Healthcare Services in India

Karthik Muralidharan has a chapter on the healthcare system in India in Accelerating India’s Development. Unsurprisingly, across India, the majority of healthcare providers are private players.

 

In the private sector, both in rural areas and in poorer urban areas, the private sector practitioners are not MBBS qualified.

“How then do they learn what to do?”

By being in roles like compounder, ward boys or assistants. Many also “learn” from pharma representatives who tell what medicines do as well as their dosages. You’d think the pharma guys would exaggerate the effectiveness, but that tendency is balanced by their need to maintain long term relations. Overall, the private providers do have a decent amount of medical knowledge.

 

How effective are these unqualified practitioners? At least for primary care, they are comparable to MBBS doctors. But as things get complex, an MBBS is definitely better. How to measure the effectiveness of medical practitioners isn’t obvious, since it includes: (1) definitions of the relevant outcome (cure? pain relief?), (2) assessing under- and over-treatment, and (3) adjusting for case complexity. A standard solution for this is to use standardized (“fake”) patients. This fake patient lists the same set of symptoms to different doctors and then seeing what they do next (follow-up questions, tests recommended, diagnosis, and treatment prescribed).

 

More interesting findings were that (1) even among MBBS, there is state to state variation, and (2) the level of non-qualified practitioners is correlated to the level of the MBBS docs in the state, i.e., a state with better MBBS doctors also has better non-MBBS healthcare practitioners.

Another interesting finding was that the per-patient cost to the state reduces if more patients use the public health system. That is because the fixed cost (clinics, hospitals, salaries) caters to more patients, so the per-patient cost will reduce. A takeaway from this is that having better connectivity (roads, public transport) to public health centers is more cost effective than trying to open new facilities in every nook and cranny.

 

Models like ASHA involve training local young women as primary healthcare providers who live and serve in their communities. This is far more effective than trying to incentivize highly qualified candidates to go work in non-urban areas.

 

An interesting proposal by Muralidharan is to have the private clinics register on a government portal. Give them good primary healthcare trainings, certify them as mid-level health providers (not MBBS), and list their qualifications on the site. Then add the ability for patients to rate such clinics via some identity like Aadhar. This would make it easy for people to find good primary clinics nearby.

“A critical mindset shift we need in thinking about informal providers is to stop seeing them as malevolent actors, operating illegally.”