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Inaugural KEYSTONE Course on Health Policy and Systems Research 2015

HPSR Research Ideas Economic Perspective

HPSR Research Ideas

Economic Perspective

Positivist Perspective Normative or Descriptive purpose

• Almost all interventions have either of this purpose:– Improve coverage or utilization (demand)– Influence provider number or behaviour (supply)

• Which interventions work and to what extent?– User charges– Demand-side financing mechanisms– Performance based payments– Task shifting

Impact of User Fees on Inpatient Care in Haryana

Prinja S et al (2012). Ind J Med Res. 136; 868-76

Impact of User Charges (Surgery Package Program) on Surgical Services in Haryana

Balasubramanian D et al (2015). Effect of User Charges on Secondary Level Surgical Care Utilization and Out-of-Pocket Expenditures in Haryana State, India. PLoS One (Submitted)

• Assessment of health systems from efficiency viewpoint (Technical or allocative efficiency)?

– What is the ideal allocation of ambulances?– Which is a better strategy: 1 versus 2 ANM?– How many sex workers should a TI program have?– Should a new vaccine be introduced?– What should be the price of the vaccine, or how much

should government subsidize the price?– Which services should be part of benefit package?

Positivist Perspective Normative or Descriptive purpose

India’s female sex worker HIV prevention program

Prinja S, et al. Sex Transm Inf. 2011; 87: 354-61.

Incremental Cost Effectiveness Ratio (ICER) Value

Government perspectiveUSD per DALY averted 819USD per life year gained 885USD per Hib case averted 115USD per Hib death averted 26,004Societal perspectiveUSD per DALY averted 277USD per life year gained 300USD per Hib case averted 39USD per Hib death averted 8,809

Hib vaccine in UIP: Haryana state, India 8

Gupta M, Prinja S et al. Health Policy and Planning (2012).

Cost Effectiveness of IMNCI program in India

Prinja S, et al (2015). Unpublished

Incremental CostICER, using different Perspective for ICER

Health system Societal

Per illness averted 1699 1183

Per infant death averted 49963 34799

Per DALY averted 1554 1082

Technical Efficiency of Public Sector Model of Referral Transport

Prinja S et al (2013). Indian J Med Res; 138: 1003-11.

Effect of Vaccine Price on Efficiency

Gupta M, et al. Health Policy and Planning (2012).

Ambulance Service: What is the most efficient level to operate?

Average Costs(INR per person)

Prinja S et al (2013). Indian J Med Res; 138: 1003-11.

Most optimum level of operation: 4-5 patients per ambulance per day

• Assessment of health systems from an equity perspective– Who utilize the health care services: rich or the poor?– Who utilize the benefits of public subsidy: rich or

poor?– how much does a rich and a poor may pay for health

care as a proportion of his ability to pay? – Which is a better way to finance health care: taxation,

social health insurance, PHI or OOP (from equity perspective)?

Positivist Perspective Normative or Descriptive purpose

Public Sector Utilization for Institutional Delivery

Q1 Q2 Q3 Q4 Q5Wealth Quintiles Overall

0

20

40

60

80

100

78 7770

63

47

65

Perc

enta

ge (%

)

Concentration Index (95% CI): -0.102 (-0.110,-0.093)

Prinja S et al (2014). Coverage and Financial Risk Protection for Institutional Delivery: How Universal is Provision of Maternal Health Care in India? PLoS One (Submitted)

Hospitalization Rates (per 1000) in Public and Private Sector

Prinja S et al (2013). Equity in Hospital Use in India. Econ and Political Wkly.

• Assessment of the responsiveness of health care system– how does quality gets affected by the way you pay

providers: fee for service, capitation, salaries, global budget etc.

Positivist Perspective Normative or Descriptive purpose

• What if studies (using assumptions of course!)

– What is the optimum level of health spending?

– How much will country need to invest if it goes ahead with universal health care program, or a health insurance system?

Positivist Perspective Normative or Descriptive purpose

Relativist PerspectiveExploratory or Explanatory Purpose

• Why do some regions perform better in terms of equity in utilization of care?– Is it the way they finance health care, – or the way they provide health care, – or the way they govern health care; – and how much do each of these things

contribute?

Equity and Public Health Spending

Prinja S et al (2013). Equity in Hospital Use in India. Econ and Political Wkly.

Higher the Public Health Spending, More Equitable is the Utilization

• Why do some interventions work well in one setting, whereas not so well in another?

– voucher scheme in Gujarat has been reported to be associated with high utilization, but a similar scheme proposed in Haryana failed to take off?

– Incentives or PBP worked for one type of health care provider but not for other (behavioural economics)?

– Why did PBP worked for well for some service but not for others?– Why do publicly financed health insurance schemes not achieve

the desired goals of financial risk protection?

Relativist PerspectiveExploratory or Explanatory Purpose

• Why is there a skewed distribution of health care providers?

• Why is it that there is more competition in drug procurement system of Tamil Nadu than in Haryana?

• Why is it that one State Government is perform differently in its ability to – achieve private sector participation for provision of health

care, – or for regulation of private sector, – or for ensuring greater compliance of private sector in some

public health programs such as IDSP

Relativist PerspectiveExploratory or Explanatory Purpose

• Understanding demand for health care

– Why is it that the public sector is able to provide for about 65% of outpatient consultations in HP compared to less than 20% in Haryana?

– While the overall utilization of health care services from private sector is 60-70% for OP care, why does the same figure go upto 95% for paediatric consultations?

– What influences the choice of a provider for utilizing health care services? Why is it that women avail ANC care at private facility but public facility at public facility? Or why do people visit public facility for preventive care and private facility for curative care?

– Who is the family member who gets excluded from RSBY enrolment among a family of 5? How does it affect equity and efficiency?

Relativist PerspectiveExploratory or Explanatory Purpose

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