Indian healthcare must be evidence-based
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The Union cabinet recently approved the National Health Policy, 2017. In a welcome move, the policy includes progressive steps towards universal and affordable access to healthcare services for the underprivileged. It does this by making provisions for comprehensive primary care via the conversion of 150,000 sub-centres (the first contact point between the primary healthcare system and the community) in Indian villages to “Health and Wellness Centres”. There is provision for every family to be provided with a health card that will link it to the primary care facility and make it eligible to receive a defined package of services anywhere in the country. While this is a positive step, the government will require a robust mechanism to implement and monitor the mammoth mission.
In the past, policymakers’ good intentions have been marred by the lack of effective public service delivery mechanisms. An inefficient service delivery mechanism creates inequity in access to healthcare and results in the suppressed uptake of services by the masses as they turn to private alternatives. In a study conducted by the World Bank and Harvard University in 2003, it was found that in 1,500 primary healthcare centres across India, 40% of healthcare workers in government health clinics were absent from work. While this was found through direct observation, official records may not have reflected the absence.
The National Health Policy states that to increase “accountability and governance”, the government will aim at increasing both horizontal and vertical accountability by providing a greater role for local body participation and encouraging community monitoring. A study, conducted by the researchers at the Massachusetts Institute of Technology, US, with NGO Seva Mandir in the sub-centres of 135 villages of Udaipur from 2005-07, suggested that monitoring, coupled with punitive pay incentive, reduced the absence of nurses from 60% to 30% in healthcare centres. This proves that healthcare workers are responsive to properly administered incentives, and that comprehensive monitoring does make a difference.
The issue of poor uptake of healthcare programmes by the masses is a result of mismanaged health centres and, to some extent, human psychology. For the underprivileged, a visit to a primary healthcare centre may mean the loss of a day’s wage. Given that a full immunization schedule requires at least five visits to the sub-centres, for a poor family the opportunity cost is huge, especially given a bad service delivery system. A lack of understanding of the benefits of vaccination, and, to some extent, distrust in government healthcare services, exacerbate the problem. The World Health Organization reported that in 2015, 19.4 million infants worldwide were not reached with routine immunization services. More than 60% of these children live in 10 countries, including India. Could there be a way of incentivizing the poor to immunize their infants? A research study done by the MIT on 2,000 children from 134 villages of Udaipur, from 2004-07, helped provide immunization services through mobile camps on fixed days in one intervention. In the other intervention, it incentivized parents with a gift of 1kg of lentils on immunization days and a thali on the completion of the whole schedule. It showed that providing poor families with non-financial incentives in addition to reliable services and education about immunization was more effective in nudging them to complete their child’s immunization schedule than just providing reliable services alone.
While the healthcare policy relies heavily on technical research in pharmaceuticals and equipment, when it comes to service delivery, evidence-based policy has been absent in India. Policymakers need to know what works and what doesn’t. There is evidence to show that projects fail largely as they are not evidence-based. However, the biggest dilemma that policymakers face is that though there is abundant evidence available, there is a lack of consensus about its quality. Some of the evidence is not available in a suitable form, but, primarily, policymakers have multiple goals other than research effectiveness to focus on. Policymakers’ demands for quick results restrict policymaking processes from being evidence-based.
The government has allocated Rs48,878 crore to the health sector in the recent budget, increasing it to 2.2% of the total Union budget . With such a massive investment, the government would do well to ensure that healthcare services reach the intended beneficiaries and that the beneficiaries avail of them fully. There is an immediate need for policymakers to sit across the table with researchers and have a meaningful dialogue. Think tanks are now focusing increasingly on building evidence bases for policies and programmes that can improve development outcomes. Researchers are aiding the government and stakeholders in conducting rigorous research and utilizing research findings.
The National Health Policy aims at inclusive partnerships with academic institutions, NGOs, and the healthcare industry. It also speaks of “research collaboration” in healthcare delivery. Spending some resources on research will help the government deliver benefits in an effective way as well as avoid the often-repeated mistakes of earlier mechanisms. With minimal investment, the government will stand to gain from robust evidence. Research can prove to be a shot in the arm for safeguarding the government’s health goals—and the population.
Nayan Chakravarty, Kavita Tatwadi and Krithika Sambasivan are, respectively, head of policy and outreach at IFMR LEAD, a public policy analyst, and policy associate at IFMR LEAD.