Arijita Dutta

Measurement and determinants of public hospital efficiency in West Bengal, India

This article focuses on analysing the efficiency of secondary-level government-run hospitals in West Bengal, a medium performer state in terms of health indicators, in India. Two main objectives of this article are (1) to measure the technical efficiency of the same and (2) to identify the factors determining their inefficiency. For the first purpose, output-oriented data envelopment analysis (DEA) under variable returns to scale has been used. For the second purpose, we have used two-part regression models, first showing why some hospitals are efficient while others are not and, secondly, what are the factors that determine the relative efficiency of inefficient hospitals. We have used different forms of regression models for both types. The results show that the overall mean efficiency of all hospitals is 0.728, suggesting that on average the hospitals could produce at least 37 per cent more of output with same input volume if they had produced efficiently. The results also reveal that the highest contributor to slack is the group D staff, followed by doctors. It is found that increase in average length of stay, availability of free medicine from the hospital, ratio between doctor and non-doctor staff strength, outpatient bed day and share of emergency admission significantly decrease the efficiency of a hospital, while the ratio of nurses to non-nurses affects it positively. The article concludes with policy suggestions based on the analysis that decrease in average length of stay (ALOS) by better medical intervention and improved quality of care would definitely allow for more patients to be treated, while increase in nursing staff vis-à-vis other staff would also result in better care. Furthermore, as far as availability of medicines is concerned, the policy should not be to reduce access and coverage, but should rather centre round improving the quality of the drugs procured and distributed through the hospitals. The article concludes that the main source of inefficiency in a specialist hospital in a typical developing country is not just resource crunch, but huge gaps in planning and implementation by the central authorities as well as managerial inefficiency of the local hospital establishment. The determinants that play a vital role in increasing efficiency levels also indicate that most of the inefficiencies can be tackled either with long-term planning or by quick intercession by the hospital authority itself.

INEQUITY IN HOSPITALIZATION CARE: A STUDY ON UTILIZATION OF HEALTHCARE SERVICES IN WEST BENGAL, INDIA

BACKGROUND Out of eight commonly agreed Millennium Development Goals (MDG), six are related to the attainment of Universal Health Coverage (UHC) throughout the globe. This universalization of health status suggests policies to narrow the gap in access and benefit sharing between different socially and economically underprivileged classes with that of the better placed ones and a consequent expansion of subsidized healthcare appears to be a common feature for most of the developing nations. The National Health Policy in India (2002) suggests expansion of market-based care for the affording class and subsidized care for the deserving class of the society. So, the benefit distribution of this limited public support in health sector is important to examine to study the welfare consequences of the policy. This paper examines the nature of utilization to inpatient care by different socio-economic groups across regions and gender in West Bengal (WB), India. The benefit incidence of public subsidies across these socio-economic groups has also been verified for different types of services like medicines, diagnostics and professional care etc. METHODS National Sample Survey Organization (NSSO) has collected information on all hospitalized cases (60(th) round, 2004) with a recall period of 365 days from the sampled households through stratified random sampling technique. The data has been used to assess utilization of healthcare services during hospitalization and the distribution of public subsidies among the patients of different socio-economic background; a Benefit Incidence Analysis (BIA) has also been carried out. RESULTS Analysis shows that though the rate of utilization of public hospitals is quite high, other complementary services like medicine, doctor and diagnostic tests are mostly purchased from private market. This leads to high Out-of-Pocket (OOP) expenditure. Moreover, BIA reveals that the public subsidies are mostly enjoyed by the relatively better placed patients, both socially and economically. The worse situation is observed for gender related inequality in access and benefit from public subsidies in the state. CONCLUSION Focused policies are required to ensure proper distribution of public subsidies to arrest high OOP expenditure. Drastic change in policy targeting is needed to secure equity without compromising efficiency.

Health reform and infant mortality in West Bengal, India: an untold story

ABSTRACT Though studies have focused on the expansion of coverage of health care utilization after India’s health care reform in 2004–2005 under the National Rural Health Mission, the effect of limited risk protection of the programme, measured by non-availability of services at institutions, has remained under-studied. Using bivariate probit models on birth history data of 6568 children in two districts in West Bengal, an eastern state of India, this paper finds that in post-reform era, health care utilization in the form of institutional delivery has a tendency to enhance the risk of infant mortality, primarily owing to lack of timely services received at the institutions.

THE GAP BETWEEN CONSTRUCTION AND USAGE OF TOILETS: AN UNDER-IDENTIFIED PROBLEM

Background Government of India initiatives have been instrumental in constructing or partially subsidising the construction of toilets for poorer households. However, even after two decades of such large-scale efforts, the programme failed to tackle the water-borne disease burden. Of late, studies have located the rift between construction and use of toilets. Scientific analyses of identifying inter- and intra-household barriers to the use of toilets have rarely been undertaken. The present study paper attempts to bridge this gap using a primary survey of households in four villages of Jalpaiguri district, West Bengal. Methods In this study, we used data from a survey of 300 households in four villages, selected from a total of 62, of Jalpaiguri district, West Bengal. We applied stratified random sampling at three levels. At the first level, two blocks were selected from Jalpaiguri district depending on their female literacy, an important indicator of human development. The two blocks selected were Nagrakata, with lowest female literacy rate (48.5%), and Jalpaiguri with highest female literacy rate (65.3%) as per Census 2011 data. Once the blocks were defined, at the second level we selected two big villages from each block with highest concentration of Scheduled Tribe (ST) population. The reason behind choosing ST-dominated villages was to explore how far socially marginalised classes have so far reacted to the public policy in terms of ownership and usage of toilets. In Nagrakata block we found six villages with more than thousand households (Bhagatpur Tea Garden, Chengmari Tea Garden, Gatia Tea Garden, Grassmore Tea Garden, Luksan Tea Garden and Naya Saili Tea Garden); in Jalpaiguri block we found 13 (Bahadur, Barpatina Nutanbus, Berubari, Bhelakoba, Boalmari, Garalbari, Kharia, Kharija Berubari, Mandalghat, Nandanpur, Paharpur, Patkata and Satkhamar). Next, considering the concentration of ST population among these villages in both blocks, we selected two villages in each block, namely Gatia Tea Garden and Grassmore Tea Garden in Nagrakata block (with a share of ST population of 79.4% and 72.4% respectively) and Barpatina Nutanbus and Patkata from Jalpaiguri block (with a share of 27.2% and 24.9% respectively). At the final step, we needed to select households within the village where we would run our questionnaires. For randomisation, we started from southeast corner of a village and chose the first household at the edge. Then we moved to left-hand corner and we choose the third household, thus moving towards the centre of the village. This way we assumed to cover all types of households, more prosperous ones at the centre and more marginalised ones on the edge of a village. We covered 75 households from each village surveyed. Following this method, we covered 150 (75×2) households from each block; hence total number of households was 300. Multinomial logistic regression was used for the three categories of usage habits of toilets (exclusive home toilet, mixed usage of home toilet and open defecation, and exclusive open defecation) in order to find out the inter-household and intra-household factors responsible for specific categories of toilet use. Findings Among 135 of selected households (715 members) who have toilets within their premises, the following usage habits were found: exclusive defecation in home toilets (56.7%), mixed usage of home toilets and open defecation (32.6%) and exclusive open defecation (10.7%). Though more than half of the individuals used home toilet, most of them (about 64%) used pit toilet compared to flush toilets. In case of pit toilet, household members tend to use open defecation more. In fact there was no household with flush toilet where all members exclusively used open defecation. The study posits that, within a household, the issues like sex, age and its square impose strong barriers on regular usage of existing toilets. Men prefer to use toilets less compared to women. Both age and square of age appeared to be highly significant, representing a non-linear relationship with choice of place. Muslims are more likely to practice open defecation than using exclusive home toilet compared to Hindus. Good condition of toilet induces the members to reduce open defecation. Economic condition of a household, education, marital status and technology of existing toilet facilities have no significant effect on toilet use. Discussion Our study points out the problem of under-utilisation of constructed toilets in a typical under-developed setting in the state of West Bengal. The problem of absence of systematic and consistent use of the available toilets has been identified as one of the main reasons behind the failure of substantial public investment in creating sanitation facilities to reduce the burden of diarrhoea among Indian households. While creation of toilets is a necessary first step towards improved sanitation facilities for the vulnerable sections of the population, it is not a sufficient one. Addressing the issues of acceptability and accommodation should be dealt with more seriousness and enthusiasm. The combined condition index emerged a significant determinant of utilisation in both panels of multinomial logistic regressions. This particular result implicitly brings into focus the critical availability of masons and plumbers at village level, who are required to correct construction defects and clogging of the existing toilets. Mass-scale adult awareness generation might be one step towards this end, to lead the way in eradicating open defecation by 2019. Having identified key barriers, our study expects to contribute to a change in direction of public policy, from just construction and use for dignity of women to a more broad-based right-oriented approach. Grant funding (FINISH programme – Financial Inclusion for Sanitation and Health, WASTE, The Hague, the Netherlands) for research but no other competing interests.

Policy intervention for access to medicine: Does it work similarly for poor and non-poor?

Many federal states in India have recently taken steps to improve distribution and affordability of medicines across public hospitals for reducing high out-of-pocket (OOP) expenditure. West Bengal has introduced a Public-Private Partnership (PPP) scheme, Fair Price Medicine Shops (FPMS) within government hospitals in 2012, which offers high discounts on maximum retail price of the drugs. This model introduces the state as a facilitator, rather than provider or financer, of health care. This paper attempts to measure its impact on OOP expenditure (OOPE) of patients using propensity-score-matching technique on the data collected from primary survey among patients. The study finds that although for non-poor patients, the average OOPE has reduced significantly, the impact has been counter-productive for the poor patients, hinting that PPP intervention seems to work only for relatively better-off people, as the best alternative for the poorest remains to be free provision of drugs from the government. The difference in outcome lay in the fact that the nature of control groups differed between poor and non-poor patients. Those poor patients who did not visit FPMS received most of the medicines free (hence OOPE nearly zero), while for the non-poor patients not visiting FPMS bought the drugs from outside retail shops.

Microfinance and Human Development: A Cross-Generation Study

Microfinance has been accepted as a potent instrument to improve the living standards of the ultra-poor women in developing and least developed countries in the world. Most of the research studies inferred that participation in microfinance initiatives has a positive impact on female labor force participation rate, which in turn improve their initial consumption and empowerment. A relatively more empowered woman is expected to exercise agency and make strategic life choices in a context, where women’s ability to set their own goals and pursue them is seriously constrained by an in egalitarian gender system. These strategic life choices normally include their children’s schooling and education, their own healthcare options, and ability to earn and spend according to their own will. Thus, involvement in income-generating activities using microfinance which leads to improving/enhancing decision making of women may not only improve their own lives but is expected to improve the quality of human development over generations. It would be thus interesting to explore how far a mother with long-term engagement in microfinance can take progressive steps to reduce early dropouts of her daughters from educational institutions and also to give freedom to her daughter-in-law to pursue career choices, as manifestations of comprehensive long-term development. Given this backdrop, the chapter aims to capture the impact of microfinance use on 1200 middle-aged women on the overall human development of women of their next generation. The specific objective of the study is to assess the impact of microfinance on education and career choice of the second generation of microfinance users, daughters and daughters-in-law, compared to the original microfinance borrowers and non-borrowers. Using propensity score matching techniques of impact evaluation, the chapter does not identify that among the second-generation women of microfinance borrowers, education nor financial inclusion appears to be statistically higher compared to that of non-borrowing control groups. Thus, the impact of microfinance seems to fizzle out without sustainability, representing a sure sign of mission drift.

Impact of integrated child development scheme on child malnutrition in West Bengal, India

With child malnutrition detected as a persistent problem in most of the developing countries, public policy has been directed towards offering community-based supplementary feeding provision and nutritional information to caregivers. India, being no exception, has initiated these programs as early as 1970s under integrated child development scheme. Using propensity score matching technique on primary data of 390 households in two districts of West Bengal, an Eastern state in India, the study finds that impact of being included in the program and receiving supplementary feeding is insignificant on child stunting measures, though the program can break the intractable barriers of child stunting only when the child successfully receives not only just the supplementary feeding but also his caregiver collects crucial information on nutritional awareness and growth trajectory of the child. Availability of regular eggs in the feeding diet too can reduce protein-related undernutrition. Focusing on just feeding means low depth of other services offered under integrated child development scheme, including pre-school education, nutritional awareness, and hygiene behavior; thus repealing a part of the apparent food-secure population who puts far more importance on the latter services.

On diarrhoea in adolescents and school toilets: Insights from an Indian village school study

Abstract The economics literature on the determinants of diarrhoea focuses on infants; but what about school going adolescents? Our survey in an Indian village school affirms that sanitation, defecation practices at home and school, and the degree of crowding of living space at home are all significant determinants of diarrhoeal incidence for adolescents. Usage of toilets at school varies as a function of gender and existence of a toilet in student’s home. Access to toilets is not sufficient to guarantee their usage. To eliminate open defecation: toilets installation, behavioural change, and sustainable mechanisms to maintain school toilets seem necessary.

The gap between construction and usage of toilets: An under-identified problem

State initiatives in India have been instrumental in constructing or partially subsidizing the construction of toilets for poorer households of the population. However, even after two decades of such large-scale efforts, the program failed to tackle the water borne disease burden. Though, of late, studies have located the rift between construction and use of toilets; scientific analysis of identifying inter and intra-household barriers to use of toilets have rarely been undertaken. This paper attempts to bridge this gap using a primary survey of 300 households in four villages of Jalpaiguri district in state of West Bengal. Among 300 households, 165 households have no toilet, among rest 135 households with toilets in survey, 741 members were located to have different types of sanitation usage habits: exclusive defecation in home toilets (56.71%), mixed usage of home toilets and open defecation (32.58%) and exclusive open defecation (10.71%). Ordered Logistic Regression was used for these four categories of usage habits in order to find out the inter-household and intra-household factors responsible for specific categories of toilet use. The study posits that within household the issues like sex, age and religion impose strong barriers on regular usage of existing toilets. Conditions of toilet also determine the choice of place of defecation. Identifying these barriers, the study expects to contribute in changing direction of the public policy from just construction and use for dignity of women to a more broad-based right-oriented campaign to usher India to the new dawn of Swachh Bharat.

Access to Medicine in Public Hospitals and Some Crucial Management Issues

Access to medicines (drugs, diagnostics and vaccines) is essential to promote equitable health care for all though one third of the world’s population does not have access to basic and essential drugs, particularly in the poorest parts of Africa and Asia. In a third world country like India with high industrial capabilities, a large part of the population still lives below the poverty line and there the role of the government becomes crucial in creating the aforesaid access. The chapter deals with three main objectives: (1) to find status of access to free medicine in public secondary hospitals in West Bengal, (2) to identify the factors affecting this access to free medicine and (3) to analyse how this availability of free medicine affects the overall efficiency of these government-run hospitals in West Bengal. For the first purpose, we used descriptive statistics from the secondary data of National Sample Survey Organization (NSSO) and from primary survey on more than 2,000 patients in 86 secondary level hospitals in West Bengal. For the second purpose, we used a multinomial logit regression model. For the third purpose, we used a regression technique to determine what are the barriers of access and how does the efficiency score of hospitals (measured by Data Envelopment Analysis) affect the access to medicine. The chapter concludes that managerial steps should be immediately taken to improve both the quantity and quality of the drugs supplied to these hospitals. Some improvements are also suggested about the prescription system, procurement, storage and distribution system of essential drugs based on some field experience. Need for a modification of the State Essential Drug List is also suggested.