FM_Yazbeck 8/14/03 3:16 PM Page iii Human Development Network Health, Nutrition, and Population Series Health Policy Research in South Asia Building Capacity for Reform Abdo S. Yazbeck David H. Peters EditorsAtsuko AoyamaAtsuko Aoyama THE WORLD BANK Washington, D.C. FM_Yazbeck 8/14/03 3:16 PM Page iv © 2003 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433 Telephone 202-473-1000 Internet www.worldbank.org E-mail [email protected] All rights reserved. First printing August 2003 1 2 3 4 06 05 04 03 The findings, interpretations, and conclusions expressed herein are those of the author(s) and do not necessarily reflect the views of the Board of Executive Directors of the World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. 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All other queries on rights and licenses, including subsidiary rights, should be addressed to the Office of the Publisher, World Bank, 1818 H Street, NW, Washington, DC 20433, USA, fax 202-522-2422, e-mail [email protected]. ISBN 0-8213-5531-7 Library of Congress Cataloging-in-Publication Data Health policy research in South Asia : building capacity for reform / edited by Abdo S. Yazbeck and David H. Peters. p. cm. — (Health, nutrition, and population series) Includes bibliographical references. ISBN 0-8213-5531-7 1. Medical policy—Research—South Asia. 2. Medical policy—South Asia. 3. Health care reform—South Asia. 4. Public health administration—South Asia. I. Yazbeck, Abdo. II. Peters, David H., 1962– III. Series. RA395.S628H436 2003 362.1'07'2054—dc21 2003052538 FM_Yazbeck 8/14/03 3:16 PM Page v Contents Foreword xvii Sadiq Ahmed, World Bank Acknowledgments xix Acronyms and Abbreviations xxi Section I: Introduction 1 1 Overview 3 Abdo S. Yazbeck, World Bank David H. Peters, Johns Hopkins University 2A Framework for Health Policy Research in South Asia 23 David H. Peters, Johns Hopkins University Abdo S. Yazbeck, World Bank Section II: Analysis of Inequality 31 3 The Distribution of Public Health Subsidies in India 33 Ajay Mahal, Harvard University v FM_Yazbeck 8/14/03 3:16 PM Page vi vi • Health Policy Research in South Asia 4 Equity in Financing and Delivery of Health Services in Bangladesh, Nepal, and Sri Lanka 65 Institute of Policy Studies, Sri Lanka 5 Geographic Resource Allocation in Bangladesh 101 Tim Ensor, University of York Atia Hossain, Priti Dave Sen, Liaquat Ali, Shamin Ara Begum, and Hamid Moral, Ministry of Health and Family Welfare, Bangladesh Section III: Expenditure Analysis 129 6 Public Expenditure Review of the Health and Population Sector Program in Bangladesh 131 Tim Ensor, University of York Atia Hossain, Priti Dave Sen, Liaquat Ali, Shamin Ara Begum, and Hamid Moral, Ministry of Health and Family Welfare, Bangladesh 7 Sri Lanka’s National Health Accounts: National Health Expenditures 1990–1999 163 Institute of Policy Studies and Ministry of Health, Sri Lanka 8 The Bangladesh Health Facility Efficiency Survey 195 Ravi P. Rannan-Eliya, Institute of Policy Studies, Sri Lanka Aparnaa Somanathan, Institute of Policy Studies, Sri Lanka Section IV: Private Sector Analysis 227 9 Private Health Care Sector in India—Policy Challenges and Options for Partnership 229 V. R. Muraleedharan, Indian Institute of Technology (Madras) Sunil Nandraj, World Health Organization, India Office FM_Yazbeck 8/14/03 3:16 PM Page vii Contents • vii 10 Private Health Provision in Uttar Pradesh, India 257 S. Chakraborty, Indian Institute of Management, Lucknow, Uttar Pradesh, India 11 Private Primary Care Practitioners in Sri Lanka 279 Ravi P. Rannan-Eliya and Prashanthi Jayawardhane, Institute of Policy Studies, Sri Lanka Leela Karunaratne, Department of Family Medicine and Community Medicine, University of Sri Jayawardanepura, Sri Lanka Section V: Consumer and Provider Perspectives 305 12 Consumer Redress in the Health Sector in India 307 Bejon Misra, Consumer VOICE, Delhi 13 Quality Health Care in Private and Public Health Care Institutions 333 Prasanta Mahapatra, Institute of Health Systems, Hyderabad, Andhra Pradesh, India 14 Voices of Stakeholders in the Health Sector Reform in Bangladesh 369 Nilufar Ahmad, South Asia Social Development and Environment, World Bank Tables 1.1 Selected Health Indicators in South Asian Countries 4 1.2 Inequality in Health Outcomes and Health Sector Outputs in South Asia 8 3.1 Unit Cost Estimates from Facility-Level Data in India 39 3.2 Distribution of Health Care Services in Public Health Facilities by Type of Service, State/Region, and Socioeconomic Status, 1995/96 42 FM_Yazbeck 8/14/03 3:16 PM Page viii viii • Health Policy Research in South Asia 3.3 Distribution of Use of Services by Public and Private Facilities by Type of Service, State/Region, and Per Capita Expenditure Quintile, 1995/96 44 3.4 Share of Richest 40 Percent of the Population in Total Hospital Charges Paid to Public Health Facilities by State and Region, 1995/96 51 3.5 Distribution of Public Subsidies by State/Region and Socioeconomic Status, 1995/96 55 4.1 General Indicators for Bangladesh, Nepal, and Sri Lanka, 1997 72 4.2 Background Information on National Health Systems of Bangladesh, Nepal, and Sri Lanka 73 4.3 Overview of Survey Data Used in the Study 76 4.4 Infant and Under-Five Mortality Rates by Income Quintile of Equivalent Consumption for Bangladesh, Nepal, and Sri Lanka 78 4.5 Infant and Under-Five Mortality Rates by Education of Mother and Place of Residence for Bangladesh, Nepal, and Sri Lanka 79 4.6 Distribution of the Benefits of Government Expenditures on Personal Medical Services in Bangladesh and Sri Lanka 84 4.7 Distribution of the Benefits of Government Expenditures on Collective Services and on All Services in Bangladesh and Sri Lanka 85 4.8 Variations in Government Expenditures on Health by Region 86 4.9 Distribution of Payments for Health Care for Each Source in Bangladesh and Sri Lanka by Income Decile 90 4.10 Kakwani and Suits Indexes for Different Payment Mechanisms for Health Care in Sri Lanka 91 4.11 Redistributive Impact of Government Taxation and Financing of Health Care Services in Sri Lanka, 1995/96 92 FM_Yazbeck 8/14/03 3:16 PM Page ix Contents • ix 4.12 Redistributive Impact of Government Taxation and Financing of Health Care Services in Bangladesh, 1996/97 93 5.1 Allocation of Funding to Public Facilities 104 5.2 Typical Budgets for a District Hospital and an Upazila Health Complex 106 5.3 Distribution of Spending on Public Health in an Average District by Type of Facility 107 5.4 Range of Public Health Spending Per Capita across Districts by Division and Presence of a Medical College Hospital (MCH), Fiscal 2000 108 5.5 Inpatient and Outpatient Use of District Hospital (DH) and Medical College Hospital (MCH) Facilities, by Selected District and Proximity of Patient Residence to Facility 119 6.1 Financial Indicators of the HPSP 133 6.2 Public Expenditure Allocation of Benefits by Gender and Type of Service 149 6.3 Average Payments per User by Income Group and ESP Category 152 6.4 Revenue Projections under Different Assumptions 158 7.1 Total Expenditures on Health (TEH), 1990–99 168 7.2 Per Capita Health Expenditures, 1990–99 169 7.3 Total Expenditures on Health at Current Market Prices, 1990–99 169 7.4 Total Expenditures by Function, 1990–99 174 7.5 Relative Share of Funding by Public and Private Expenditures to Selected Functional Categories in 1997 175 7.6 Relative Share of Funding by Central, Provincial, and Local Governments to Selected Functional Categories in 1997 177 7.7 Total Government Expenditures by Function, 1990–99 178 FM_Yazbeck 8/14/03 3:16 PM Page x x• Health Policy Research in South Asia 7.8 Total Nongovernment Expenditures by Function, 1990–99 179 7.9 Total National Expenditures by Type of Provider, 1990–99 180 7.10 Total Government Expenditures by Type of Provider, 1990–99 181 7.11 Total Nongovernment Expenditures by Type of Provider, 1990–99 182 7.12 Per Capita Expenditures by Source, 1997 185 7.13 Per Capita Expenditures by Central Government, 1990–99 185 7.14 Per Capita Expenditures by Provincial Council and Local Government, 1990–99 186 7.15 Total Expenditure on Health Per Capita Not Directly Attributable to Any Province, 1990–99 186 7.16 National Health Expenditures in Selected Asia-Pacific and Organisation for Economic Co-operation and Development Countries and Economies 190 7.17 International Comparison of Expenditures by Source 191 8.1 Allocation of Recurrent Costs to Inpatient and Outpatient Services 203 8.2 Distribution of Sampled Facilities in Survey by Type and Division 204 8.3 Key Statistics by Category of Facility 205 8.4 Available Equipment at Facilities 207 8.5 Available Utilities at Facilities 207 8.6 Staffing Indicators and