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MEASURING EQUITY AS A DIMENSION OF PROGRESS TOWARDS UNIVERSAL HEALTH COVERAGE (UHC)
Abstract and Figures
Background: Recently world has moved from Millennium Development Goals (MDGs) to Sustainable Development Goals (SDGs), where Universal Health Coverage (UHC) is one of the important goals (Goal 3). Equity is considered as one of the integral dimensions for selection of a path towards UHC. Present study is based on India’s 71st Round National Sample Survey (NSS) and Fourth Round of District Level Household and Facility Survey (DLHS), and presents a comparative study of progress towards UHC in dimensions of access and financial protection in India (population: 1221 million) and its two most populous states, Uttar Pradesh (population: 199 million) and Maharashtra (population: 112 million) - which are at very different levels of social economic development.
Methodology: Data collection under 71st Round of National Sample Survey was done for 65932 households (rural: 36480, urban: 29452) in India which included 3, 33,104 individuals (male: 1, 68,697 female: 1, 64,407). Also, 7921 and 5403 households were selected from Uttar Pradesh (UP) and Maharashtra, respectively. Under DLHS-4, data collection was done for non- Empowered Action Group States (EAG). In Maharashtra data collection for 26,578 households and 24836 ever married women was done. Hospitalization rates- reflective of access to secondary care, catastrophic health expenditure (CHE) at 10% (CHE-10) and 25% (CHE-25) and impoverishment due to hospitalization cost were taken as outcome variables for the study. Expenditure was considered as catastrophic for 10% and 25% threshold, if OOPE proportion compare to total usual consumption expenditure of the household, was higher than given threshold. For impoverishment calculation, poverty line was taken from Planning Commission Report, 2014. Different maternal and child health indicators for India (non-EAG) and Maharashtra was calculated from DLHS-4. Simple and two way cross tabulation, multivariate logistic regression and propensity score matching were main analytical methods.
Results: Maharashtra had better healthcare utilization rate compare to India for various maternal and child health indicators. Hospitalization rates were 4.4% in India, 4.9% in Maharashtra and 3.4% in Uttar Pradesh. Overall public health care utilization was relatively lower in all three contexts for hospitalization and ambulatory care, but still more than half of the poorest and ST/SC category population availed care from there. Proportion of population who did not take treatment on medical advice was highest for lower socio-economic categories. In all three contexts entire poorest population was already below poverty line before meeting the expense of hospitalization. At a 10% threshold 39.7% of hospitalized population had CHE in India. For Uttar Pradesh and Maharashtra it was 43.7% and 49.2% respectively. Public provisioning was manyfold financially protective compare to private provisioning in parameters of average OOPE per hospitalization, CHE, impoverishment and borrowing. Both Maharashtra (7.2%) and Uttar Pradesh (4.1%) had modest insurance coverage compare to India (15.2%). Propensity score matching showed government funded insurance schemes reduced CHE incidence at the 25% threshold by a meagre 6% ( 95% CI: 4-9) in India. Furthermore in all the three contexts insurance did not help the household from getting impoverished. Relationship between coverage and equity by income quintile or social group were context specific and varied across various mother and child services. Higher coverage did not always mean higher equity especially when quality parameters are factored in. For various health care services Maharashtra was relatively more equitable compare to India and Uttar Pradesh.
Conclusion: A number of indicators available in these two surveys to measure progress towards UHC and equity as a dimension in this progress were identified. Public provisioning as a form of achieving financial protection was more effective and equitable in all three contexts- though levels of utilization of public services were relatively low. In a highly privatized healthcare system like India, still the poorer and more marginalized people go to public provider for their healthcare needs. However OOPE and CHE even in the public sector are high and its level of financial protection is inadequate. In the given contexts insurance coverage did not facilitate access or financial protection for hospitalization. Progress in average coverage rates and progress in equity are not parallel and policy makers need to make choices with caution while choosing mix of strategies for the path towards UHC.
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... A 2014 national survey found that in Maharashtra, only 7.5% of people seeking ambulatory care utilized primary-level tiers in the public health system. 28 This study was undertaken in one small rural area. The name of the area as well as the district have been masked to protect the participants. ...
Background:
In this study, we use the case of medical doctors in the public health system in rural India to illustrate the nuances of how and why gaps in policy implementation occur at the frontline. Drawing on Lipsky's Street Level Bureaucracy (SLB) theory, we consider doctors not as mechanical implementors of policies, but as having agency to implement modified policies that are better suited to their contexts.
Methods:
We collected data from primary care doctors who worked in the public health system in rural Maharashtra, India between April and September 2018 (including 21 facility visits, 29 in depth interviews and several informal discussions). We first sorted the data inductively into themes. Then we used the SLB theoretical framework to categorise and visualise relationships between the extracted themes and deepen the analysis.
Results:
Doctors reported facing several constraints in the implementation of primary care- including the lack of resources, the top-down imposition of programs that were not meaningful to them, limited support from the organization to improve processes as well as professional disinterest in their assigned roles. In response to these constraints, many doctors 'routinized' care, and became resigned and risk-averse. Most doctors felt a deep loss of professional identity, and accepted this loss as an inevitable part of a public sector job. Such attitudes and behaviours were not conducive to the delivery of good primary care.
Conclusion:
This study adds to empirical literature on doctors as Street Level Bureaucrats in lower and middle income countries. Doctors from these settings have often been blamed for not living up to their professional standards and implementing policies with rigour. This study highlights that doctors' behaviours in these settings are ways through which they 'cope' with their loss of professional identity and organizational constraints; and highlights the need for appropriate interventions to counter their weak motivation.
... One analysis of Maharashtra data (NSSO 2014) shows that for ambulatory care, only 7.5% of people used primary-level public tiers; 10.4% used public hospitals; and the rest accessed private care. [21] This clearly highlights the need for interventions at PHCs beyond improvements in structure. How do we go about this? ...
Introduction:
Primary Health Centers (PHCs) are intended to be the "backbone" of the Indian public health system. Yet, these do not get utilized as frontline institutions for basic curative care. As we embark on comprehensive primary health care initiatives, it is important to understand people's perceptions on PHCs; and design services that cater to their felt needs.
Aim:
In this paper, we examine explanations that communities give for the use or bypass of PHCs. From these perspectives, we derive some policy directions for improving basic curative care services at PHCs.
Methods:
This qualitative study is based on data from 14 Focus Group Discussions in a rural area in Maharashtra in the catchment area of 8 PHCs (total 91 community participants). The discussions were coded and analyzed thematically with the aid of a qualitative software.
Results:
PHCs were not viewed as first-access points for health care, though these were valued for specific services. The limited use of PHCs was attributed to the lack of availability of drugs/services of perceived relevance to communities; prevalent healing norms that mismatched with PHC services; doctor-patient interactions that were colored with mistrust; and widespread poor opinions of public-sector services in health.
Conclusions:
Currently, there seems to be little in the design of PHC services- that appeals to the "felt" needs of communities. Thus, the proposed Health and Wellness Centers (HWC) initiative resonates with people's expectations. In addition, staff at the periphery must provide "attentive" care and be prepared to contend with pre-existing poor expectations of care.
... These include issues like long waiting queues, rude behavior by health care staff and lack of appropriate care. 35 Including rheumatic diseases in the list of essential services that government is committed to and strengthening the capacity of public institutions to provide quality care for patients with RD are clearly the most important recommendations evolved out of this study. ...
Aim
This study aims to measure current situation with regard to access and financial protection towards healthcare for rheumatic diseases (RDs) in India.
Method
The first part of this study is quantitative, and uses the data generated by the 71st Round of National Sample Survey 2014, which measured self‐reported morbidity, choice of provider and utilization of services and out of pocket expenditure (OOPE) incurred on healthcare services in a sample of 65 932 households and 333 104 individuals from all across India. The second qualitative part of the study was done in one sample district to understand the barriers to access and financial protection.
Results
3.5% of all hospitalizations in the preceding one year and 9.9% of all ambulatory care in the preceding 15 days of this study period were due to RDs. Cost of care for RDs was three times higher in private sector. Cost on medicines comprised the largest share in both sectors. 54% of the households faced catastrophic health expenditure at 10% threshold (CHE‐10) and this was nine times higher in private provisioning (OR: 8.8, CI: 6.8‐11.4). 24% of the households had to borrow or sell household assets to meet the hospitalization expenditure. Insurance had marginal impact and it did not help in preventing household from facing CHE‐10 for the lowermost three economic quintiles. There was significant unmet health care needs and lack of continuity of care of RDs in India.
Conclusion
Addressing the gaps in access and financial protection for patients with RDs need greater emphasis in policy as well as implementation, if the country has to achieve Universal Health Coverage.
... This could be explained by unsatisfactory quality (42.7%), long waiting times (27. 4%), distant facilities (11.6%), unavailable services (10.3%) and other causes (8.1%) [28,29]. All of these are reflective of underperforming public health systems, which have been attributed to very low public health spending as well as many issues of design and implementation [30]. ...
Background:
In the past decade, India has seen the introduction of many 'publicly funded health insurance' schemes (PFHIs) that claim to cover approximately 300 million people and are essentially forms of purchasing care from both public and private providers to reduce out-of-pocket expenditure (OOPE) for hospitalization.
Methods:
Data from a recent government-organized nationwide household survey, The National Sample Survey 71st Round, were used to analyse the effectiveness and equity of tax-funded public health services and PFHIs as distinct but overlapping approaches to financial protection for hospitalization across different socio-economic categories. Cross-tabulation analysis, multivariate logistic regression and propensity score matching were the main analytical methods used.
Results:
Government hospitals provide access to 45.6% of all hospitalization needs. Although poorer quintiles use public hospitals more often, even in the poorest quintile, as many as 37.2% are utilizing private hospitals. The average OOPE that a household experiences for hospitalization in public hospitals is approximately only one-fifth of the OOPE for hospitalization in the private sector. PFHI schemes cover 12.8% of the population, and coverage is higher in upper quintiles and in urban areas. Hospitalization rates increase with PFHI coverage, and this occurs with both public and private providers. Propensity score matching shows that PFHI contributes to a marginal reduction (1%) in 'catastrophic health expenditure incidence at the 25% threshold' (CHE-25) for the bottom three quintiles. The reported coverage of PFHIs was greater in the upper income quintiles. Utilization of public services was greater in the poorer income quintiles and more marginalized social groups.
Conclusions:
Periodic surveys are essential to guide policy choices regarding the appropriate mix of strategies for financial protection in pluralistic systems. There is a need for caution regarding any shift in the role of governments from providing services to purchasing care, given the contexts and limitations of currently available PFHIs. Even with tax-funded public services, although the average OOPE is lower than the care purchased through PFHIs, there is still a modest level of CHE and impoverishment due to health care costs that persist. Both strategies need to be synergized for more effective financial protection.
Introduction
In this paper, we elucidate challenges posed by contexts to the implementation of the Primary Health Care (PHC) approach, using the example of primary health centres (rural peripheral health units) in India. We first present a historical review of ‘written’ policies in India—to understand macro contextual influences on primary health centres. Then we highlight micro level issues at primary health centres using a contemporary case study.
Methods
To elucidate macro level factors, we reviewed seminal policy documents in India and some supporting literature. To examine the micro context, we worked with empirical qualitative data from a rural district in Maharashtra—collected through 12 community focus group discussions, 12 patient interviews and 34 interviews with health system staff. We interpret these findings using a combination of top–down and bottom–up lenses of the policy process.
Results
Primary health centres were originally envisaged as ‘social models’ of service delivery; front-line institutions that delivered integrated care close to people’s homes. However, macro issues of chronic underfunding and verticalisation have resulted in health centres with poor infrastructure, that mainly deliver vertical programmes. At micro levels, service provision at primary health centres is affected by doctors’ disinterest in primary care roles and an institutional context that promotes risk-averseness and disregard of outpatient care. Primary health centres do not meet community expectations in terms of services, drugs and attention provided; and hence, private practitioners are preferred. Thus, primary health centres today, despite having the structure of a primary-level care unit, no longer embody PHC ideals.
Conclusions
This paper highlights some contextual complexities of implementing PHC—considering macro (pertaining to ideologies and fiscal priorities) and micro (pertaining to everyday behaviours and practices of actors) level issues. As we recommit to Alma-Ata, we must be cautious of the ceremonial adoption of interventions, that look like PHC—but cannot deliver on its ideals.
The book represents an attempt to bridge — through a systematic collection and
analysis of primary and secondary data on the provision, financing, and regulation of health care services — the significant knowledge gaps on the private health sector in Sri Lanka, and foster a dialogue on opportunities for collaboration between the government and the private sector.
It is the argument of this book that health systems exist to fulfil purposes, including protecting and improving health and the provision of professional, ethical, accountable and accessible health care for all. Therefore policies that influence the nature and extent of health care commercialization should be designed to further those purposes. To achieve this, better economic, social and technical analysis of health care commercialization is required as a foundation for effective health policy.
This paper presents the results of a ten-country comparative study of health care financing systems and their progressivity characteristics. It distinguishes between the tax-financed systems of Denmark, Portugal and the U.K., the social insurance systems of France, the Netherlands and Spain, and the predominantly private systems of Switzerland and the U.S. It concludes that tax-financed systems tend to be proportional or mildly progressive, that social insurance systems are regressive and that private systems are even more regressive. Out-of-pocket payments are in most countries an especially regressive means of raising health care revenues.
The private for-profit sector's prominence in health-care delivery, and concern about its failures to deliver social benefit, has driven a search for interventions to improve the sector's functioning. We review evidence for the effectiveness and limitations of such private sector interventions in low-income and middle-income countries. Few robust assessments are available, but some conclusions are possible. Prohibiting the private sector is very unlikely to succeed, and regulatory approaches face persistent challenges in many low-income and middle-income countries. Attention is therefore turning to interventions that encourage private providers to improve quality and coverage (while advancing their financial interests) such as social marketing, social franchising, vouchers, and contracting. However, evidence about the effect on clinical quality, coverage, equity, and cost-effectiveness is inadequate. Other challenges concern scalability and scope, indicating the limitations of such interventions as a basis for universal health coverage, though interventions can address focused problems on a restricted scale.
Private health care in low-income and middle-income countries is very extensive and very heterogeneous, ranging from itinerant medicine sellers, through millions of independent practitioners—both unlicensed and licensed—to corporate hospital chains and large private insurers. Policies for universal health coverage (UHC) must address this complex private sector. However, no agreed measures exist to assess the scale and scope of the private health sector in these countries, and policy makers tasked with managing and regulating mixed health systems struggle to identify the key features of their private sectors. In this report, we propose a set of metrics, drawn from existing data that can form a starting point for policy makers to identify the structure and dynamics of private provision in their particular mixed health systems; that is, to identify the consequences of specific structures, the drivers of change, and levers available to improve efficiency and outcomes. The central message is that private sectors cannot be understood except within their context of mixed health systems since private and public sectors interact. We develop an illustrative and partial country typology, using the metrics and other country information, to illustrate how the scale and operation of the public sector can shape the private sector's structure and behaviour, and vice versa.