In a recent article, I argued how increasing rural spending on schemes such as the Mahatma Gandhi National Rural Employment Gurantee Act (MGNREGA), skill development (STRIVE, SANKALP) and agricultural development (Fasal Bima Yojana, e-NAM) has not significantly impacted outcomes. This makes it pertinent for the government and policymakers to consider evidence from outcome assessments before appropriating massive sums of taxpayer’s money.
As an illustrative example, we may take the case of public healthcare in rural India. While most policy discourse tends to argue for an increase in healthcare spending to improve overall services, little attention is paid to the quality of healthcare facilities. Data on human resources, medical records and patient charts are scarce, making the problem all the more difficult to solve.
Don’t just spend more – spend right
A recent study by Jishnu Das and Aakash Mohpal offers a comprehensive look at severe deficits in healthcare quality in India, using case studies from Madhya Pradesh, Delhi, West Bengal and Tamil Nadu. In most of rural India, doctors are untrained and providers may prescribe high rates of antibiotics. The findings of the study are central to shifting the mainstream discourse. Rather than merely building public clinics, there should be a focus on measuring access to high-quality healthcare in rural areas. Moreover, as Das and Mohpal argue, quality measures based on a random sample of healthcare providers may not reflect the quality of providers that people most commonly use.
Das and Mohpal also observed that while doctors may possess qualifications, this does not necessarily translate into medical knowledge in practice. The divergence between “medical qualifications and knowledge” and “knowledge and practice” implicitly highlight a significant methodological limitation in appraising and improving the healthcare industry.
Additionally, our understanding of patient behaviour and the quality of healthcare providers suffers from the “good doctor-naive patient” model. We assume that doctors always know more than patients and that it is always the patient’s fault if they fail to receive adequate and fair medical treatment. This is the norm across most global health economics literature and policy practice as well.
However, studies like that of Das and Mohpal bring us to one crucial conclusion – it is the socio-economic status of the village, and not of the household, which is traditionally used as a unit of economic analysis to ultimately determine the quality of healthcare people receive.
Constructing a household socio-economic status index using three characteristics – namely, wealth, education and caste – and a sampled data analysis shows that villages with high socio-economic status (higher household consumption, education, wealth concentration) are larger than those with low socio-economic status. Further, such villages have a significant population of households with low socio-economic status within them. Thus, there are vital policy implications when considering equity as access to and use of high-quality healthcare services in rural areas.
The table below offers more details on healthcare providers present in villages.
Table 1: Availability and use of healthcare providers by 23,275 poor rural households in 100 villages in MP, India
|All Villages (Mean)||Main Villages (Mean)||Cluster Villages (Mean)|
|Available Healthcare Providers
|Distance traveled to see a provider (km)||1.65||1.34||6.34|
Source: Exhibit 1 in Das and Mohpal (2016)
Three major results emerge from a village-based sample analysis on assessing healthcare in India. First, out of an average of 11 healthcare providers, three are in the main village (who could be private and untrained) and eight are in cluster villages, which are more than 1 km away from the main villages. Most of these are healthcare service providers in the private sector. Second, almost 49% of the 11 healthcare providers have no formal medical training. Lastly, people in villages prefer travelling outside their villages to seek higher quality healthcare service in district hospitals, for example.
From a policy perspective, some major questions arise around the accessibility and use of high quality healthcare for lower socio-economic status rural households located in higher socio-economic status villages. This problem is likely to get worse in the future as there is a tendency among rural residents to travel to private clinics and district hospitals so they may receive better healthcare services that may be available at district hospitals or private clinics.
To resolve this, the state can invest in improving capacities in district hospitals instead of investing more money in primary healthcare clinics in villages, where rural residents tend not to seek medical help. On the other hand, if patients can’t be brought to doctors, then improving the ‘competence’ of healthcare providers within villages provides an alternative solution from a policy perspective.
Deepanshu Mohan is assistant professor of economics at Jindal School of International Affairs, O.P. Global Jindal University.