Adam Wagstaff's blog

Taking high-quality affordable primary care to the rural poor with the help of handheld computers, telemedicine, and P4P.

In our first post in this series, we showed how illness in India causes financial hardship and leaves Indians—especially poor ones—with limited access to affordable good-quality health care that can actually make them better. In our last post, we outlined the Aarogyasri scheme—a novel government-sponsored health insurance program in the state of Andhra Pradesh that has the potential not just to reduce financial impoverishment but also raise quality standards in hospital care. In this post, we discuss an innovative private-sector approach to delivering and financing primary health care in rural Andhra Pradesh.

India’s health system faces some major challenges. In some respects, the hill India’s health system has to climb is steeper than that facing other developing countries. The good news is that the innovation that India is famous for in other sectors, as well as in health technology, is now starting to make itself felt in the health system. Not only may these ideas benefit India’s poor; they may also provide food for thought for other countries.

In this post, we sketch out the challenges facing India’s health system. In the next two, we outline two innovative approaches—one government, one private—in the state of Andhra Pradesh.

Amanda Glassman’s blog post on Ghana’s health insurance program and the firestorm it produced (hat tip to Mead Over) is a reminder of the passions that health reform debates still generate. This is intriguing because my sense is that while we health-reform aficionados are berating one another in the blogosphere, policymakers in Asia are quietly iterating toward something of a consensus on a whole swathe of key issues on health reform. The process isn’t always driven by hard evidence, but that’s because there isn’t much hard evidence either way. I certainly don’t see compelling evidence against the emerging consensus—if that’s what it is. And what’s emerging is rather interesting.

The Economist carried a couple of stories recently about how two hitherto major institutions in my home country (newspapers and pubs) have been forced to adapt in the face of changes in public preferences. Many didn’t—as a result newspaper circulation and pub numbers have both fallen dramatically. The newspapers and pubs that did survive operate very different business models from the newspapers and pubs in existence even 10 years ago.

Some data I’ve assembled make me wonder whether—like the newspaper and pub—the development-agency flagship might not also be an institution in need of reform.

The flagship

Most big development and international agencies have a flagship. The World Bank launched its World Development Report in 1978. The IMF’s World Economic Outlook started two years later. The UNDP launched its Human Development Report in 1990, and WHO followed with its World Health Report five years later. Several other UN agencies have annual or periodic flagship reports too.

We now know quite a lot about the supply of research on development, and about the part the World Bank plays. We know that the World Bank publishes a lot, that most research in the world is by researchers in high-income countries, and that were it not for the Bank there would be far fewer journal articles about developing countries.

We know much less about the demand for development research and Bank publications in particular. We know that Bank publications get cited a lot in scholarly journals, books, and technical reports. What we don’t know is: who is reading and citing the Bank’s work?  

An optimist would argue that Bank authors get read largely by people in developing countries, and this in turn helps move policy forward. A cynic would argue that the audience for Bank publications is largely made up of others in the North working on international development. Bank reports that end up in developing countries are, according to this view, at risk of being turned into papier-mâche masks for puppet shows. We call this the "puppeteers view".