PHM-Exch> Selected Readings on Indian Health Systems

Fri Dec 9 21:41:49 PST 2011

   From:    km at iphindia.org
  Selected Readings on Indian Health System
**

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       Issue.2 October 2011*

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We are happy to present you with the second issue of ‘selected readings on
Indian health systems’. You can check out the earlier one
here<https://docs.google.com/a/iphindia.org/viewer?a=v&pid=sites&srcid=aXBoaW5kaWEub3JnfGtub3dsZWRnZS1tYW5hZ2VtZW50fGd4OjIzNmQzZjMyN2U4OTE3OTU&pli=1>.
This is one of the initiatives of the Indian Hub on Health
Systems<http://www.iphindia.org/resources/ihhs>at Institute
of Public Health <www.iphindia.org>, supported by
SWIHPS<http://www.itg.be/itg/generalsite/Default.aspx%3FWPID=705%26MIID=528%26L=E>(Switching
International Health Policies & Systems) network. We compile selected
recent articles on Indian health system from national and international
journals and get it reviewed by public health experts for your ease in
selecting the relevant readings. This issue carries six scientific papers
and a few relevant news items. This time, we have included two papers about
health insurance, much talked about issue in the country; one on evaluation
and another more broadly on providers’ perceptions of insurance. We have
one paper each on public-private partnership and reforms (needed) in
community health education. Finally we included couple of papers health
services/challenges in general. We welcome your feedback as well as
volunteers to suggest/review papers for future issues. You can reach us at
dipalee at iphindia.org. Wish you happy reading!

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*Scientific articles***

*1.     **Evaluating the RSBY: lessons from an experimental information
campaign **[Reviewed by Tanya Seshadri]*

Jishnu Das and Jessica Leino

Economic & Political Weekly August 6, 2011 vol xlvi no 32

 In this paper, the authors use the experimental nature of information,
education, and communication (IEC) campaign and a household survey to
estimate the causal effects of IEC on enrolment and hospital claims. After
a brief review of the rollout of Rastriya Swasthya Bima Yojana (RSBY) in
India and its important shortcomings, authors describe the issues with
implementation of the scheme in Delhi, thus, providing the context of this
study. In the remaining sections, the empirical strategy, research
methodology, and results have been clearly described in detail.

 Interestingly, the study finds that IEC by itself had no impact on
enrolment in the scheme while it did have an impact on utilisation among
enrolled households. The household survey itself was found to increase
enrolment possibly attributed to the ‘hawthorne effect’. From
administrative issues to methodological issues, the findings have been
discussed keeping the limitations and possible implications in mind. The
results of this study also have implications for the design of evaluations
of the RSBY programme not only in Delhi but across the nation.

 This paper is useful for programme managers and health researchers who are
involved in planning, implementation, and particularly evaluation of IEC
campaigns for any programme.

Click here for full text
article<http://beta.epw.in/static_media/PDF/archives_pdf/2011/08/SA_XLVI_32_060811_Jishnu_Das.pdf>

<http://beta.epw.in/static_media/PDF/archives_pdf/2011/08/SA_XLVI_32_060811_Jishnu_Das.pdf>

*2.        **Health Insurance in India—A Study of Provider’s Perceptions in
Delhi & the NCR [Reviewed by Thriveni BS]*
Rohit Kumar, K. Rangarajan, and Nagarajan Ranganathan
Journal of Health Management 2011; 13 259-277

In this study, researchers attempt to understand healthcare providers’
perceptions about their relationship with insured, the insurer and the
third party administrators (TPAs). Study specifically looks at the
awareness among the insured people and their attitude towards treatment
cost and moral hazards as well as the role of TPAs and impact of cashless
services on the cost of treatment. The researchers study selected hospitals
that provided cashless services using a mixed method design (i.e.
unstructured interview with the insured and providers, and Likert scale to
study the perception of the health care providers).

 Authors report that 63% of hospitals felt that patients with cashless card
were more demanding and 61% of them did not care for the cost of treatment.
Patients with a cashless card preferred better category hospital rooms than
those without. Nearly 53% respondent did not agree that the hospitals were
making false/inflated bills or medical documents. Study revealed little
contradictory notion in those 64% providers strongly agreed that the TPAs
model is a successful model while on the other side 69% strongly disagreed
that payments by the TPAs were done within 20 days. Study discovered that
all categories of hospital preferred individuals from middle-income groups
for cashless benefits with less preference for those from lower and
high-income groups.

 The study shows that the level of awareness among the insured population
is low with regard to policy terms and conditions. This study has not
attempted to go beyond numbers to explore reasons for each finding. Finally
this study shows that the TPA model has not been successful in bringing
down the claim cost but has definitely helped in providing unbiased
services to the insured population, including cashless benefits.

Click her for abstract<http://jhm.sagepub.com/content/13/3/259.abstract?etoc>

 <http://jhm.sagepub.com/content/13/3/259.abstract?etoc>

*3.       **Predicting performance in contracting of basic health care to
NGOs: experience from large-scale contracting in Uttar Pradesh, India
[Reviewed by Prashanth NS]**
*

        Anna Heard, Maya Kant Awasthi, Jabir Ali, Neena Shukla and Birger C
Forsberg

        Health Policy and Planning, July 2011; 26 (1): i13-i19

**

Anna Heard and colleagues present the findings of a study of public-private
partnership (PPP) scheme in Uttar Pradesh (UP), where basic health services
provision has been contracted out to 294 non-governmental organisations
(NGO) since 2003 to till date. The scheme has seen high rates of
discontinuation and non-renewal and they undertake the study to understand
better the performance of such contracting initiatives. UP being the
largest state in the country “…has a considerable problem with the health
infrastructure”.

 In 2003-04, UP chose 73 NGOs and assigned one health post to each NGO
under a contract. The details of the PPP are provided in the paper.
Researchers explicitly defined outcomes that were assessed by a third party
using field-tested questionnaires with data analysed using factor analysis.
They perform a series of regression tests to understand the performance.

 The authors find that NGOs, which had experience in training field staff,
and the ones that had better quality project proposals, were more likely to
perform better. Interestingly, the assets of an organisation, its financial
turnover and number and volume of previous projects were not found to be
associated with a good outcome score. So was the case with previous
experience with health projects. The authors emphasised the training skills
of the NGO as an important predictor of good performance.

 The authors clarify that they did not assess whether contracting with NGOs
was better or worse than expanding government services. The paper is an
important contribution to the scarce literature on contracting-out and PPP,
which is being either increasingly advocated or criticised with hardly any
evidence either way.

Click here for abstract<http://heapol.oxfordjournals.org/content/26/suppl_1/i13.short>

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*4.       **A Study of Determinants of Use of Healthcare Services in India
[Reviewed by Maya Annie Elias]** *

        Gulrez Shah Azhar, Ali Amir, Najam Khalique, and Zulfia Khan**

International Journal of Medicine and Public Health July-September 2011;
1(3): 62-66

**

In this paper the authors have presented the findings of a study on the
health service utilisation patterns conducted in the district of Aligarh.  The
burden of illness and the healthcare seeking behavior were assessed both in
rural and urban settings. Household was used as the sampling unit for the
study. Authors report that presence of illness was high in the above-60
year age group followed by below-5 year age group both in rural as well as
urban areas. Researchers found that prevalence of illness was higher among
females in all age groups except below-5 years.

 Only about 20% illnesses were perceived to be severe, and the perception
about the severity of illness was the main reason in determining the
utilisation of services in rural areas. In urban areas, people did not seek
treatment due to poverty (58%). Of those seeking care, 44% of people had
the first contact with government facilities and 30.8% had visited private
facilities. The government facilities in the study area provided care at no
direct cost and authors attribute this as the reason for preference for
government facilities. Study found that the urban population used
government facilities more compared to rural, and authors discusses issues
in terms of access to services to explain this difference. Though the
authors themselves have raised concerns over the generalisability of the
study findings, the results show a similar pattern of the utilisation of
the health care services, as reported by many other studies.

Click here for full text
article<http://www.ijmedph.org/files/issue3/ijmedph07-092011_v1_3_p062-066.pdf>

 <http://www.ijmedph.org/files/issue3/ijmedph07-092011_v1_3_p062-066.pdf>

*5.      **Public Health Challenges in Kerala and Sri Lanka [Reviewed by
Raveesha MR]*

        C U Thresia, K S Mohindra
Economic & Political Weekly 2011;XLVI (31): 99-107

**

This paper is about public health scenario in Sri Lanka and a south Indian
state of Kerala, both having excellent health indicators similar to that  of
wealthiest countries in the world. Authors deliberate on factors that led
to these health achievements as well as current challenges and suggestions
for the future research/policy in Sri Lanka and Kerala.

 Authors summarises that historically the early health achievements were
mainly due to indigenous healthcare provision, and investment in education;
in colonial period due to efforts of the missionaries to adopt western
education and health care; and in post-independence period due to
governments pursuing free healthcare services, free education, widespread
public distribution systems, and land reforms. These consistent efforts
contributed for reduction of infant and maternal deaths and increase in
life expectancy. From the past three decades, shift in policies leading to
reduction in public investments in health, education, and public
distribution systems has adversely affected access to healthcare by poor.

 Authors highlight the persisting burden of Infectious diseases (namely
dengue, malaria, tuberculosis, and re-emerging infectious diseases) along
with poor sanitation, urbanisation, and environmental degradation worsening
impact of these diseases. Chronic diseases like diabetes, hypertension, and
cancers are on rise due to unhealthy diet, physical inactivity, and tobacco
use. Economic deprivation, suboptimal use of health services and
psychological stress contributed to chronic diseases. These societies carry
high burden of mental illness to the tune of 20 per 1000 population.  Suicide
rates in these regions are highest in the world, with Kerala reporting 26.8
per 1,00,000 and Sri Lanka reporting 23.9 per 1,00,000 populations per
year. These high suicide rates are associated with depression, family
stress, alcohol dependence, gender discrimination, and marital problems.
Rigid hierarchical structures and conflicts between individualism and
collectivism have been cited as other reasons for high suicide rate.

 Highest reduction of public health expenditure has happened in the recent
past in Kerala. On the contrary, highest increase has happened in private
funding in health care leading to substantial growth of private sector.
Private sector poorly regulated causing rapid increase in the medical
expenditure for users.

 In summary, authors have portrayed changing health scenario and outlined
public health challenges for Kerala and Sri Lanka through exhaustive
literature review. Regulation of private sector, increase in public
financing of health, attention to social determinants of health in various
domains including infectious diseases, chronic diseases, and psychiatric
illnesses are the apt agends for the policy makers and researches in the
near future in these settings.

Click here for full text
article<http://beta.epw.in/static_media/PDF/archives_pdf/2011/07/SA_XLVI_31_300711_C_U_Thresia_K_S_Mohindra.pdf>

<http://beta.epw.in/static_media/PDF/archives_pdf/2011/07/SA_XLVI_31_300711_C_U_Thresia_K_S_Mohindra.pdf>

*6.     **Are we really producing public health experts in India? Need for
a paradigm shift in postgraduate teaching in community medicine? [Reviewed
by Kavya Rangaswamy]*
Rajesh Garg, Sanjeev Gupta
Indian Journal of Community Medicine 2011; 36 (2): 93-97

 Authors in this paper evaluates the design, curriculum, course content,
the teaching methodology of the current post graduate course in community
medicine offered in India. Absence of a uniform curriculum across various
medical colleges, lack of clinical skill enhancement, limitation of course
content to text book learning and in addressing current and emerging public
health issues, scarce knowledge on existing field realities and prevailing
government programmes/policies are some of the important shortcomings put
forth in the paper. Authors argue that as a result of this deficient
course, the qualifying postgraduates are ill equipped to face the existing
and forthcoming health care challenges. They lack the skills and knowledge
to analyse problems, evaluate programmes and propose recommendations.

 Furthermore, authors advocate need for a paradigm shift in postgraduate
training. Major recommendations for such shift include: student-centered,
practice based curriculum addressing the current public health issues,
liaising with government departments and officers, exposure to diverse
departments within the hospital, enhancing skills on communication,
leadership, data analysis and journal writing skills, problem based
learning with integrated teachings and periodical revision of the
curriculum.

 This paper provides a very good insight about gaps in the current Indian
medical education especially on community medicine but the issues raised
are quite common to both undergraduate and post graduate education. While
the paper does mention the changing role of educator particularly in
reference to pedagogy, it does not recommend ways of improving their
current skills and knowledge and motivating them to bring about this change.

Click here for full text
article<http://www.ijcm.org.in/temp/IndianJCommunityMed36293-245813_064941.pdf>

 <http://www.ijcm.org.in/temp/IndianJCommunityMed36293-245813_064941.pdf>

*News*

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*1.     **Private sector involvement in women’s and children’s health is
crucial to saving 16 million lives, says UN Secretary-General*

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The UN Secretary-General Ban Ki-moon today praised the involvement of
leading businesses in the UN’s effort to tackle women’s and children’s
health. During the Every Woman Every Child meeting attended by Heads of
State, CEOs of the Private Sector and NGOS, and other UN and government
officials, the Secretary-General announced progress in the effort to save
women’s and children’s lives, and highlighted new and game-changing
commitments made during the past year. *Read
more…<http://www.who.int/pmnch/media/press_materials/pr/2011/20110920ewecpressrelease.pdf>
*

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*2.     **India to roll out world’s largest non-communicable diseases drive*

As many as 26 "mini interventions" will make up the world's largest
programme to combat non-communicable diseases (NCDs) that will be launched
by India soon. The "New Delhi Call for Action on combating NCDs in India"
initiative will be against specific diseases, and some will exclusively
address major risk factors like obesity, junk food and tobacco consumption.
*Read more…<http://timesofindia.indiatimes.com/india/India-to-roll-out-worlds-largest-non-communicable-diseases-drive/articleshow/10163952.cms>
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*3.     **Implement law against sex selection stringently: Azad*

Health Minister Ghulam Nabi Azad raised concern over gender imbalance in
India and appealed to the states for a stringent implementation of the law
against sex determination. Speaking at a meeting of health ministers from
18 states, where recent census figures show a declining child sex ratio,
Azad said declining sex ratio is a matter of grave concern. *Read
more… <http://www.deccanherald.com/content/194310/implement-law-against-sex-selection.html>
***

*SWIHPS<http://www.itg.be/itg/generalsite/Default.aspx%3FWPID=705%26MIID=528%26L=E>
** (Switching International Health Policies & Systems) is **a network to
disseminate and exchange information, expertise and practice in
International Health Policies and Health Systems, to contribute to stronger
health systems and improved policy making. Both Institute of Public
Health<http://www.iphindia.org/>
** and Institute of Tropical Medicine <http://www.itg.be/> are SWIHPS
members.*

*
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*This issue of Sel Red on IHS is compiled and coordinated by Ms. Dipalee
Bhojani and edited by Upendra Bhojani. We thank all the reviewers. We
welcome your feedback at dipalee at iphindia.org. Suggestions for the recent
papers and volunteers to review papers for future issues are welcome.*
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