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378 Pages·2002·13.09 MB·English

by  World Bank Group

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Health, Nutrition, and Population Series
This series is produced by the Health, Nutrition, and Population
Family (HNP) of the World Bank's Human Development Network.
It provides a vehicle for publishing polished material on the Bank's
work in the HNP Sector, for consolidating previous informal publi-
cations, and for improving the standard for quality control, peer
review, and dissemination of high-quality analytical work.
The series focuses on publications that expand our knowledge of
BNP policy and strategic issues that can improve outcomes for the
poor and protect vulnerable populations against the impoverishing
effects of illness. Best practice examples of both global and regional
relevance are presented through thematic reviews, analytical work,
and case studies.
The Editor in Chief of the series is Alexander S. Preker. Other
members of the Editorial Committee are Mukesh Chawla, Mariam
Claeson, Shantayanan Devarajan, Gilles Dussault, A. Edward
Elmendorf, Armin H. Fidler, Charles C. Griffin, Jeffrey S. Hammer,
Peter E Heywood, Prabhat Jha, Gerard Martin La Forgia, Jack
Langenbrunner, Ruth Levine, Maureen Lewis, Samuel S.
Lieberman, Benjamin Loevinsohn, Elizabeth Lule, Akiko Maeda,
Judith Snavely McGuire, Milla McLachlan, Thomas W Merrick,
Philip Musgrove, Ok Pannenborg, Oscar Picazo, Mead Over, Juan
Rovira, George Schieber, and Adam Wagstaff.
Human Development Network
Health, Nutrition, and Population Series
Better Health Systems
for India's Poor
Findings, Analysis, and Options
David H. Peters
Abdo S. Yazbeck
Rashmi R. Sharma
G. N. V Ramana
Lant H. Pritchett
Adam Wagstaff
THE WORLD BANK
Washington, D.C.
© 2002 The International Bank for Reconstruction and Development / The World Bank
1818 H Street, NW
Washington, DC 20433
All rights reserved. Published 2002
Manufactured in the United States of America
1 2 3 405 0403 02
The findings, interpretations, and conclusions expressed here are those of the author(s) and
do not necessarily reflect the views of the Board of Executive Directors of the World Bank or
the governments they represent.
The World Bank cannot guarantee the accuracy of the data included in this work.
The boundaries, colors, denominations, and other information shown on any map in this work
do not imply on the part of the World Bank any judgment of the legal status of any territory
or the endorsement or acceptance of such boundaries.
Rights and Permissions
The material in this work is copyrighted. No part of this work may be reproduced or trans-
mitted in any form or by any means, electronic or mechanical, including photocopying,
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For permission to photocopy or reprint, please send a request with complete information to
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All other queries on rights and licenses, including subsidiary rights, should be addressed to
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fax [phone], e-mail [email protected].
ISBN 0-8213-5029-3
Library of Congress Cataloging-in-Publication Data has been applied for.
Contents
Foreword xv
Preface xvii
Acknowledgments xxi
Acronyms and Abbreviations xxv
Overview 1
The Indian Health System 3
Which Way Forward? 8
Options at a Glance 17
Part 1: Raising the Sights for India's Health System 23
1 A Crossroads 2 5
Objectives of the Health System and the Health
Transition 27
The Current Policy Context 28
Historic Vision and Current Realities 29
Focusing on Four Critical Activities in the Health
System 32
The Approach to Reform 32
2 Problems of the Public and Private Sectors 39
Current Structure of the Public Sector 39
iii
iv * Better Health Systems for India's Poor
Problems of the Public Sector 40
Structure of the Private Sector 44
Problems with the Private Sector 49
Notes 52
3 Policy Actions for Critical Health System Activities 53
Health System Oversight 55
Public Health Service Delivery 64
Ambulatory Curative Services 69
Inpatient Curative Services and Health Insurance 74
Concluding Remarks 83
Notes 84
4 Putting It Together: Raising the Sights of
India's Health System 85
Different Choices for Different Parts of India 86
Choices for the Central Government 92
Choices for the States 96
Putting It All Together: The Case of Maternal
Health 113
Specific Actions for Consideration across India 118
An Agenda for the Future 123
Concluding Remarks 124
Appendix 126
Notes 128
Part 2: Theory and Evidence 131
5 Health System Framework 133
The Descriptive Framework: Health System
Actors, Functions, and Outcomes 135
Framework for the Consideration of Government
Intervention 142
A Framework for Deciding How to Intervene:
Make-Buy-Regulate-Inform 144
Notes 148
Contents * v
6 The Functioning of the Private Sector Market 151
Context: The Private Health Sector in India 155
Methods 157
Ambulatory Care 159
Inpatient Care 171
Concluding Remarks 186
Appendix 187
Notes 198
7 Setting National Health Care Priorities and
Ensuring Equitable Delivery of Public Sector
Services 201
Do Centrally Sponsored Schemes Meet India's
Health Care Needs? 201
Households' Use of Personal Health Services 212
How Well Are Public Health Services Reaching
the Poor? 217
How Does the Pattern of Public Spending
Affect Health Outcomes? 229
Appendix 230
Notes 231
8 Financing Health 233
Health Sector Spending 233
Financing Mechanisms 240
Conclusions 255
Appendix 257
Notes 264
9 Health System Outcomes 265
Health Status 269
Financial Protection 286
Responsiveness to the Public 293
Concluding Remarks 298
Appendix 300
Notes 321
vi * Better Health Systems for India's Poor
Appendixes
A Studies Conducted for the Present Report 323
B Background Papers 327
C Major Recommendations of National Health
Policy Reports since Independence 331
D Efforts to Address the Role of Private Providers in
National Tuberculosis Control Programs 335
Bibliography 337
Tables
0.1 Major Indian States, by Stage of Health Transition
and Institutional Capacity 8
0.2 Improving Health System Oversight 17
0.3 Strengthening Public Health Services 18
0.4 Strengthening Ambulatory Curative Services 19
0.5 Inpatient Care and Health Insurance 20
1.1 Examples of Health System Functions and
Challenges in India 36
2.1 International Comparisons of Health Care
Work Force and Hospital Beds, 1990-98 41
2.2 International Comparisons of Health Service
Utilization and DALYs Lost, 1990-98 41
2.3 Health Care Work Force and Health Facilities
in the Public and Private Sectors in India,
Selected Years, 1981-98 46
2.4 Distribution of Outpatient and Inpatient Health
Services across the Public and Private Sectors
in India, 1986-87 and 1995-96 48
3.1 Summary of Actions for Critical Areas of Activity
in the Health System 54
3.2 International Examples of Varying Public-Private
Mixes in the Delivery of Tuberculosis Care 59
4.1 Selected Health Status Outcomes in India and
Major Indian States, Selected Years, 1992-99 87
Contents * vi-
4.2 Selected Health Service Outcomes in Major
Indian States and India Overall, Selected Years,
1995-99 88
4.3 Categorization of Major Indian States by
Characteristics Influencing Fundamental Health
System Choices 89
4.4 Local Factors to Consider at State Level when
Prioritizing Health Systems Choices 91
4.5 Major Health System Choices Facing Indian
States, by Stage of the Health Transition, and
the Central Government 97
4.6 Pros and Cons of Actions for Improving
Oversight 10l
4.7 Pros and Cons of Actions for Improving Public
Health Services 10'
4.8 Pros and Cons of Actions for Improving
Ambulatory Curative Care 10 7
4.9 Pros and Cons of Actions for Improving
Inpatient Care and Health Insurance 1110
4.10 Allocation of Critical Health System Functions
for Maternal Care between the Public and
Private Sectors, by Type of Vision for
Public-Private Partnerships 115
4.11 Recommendations for Government Action
on Critical Functions of India's
Health System 121
4A. 1 Key Gaps in Knowledge about and Experience
in India's Health System, and Potential Uses
of the Needed Information 126
6.1 Alternative Private Practitioners Receiving
Informal Payments, Andhra Pradesh and
Uttar Pradesh 161
6.2 Participation in National Health Programs by
Private Practitioners, Andhra Pradesh and
Uttar Pradesh 170
viii * Better Health Systems for India's Poor
6.3 Performance Indicators of Private Hospitals,
Andhra Pradesh and Uttar Pradesh, 2000 180
6.4 Quality Assurance Standards in Hospitals,
Andhra Pradesh and Uttar Pradesh 181
6.5 Private Hospitals Whose Managers Favor
Various Procedures for Improving Hospital
Quality, 2000 182
6.6 Proportion of Patients Satisfied or Very Satisfied
with Overall Quality of Care at Public and
Private Health Facilities, Andhra Pradesh, by
Type of Facility and Wealth of Patient 183
6.7 Private Hospitals Offering Concessions to the
Poor, Andhra Pradesh and Uttar Pradesh 183
6.8 Proportion of Private Hospitals that Have
Received Public Benefits, Andhra Pradesh and
Uttar Pradesh 185
6.9 Participation in National Health Programs by
Private Hospitals, Andhra Pradesh and
Uttar Pradesh 186
6A. 1 Distribution of Main Reasons Given by
Alternative Private Practitioners in Andhra
Pradesh and Uttar Pradesh for Becoming a
Medical Practitioner 187
6A.2 Clinical Conditions Treated by Alternative
Private Practitioners over Two Days,
Andhra Pradesh and Uttar Pradesh 188
6A.3 Patient Fees for an Outpatient Consultation in
the Private Sector, Alternative Practitioners
Compared with Qualified Allopaths,
Andhra Pradesh and Uttar Pradesh 189
6A.4 Allopathic Therapies Offered at Clinics of
Alternative Private Practitioners, Andhra Pradesh
and Uttar Pradesh 190
6A.5 Concessions Offered to the Poor by Alternative
Private Practitioners, Andhra Pradesh and
Uttar Pradesh 190