Zeena Johar and Grant Miller

Fixing Health Care in India: Roundtable participants looking at incentives, disincentives embedded in the system

India gave health the highest priority in its 12th Five Year Plan issued in 2012, with a clear intent to increase public financing of health to 2.5 percent of India’s GDP over the next five years. Universal Health Coverage (UHC), as defined by High Level Expert Group Report on Universal Health Coverage for India, promises to ensure to all citizens of India a package of predefined services at the primary, secondary and tertiary levels.

However, neither rapid economic progress nor greater health spending alone is sufficient for the effective delivery and widespread uptake of health services or technologies. Delivery, adoption and use of health services and technologies depend critically on very real incentives and disincentives embedded in institutions and communities. Only by properly understanding and addressing these often hidden incentives and disincentives can large-scale health programs achieve their full potential.

The Stanford India Health Policy Initiative is poised to identify and examine these issues through the creation of a group focused on understanding these on-the-ground challenges. At its inaugural roundtable, a small, intimate event, the attempt was to:

A) Develop facts on “behavioural obstacles” to uptake of health policies or programs in the rural Indian landscape based on the experiences of its members;

B) Develop key priority areas to focus collaborative projects among stakeholders at the Stanford India Health Policy Initiative and their counterparts in India;

C) Conduct real-time investigations to address the on-the-ground realities in care delivery in rural India identified by this group.

The roundtable was jointly hosted by the Stanford India Health Policy Initiative and the Centre for Policy Research in India. It brought together a select group of close to 35 bureaucrats, practitioners, health care entrepreneurs and academics. Among those participating in the discussion was the previous secretary of India’s Ministry of Health and Family Welfare, plus representatives of the National Health Systems Resource Centre, RSBY (India’s government-run health insurance program for the poor), CARE India, and the Indian Institute of Management Bangalore.

Discussions focused on the distinctions between public and private sector health service delivery – and hybrids of the two – in rural India. After two days of discussions, three questions were identified as top priority areas for investigation by the group.

Q1: What are the broad motivations (beyond financial) of the formal sector and informal sector health care providers that may explain variation in their performance?

Much of provider performance can be explained by the financial incentives that providers face. However, many other factors – including intrinsic motivation to improve patient welfare, career concerns for promotion and professional advancement, and importance placed on the perceptions and esteem of peers and community members – surely play a significant role as well. Identifying and mapping these broader motivations is critical for the design of effective health delivery strategies that move beyond narrow reliance on financial incentives. Foundational questions include where and how providers receive their training, why they chose their profession and what guides their behaviour with patients. All ultimately require first seeing the world through the eyes of the providers themselves (across the spectrum – including public, private and informal sector providers) and using this perspective to better understand what will best motivate them to improve their performance.

Q2: What do patients value in “irrational medicine” (or do they demand “irrational medicine” simply because they are uninformed)?

Rational use of medicine is sometimes defined as patients receiving medications appropriate to their clinical needs, in doses that meet their individual requirements for clinically-appropriate periods of time. Many practices in rural primary care appear to deviate from this; for example, inappropriate and ineffective use of IV fluids, antibiotics and steroids. Formulating strategies to address these practices is complex because if patients value them and are willing to pay for them, they will be provided. An important priority identified by the group is therefore developing an understanding of demand for “irrational medicine.” Is it simply due to misinformation among patients, or are other aspects of this style of care desirable and valued? Understanding the determinants of patient choices about irrational medicine is essential for designing approaches to combat inappropriate medical practice.

Q3: What should the government’s stance toward informal sector providers be?

While the government of India has conducted multiple drives to shut down unqualified and unregistered practitioners, the prevalence of informal sector providers in India is still high. The “anti-quackery bill” aims to prescribe a maximum punishment of life imprisonment for quacks. However, poor rural patients are often not well-served by the public sector and often turn to the informal sector for health care. Should the government escalate its efforts to reduce informal sector provision – or could informal sector providers instead be trained to provide simple interventions requiring very little medical skill?

Looking forward

The goal is to design real-time projects that address priorities identified by the forum. Behavioural obstacles – human factors that limit optimal utilization and delivery of available health care services (public or private) – are as important as the adequacy of health care infrastructure, human resources and medical technologies. A collaborative and synergistic platform that brings together stakeholders from across the health care value chain is critical to ensure systematic, evidence-based delivery of health care services for India.

Based on the priorities identified by the roundtable, in the next year the initiative will focus on examining rural household provider choices, various illnesses and will investigate the motivations of formal and informal health providers in providing care. The Stanford India Health Policy Initiative will define its success by the role it plays as a catalyst for the health care sector in India, in times when traditional health care models are disruptively innovating to include the vulnerable and the inaccessible.

Zeena Johar is the co-founder and CEO of SughaVazhvu Healthcare in India and Grant Miller is an associate professor at Stanford.

Education, Environment, Health Care
public health