acharya et al (2010), Do the Poor Benefit from Public Spending on Healthcare in India?: Results from Benefit (Utilization) Incidence Analysis in Tamilnadu and Orissa

Concentration Curves for Delivery Services in Tamil Nadu Rural and Urban: 1995-2004 Tamil Nadu_R 1995-96 Tamil Nadu_R 2004

Tamil Nadu_U 1995-96 Tamil Nadu_U 2004

Concentration Curves for IP Services in Tamil Nadu Rural and Urban: 1995-2004TN Urban 1995-96TN Urban 2004

TN Rural 1995-96TN Rural 2004

Source: Girija Vaidyanathan, Debashis Acharya et al (2010), Do the Poor Benefit from Public Spending on Healthcare in India?: Results from Benefit (Utilization) Incidence Analysis in Tamilnadu and Orissa

Interventions leading to health gain: Health Systems RelatedRapid Expansion of PHC/HSC network (80s till early 90s)Introduction of Multipurpose Workers (since early 80s)High ANC level (20% in 1990 to 95% in 2006)Expenditure on primary health careAbout 35% of the budget on primary health care (last 20 years)Pubic Health Cadre/District Public Health Management (1950s)Creation of quasi-government bodies (programme specific): mid 90sInnovative Drug Delivery System (improved quality, reduced costs, etc) mid 90sVaccination Programme since early 80s and high utilization rate (early 80s)High Institutional Deliveries;Strengthening First Referral Units (mid 90s) Use of Indigenous medicines through PHCs/Secondary Hospitals

The existence of a separate cadre with its separate budget helped develop long-term planning to avert outbreaks, manage endemic diseases, prevent disease resurgence, manage disasters and emergencies, and support local bodies to protect public health in rural and urban areas.

A key observation Greater and rapid Utilization and

more efficient utilization of central funds

[Note: We are talking about Relative Efficiency]Higher Managerial Capacity

Health Gains: Role of other (non-health) factors Low fertility rate (TFR 2.1 by early 90s)Several factors responsible (including Female literacy, female autonomy, higher age at marriage)Better Infrastructure (TN state ranked within top 4 states in terms of overall infrastructure index; 1970s-1990s)

Higher Industrialisation (leading to higher disposable income and access to health care)

Source: B. Ghose, P. De. Investigating the linkage between infrastructure and regional development in India: era of planning to globalisation, Journal of Asian Economics, 15 (2005) 1023-1050Non Health Factors: Infrastructure

Non Health FactorsTamil Nadu is one of the leading States in the industrial front at the national level. In terms of number of registered manufacturing factories, the State is placed in the first position for the several successive year since 1997-98. (15%-16%)

In terms of total number of persons engaged in various activities of production process also, the State ranked first and shared 15.0 per cent at the national level.

At the national level, in terms of fixed capital, productive capital, gross value of output and net value added, the State stands next to Maharashtra and Gujarat.

High Economic Overhead Capital Index, over the years

Higher disposal incomeleading to better opportunities to seek care from private providers

Share of states in industrial output of India Source: Suresh Babu M. Rajesh Raj S N, Trends in Regional Industrial Growth in India, Manuscript

Share of states in employment 81-82 to 04-05 Source: Suresh Babu M. Rajesh Raj S N, Trends in Regional Industrial Growth in India, Manuscript

Key points..Innovative approaches have been used at various levels to address the most significant bottlenecks/barriers to the provision of primary health care services in underserved areasHigher utilization of pubic facilities by the poorer sections of societyStable and better managerial skills of the bureaucracyin the stateExpansion of private health sector (TN in particular) Tamil Nadus achievements in lowering the birth rate, improving gender equality and improving literacy rates, infrastructure and industrialization, among others

One clear Lesson for other states: Implement more faithfully the central programmes! There is much to be gained from the existing design of various programmes as such.

Key themes emerging from the research

GHLC: Bangladesh, KyrgyzstanPioneer in Family Planning Programme (Fertility drop)Primary Care (Deployment of HAs, FWAs);Role of non-state sectorDrug Policy 1976Innovator (Testing and adopting low cost technologies Zinc/childhood diarrhoea, Iodized salt, oral rehydration solution, delivery kits etc)Disaster PreparednessMicro Credit programmes Role of women --improvement in socio-economic status;

Political IndependenceImplementation of two national programmes (1996-2006, 2006-10)Shift from specialist oriented care to family practice;Implementation of basic benefits package UHC in primary careHealth sector reforms (contracting, single payer system; combination of tax based and mandatory insurance insurance; pharmaceutical sector; formation of village health committees; etc)Role of women parliamentariansDecline in poverty..

GHLC: Ethiopia, ThailandSince late 80s, stable and participative government; High priority on health care (as a way to alleviate poverty)85% have access t0 primary careRole of Development Partners highHugh deployment of Health Extension Workers (2003)District planning and village communities in planning etc.Task shifting (Nurses to take up more tasks); use of private high schools in training mid-level health professionals; etc)Emphasis on access and uptakeCreation of Pharmaceutical Funds and Distribution Agency;

Focused MCH and Primary care interventions (to reduce mortality from lower respiratory tract infections, heat failure, septicaemia, communicable and parasitic diseases and diarrhoea) among children under 5 yearsHigh priority (Govt and Royal Family support)Pro-poor/Pro-rural financing schemesSeries of financing initiatives over the past 20 yearsRole of PH professionals and health workers back bone of rural health system

GHLC 1985, 2011: what matters for good health: Political commitment to health as a social goal Strong societal values of equity, political participation and community involvement High-level investment in primary health care and other community based services Widespread education, especially of womenIntersectoral linkages for health

Major Challanges: Make efforts to Integrate complementary programmes (water, sanitation, nutrition, etc)evidence is not robust; (impact of nutrition programme not as positive as expected over the past 20 years) High proportion of neonatal deaths and presence of preventable Maternal deathsNeed for better disease surveillance systemHigh Out of Pocket ExpenditureRegulatory Issues

One key lesson for ourselves: (could we have done better? can we do better?Scare public resources:Define more clearly the benefits packageat primary level.

Implement vigorously to make it Universal (access)over a period of time

All strategies (such as PPP) should emanate from this framework

Dependence of the poor on Private Providers: Proportion Of People From The Lowest Two Quintiles Reported For Hospitalization With Respect To Major Ailments In Private Health System In Urban Tamil Nadu (NSS 60th Round, 2004)

GDP PPP per capita in USDTotal fertility rateInfant mortality rate per 1000 live births (2007) % Life expectancy at birth (years)* Under-5 mortality rate per 1000 live births** (2006)Maternal mortality rate 20042007@Full immunization (20022004)^(2009)#(2006)$(20022006)States/IndiaMaleFemale1. Andhra Pradesh319725462.965.587.715462.92. Assam18752.76658.659.38548019.33. Bihar10684.25862.260.484.831224.44. Gujarat38492.75262.965.260.916057.75. Haryana53862.75565.966.352.318662.96. Karnataka32442.14763.667.154.721374.17. Kerala38541.71371.476.316.39581.28. Madhya Pradesh16923.57258.157.994.213032.59. Maharashtra42882.1346668.446.733574.310. Orissa23032.57159.559.690.630355.111. Punjab41332.14368.470.45219275.312. Rajasthan21103.56561.562.385.438825.413. Tamil Nadu35221.7356567.435.511192.114. Uttar Pradesh14624.26960.359.596.444028.115. West Bengal283923764.165.859.614154.4India29302.85562.664.274.325447.6

Key MessageDespite low public spending on health care (TN spends not more than 1% of SGDP, as most other states);High out of pocket expenditure on health care (About 4% of expenditure is from private sources);

The challenge is to maximise the health gains from the scarce government funding for healthcare;TNs experience highlights where and how this scarce public funds could bring about greater health gains than is achieved in other states/countries.

As a former health sectary (with the Government of India) put it:

The TN state had much better combination of managerial skills at various levels, from state secretariat to district health system and even below. In my six years of association with this sector, I would say, no other state could boast of having such a blend of professionals. I would even say that overall the administrative efficiency of the state health system is far higher than that in other states of India Much of these changes should be attributed to the efforts of VHNs and the overall presence and functioning of the primary health delivery system in the state, as a senior official (now retired) commented.

The existence of a separate cadre with its separate budget helped develop long-term planning to avert outbreaks, manage endemic diseases, prevent disease resurgence, manage disasters and emergencies, and support local bodies to protect public health in rural and urban areas.