Saturday, November 19, 2016

State capacity and universal health coverage for India

This article proposes emulation of the Thailand's health care system as the model for India's own quest for universal health coverage (UHC). I am reminded of this post which attempts to explains why we systematically gloss over state capacity weaknesses when suggesting solutions to public policy failures. 

The authors outline all the ingredients of Thailand's success - purchaser-provider spilt, shift away from line-items based to outcomes based budgeting, strategic purchasing, regulation of standards and accreditation, and a robust information technology (IT) system that facilitates the development of electronic medical records. The presumption is that if these ingredients are super-imposed on the Indian health care system, then it would be possible to have a more efficient UHC system. 

While all these are necessary and should be gradually introduced, I am not sure whether they would help usher in meaningful universal health coverage, without more important complementary investments. While all these clear and distinct components of Thailand's path towards UHC are easily described, they were built on a painstakingly built up legacy of capacity building among public institutions. In fact, Thailand's journey did not start with the reforms at the turn of the century but nearly five decades earlier, with a massive campaign to build the capacity of its public health care facilities starting in early seventies. So much so that, by the late nineties Thailand could boast of an enviable network of publicly owned primary, secondary, and tertiary facilities, far superior to even the best facilities in India today. It was therefore easy to build these distinct reform blocks on this platform and embrace a capitation based model of UHC. 

In contrast, in India, we have a badly broken public health system in most states and an unregulated and informal private market. It is a stretch to imagine that such institutional atrophy can be rectified merely with the reforms suggested. In fact, the danger is that in the absence of deep-rooted refers, such measures can lead us to a worse equilibrium. Markets, especially on something like healthcare, do not just develop merely in response to incentive compatible regulations and nice IT systems. Nor does such measures alleviate deep institutional maladies. And we have not even talked about the political economy surrounding the introduction of reforms like those in budgeting. 

So what is the way forward in the UHC quest? We have outlined some of them in a just released co-authored report. We recommend a series of reforms, starting with strengthening of public institutions,  and a process of adoption that focuses on experimentation like the adoption of capitation model in a few districts, learning from it, and then gradually scale up. In the absence of such comprehensive and fundamental reforms, logically neat and distinct reforms may be just band-aid on gangrene. 

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