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Health System Innovation in India Part III

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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.

Health System Innovation in India Part II: Aarogyasri

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More than health insurance for the poor

In our last post, 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 this post, we outline a novel government-sponsored health insurance program in the state of Andhra Pradesh (AP)—a program that has the potential not just to reduce financial impoverishment but also raise quality standards in hospital care.

a) “Actors”, and their rights and responsibilities

Initiated by the then chief minister of AP, the medical doctor YSR Reddy, the Rajiv Aarogyasri scheme started in 2007 and is targeted at the below-poverty line (BPL) population. The scheme focuses on life-saving procedures that aren’t covered elsewhere in India’s patchwork of health programs, for which treatment protocols are available, and for which specialist doctors and equipment are required. Currently 938 tertiary care procedures are covered. The scheme revolves around five key “actors”, one unique to Aarogyasri and all with interesting rights and responsibilities.

Health System Innovation in India Part I: India’s health system challenges

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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.

Coping with information overload—with an iPad

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Life before the web was neatly compartmentalized. Research was produced by researchers who wrote articles for academic journals; news was written up by professional journalists who wrote for newspapers and talked on news broadcasts on the TV and the radio; policy was made by politicians and policymakers behind closed doors in smoke-filled ministries in capital cities; and entertainment was crafted by professionals and delivered in theaters, cinemas and on the TV.

Health reform: A consensus emerging in Asia?

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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.

Four cheers for the “results agenda"

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Photo © Dominic Sansoni / World Bank

The development community hasn’t exactly only just woken up to the fact that development is about achieving something. Projects have had logframes since time immemorial, showing how project activities and spending are expected to lead ultimately to development outcomes—things that matter to people, like health and learning. But the “results agenda” (an agenda that dates back to 2003 but which seems to be gaining momentum) has the scope to be transformative in at least four ways.

1) Work backwards, not forwards
First, it invites us to work backwards from these things that matter and think about alternative ways to achieving these outcomes. Take education. A lot of projects in the Bank and other development agencies have focused on building and rehabilitating schools, with the expectation that this will lead to higher school enrollments. And yet as my colleague Deon Filmer showed a while ago, proximity to a school has very little effect on the likelihood of a child enrolling in school. By contrast, as he and Norbert Schady showed in another paper, providing scholarships to poor children does increase enrollments.

Whither the development agency’s flagship report?

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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.

The (gradual) democratization of development economics

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We’ve read a good deal recently about the democratization of research. UNESCO’s Science Report 2010 showed a growth in the developing-country share of science research. As UNESCO Director General Irina Bokovo put it in her Foreword:

 Photo: istockphoto.com

“The distribution of research and development (R&D) efforts between North and South has changed with the emergence of new players in the global economy. A bipolar world in which science and technology (S&T) were dominated by the Triad made up of the European Union, Japan and the USA is gradually giving way to a multi-polar world, with an increasing number of public and private research hubs spreading across North and South.”

Who's listening to the "knowledge bank"?

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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".

What’s the “universal health coverage” push really about?

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L. Garrett, A. Chowdhury, A. Pablos-Méndez. “All for universal health coverage”, The Lancet, 2009, 374(9697), pp. 1294-1299

Maps, like pictures, are often worth a thousand words. The map above comes from an article in the medical journal The Lancet. The article is part of a campaign to make 2010 the year of a big push toward universal health coverage. Over the course of the next three days, over a thousand health systems researchers are gathering in Switzerland for the First Global Symposium on Health Systems Research; the theme of the symposium is “science to accelerate universal health coverage”. Next week, health ministers from around the world will gather at an international ministerial conference on “Health Systems Financing – Key to Universal Coverage” hosted by the German government. At the conference, the World Health Organization will launch its 2010 World Health Report entitled “Health Systems Financing: The Path to Universal Coverage”.

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