Graffiti depicting doctors on a street in Mumbai, September 5, 2020. Photo: PTI
- India’s efforts to improve its record on delivering healthcare largely rests on government-backed insurance products and a network of healthcare facilities.
- This approach may be insufficient unless steps are taken to improve the quality of care as well – with the help of performance incentives and simple behavioural nudges.
- Performance incentives for healthcare workers have been fairly popular for a while – but they generally ignore differences in workers’ skills, preferences and personality traits.
- Adding new incentive programmes may be expensive and difficult for governments because of their complexity. A more sustainable solution could be to use behavioural nudges.
India’s efforts to improve its record on delivering healthcare for everyone largely rests on two planks: government-backed insurance products and a large network of healthcare facilities. This approach, despite its intuitive appeal, may be insufficient unless steps are taken to improve the quality of care as well. Tailored performance incentive programmes and simple behavioural nudges for healthcare staff can be effective tools for policymakers to that end.
The WHO says unaffordable medical bills push around 100 million people into poverty every year, hitting people living in low-income countries the hardest. The number in India, by some estimates, could be around 60 million. Seen through this lens, the Indian government’s Ayushman Bharat programme, designed to protect the poor from financial shock and easing access to affordable health care, is a natural approach to meet its universal health coverage goals.
But such measures may not always result in effective, timely, and safe delivery of healthcare services – factors essential for high-quality care. A 2018 Lancet study found poor quality care results in more deaths in India than difficulties in getting care. The study said an estimated 1.6 million people in India died because of poor quality care in 2016, almost twice the number of deaths caused by inadequate access. In fact, India had the highest number of deaths due to low-grade care that year in South Asia after Afghanistan when adjusted for population. These grim statistics make it clear that to achieve healthcare for all, Indian policymakers need to have the same sharp focus on delivering high-quality care as they have on reducing barriers to access.
A big reason behind India’s poor quality care is the lack of trained staff. And health workers often find themselves unequipped, unprepared and overburdened, which can be fatal during critical moments such as child birth. There is indeed no magic solution, but it is possible to improve the standard of care if India can find the right way to keep its health workers sufficiently motivated. Tailored performance incentive programmes are one way to do it.
Performance incentives for healthcare workers have been a fairly popular strategy for a while now. But they generally follow a one-size-fits-all model, ignoring the differences in skills, preferences and personality traits of healthcare workers as well as local customs. An effective incentive programme must consider these subtleties, especially in a country that has as big and as diverse healthcare workforce as India.
A randomised evaluation in Karnataka makes a strong case for tailored incentives programmes.1 It found that financial rewards pegged to better health outcomes were more effective among trained medical staff. For staff members with low levels of skills, financial payouts for following proper clinical guidelines is a much more appropriate and less costly strategy. Another recent study in Pakistan’s Lahore city reaches a similar conclusion on the need for targeted incentives. Researchers found that incentive plans customised to overcome health providers’ personal tendency to procrastinate reduced delays and increased polio vaccination in Pakistan, one of the two countries in the world where polio is still endemic.
However, adding new tailored incentive programmes may be expensive and difficult for governments to run because of the complexities involved in fine-tuning them to achieve intended health goals. A more sustainable solution could be to hire high-performing healthcare workers in the first place. Behavioural nudges can be a simple and a relatively inexpensive technique to do that.
A randomised evaluation in Zambia showed that recruitment advertisements reminding health workers of opportunities for career advancement was enough to improve healthcare outcomes even though they had the same growth opportunities as everyone else.
Researchers found that recruitment posters highlighting professional growth opportunities brought in skilled community health workers who were more likely to deliver high-quality medical care and had an equal desire to enhance the welfare of their communities as their socially-minded colleagues. Places visited by these workers saw higher rates of polio immunisation, deworming, breastfeeding and lower prevalence of respiratory illnesses and malnutrition among children.
Zambia’s health ministry went on to adopt this strategy for recruiting community health workers across the country. An inexpensive solution like this has the potential to enhance the delivery of essential healthcare services in India, which like Zambia, traces much of its healthcare deficiencies to lack of enough funding and worker shortages.
To be fair, improving health worker performance and quality of care is a complicated job, in large part because it is a fight on multiple fronts. Health authorities need to, at once, hire qualified staff, invest in their training, provide mentorship and guidance and find ways to keep the most competent ones.
But other middle and low-income countries such as Thailand and Vietnam have shown that it is not an unachievable feat. Both countries have made significant strides in providing affordable healthcare for all through a combination of measures that ensure high-quality care as well as ease of access, reminding us that universal health coverage isn’t just for the rich nations. The result is that Thailand and Vietnam today are ahead of India on most health indicators.
It will take some time before India catches up to them. After all, most successful universal healthcare systems in the world have taken several decades to develop. But it will not happen unless India places an equal emphasis on the quality as well as the accessibility of care – it’s the only way to truly achieve affordable healthcare for all.
Urvashi Wattal is a senior policy and training manager at J-PAL South Asia. Moulshri Mohan is a former policy and training manager at J-PAL South Asia.
The study was conducted by J-PAL South Asia, with which the authors of this article are also affiliated.↩