Ramesh Bhat

Data Envelopment Analysis (DEA)

Measurement of efficiency of any organisation (e.g., hospital, bank, etc.) that uses multiple inputs and generates multiple outputs is complex and comparisons across units are difficult. Charnes and Cooper (1985) describe a non-parametric approach in such situations to measure efficiency and the technique is known as data envelopment analysis (DEA). This analysis method is basically a linear pro gramming-based technique used for measuring the relative performance of organisational units where the presence of multiple inputs and outputs makes comparisons difficult. It involves identification of units, which in relative sense use the inputs for the given outputs in the most optimal manner; DEA uses this information to construct efficiency frontiers over the data of available organisa tion units. This efficient frontier is used to calculate the efficiencies of the other organisation units that do not fall on the efficient frontier and provide informa tion on which units are not using inputs efficiently. The objective of this article is to introduce the technique and demonstrate it through an example to show how relative efficiencies can be determined and identify units that are relatively less efficient.

Regulation of the private health sector in India.

The expansion of the private sector in India has forced the passages of a number of regulations to promote quality of care and protect consumers. This has expanded the role of government in developing and enforcing regulations in three areas of the health sector: drugs, medical practice, and health facilities. These regulations have been promulgated by both national and state governments. Three particular Acts are examined: the Consumer Protection Act, Medical Councils, and the Nursing Home Act. These Acts have provided basic guidelines for regulation of certain aspects of the health sector, but have also created new challenges, as consumers have become more involved in monitoring health service delivery. The challenge for the future will be to ensure the quality and efficiency of health services in both the public and private sectors through these regulatory mechanisms while seeking to promote national health objectives.

Providing skilled birth attendants and emergency obstetric care to the poor through partnership with private sector obstetricians in Gujarat, India

PROBLEM India has the worlds largest number of maternal deaths estimated at 117,000 per year. Past efforts to provide skilled birth attendants and emergency obstetric care in rural areas have not succeeded because obstetricians are not willing to be posted in government hospitals at subdistrict level. APPROACH We have documented an innovative public-private partnership scheme between the Government of Gujarat, in India, and private obstetricians practising in rural areas to provide delivery care to poor women. LOCAL SETTING In April 2007, the majority of poor women delivered their babies at home without skilled care. RELEVANT CHANGES More than 800 obstetricians joined the scheme and more than 176,000 poor women delivered in private facilities. We estimate that the coverage of deliveries among poor women under the scheme increased from 27% to 53% between April and October 2007. The programme is considered very successful and shows that these types of social health insurance programmes can be managed by the state health department without help from any insurance company or international donor. LESSONS LEARNED At least in some areas of India, it is possible to develop large-scale partnerships with the private sector to provide skilled birth attendants and emergency obstetric care to poor women at a relatively small cost. Poor women will take up the benefit of skilled delivery care rapidly, if they do not have to pay for it.

Dividend Behaviour of Indian Companies Under Monetary Policy Restrictions

In this study we examine the dividend behaviour of Indian companies. We use GMM estimator, which is the most suitable methodology in a dynamic setting. Our results show that the Indian firms have lower target ratios and higher adjustment factors. The most significant result is that the restricted monetary policies have significant influence on the dividend behaviour of Indian firms, causing about 5-6 percent reduction in the payout ratios. The significance of macro economic policy variable suggest that monetary policy restrictions do have impact on cost of raising funds, and the information asymmetry between lenders and borrowers increases that forces companies to reduce their dividend payout.

Human Resource Issues Implications for Health Sector Reforms

Given the growing complexities and challenges it faces, reforms in the health sector are inevitable. They generally focus on making the health systems responsive through strengthening financial systems, ensuring local participation and public–private partnerships, and autonomy of health facilities. It is only through these reforms that deficiencies in the health sector can be addressed. The process is also likely to help in developing strategies that ensure effectiveness and efficiency of resource use. However, the reform process makes some fundamental assumptions about the intrinsic organisational and professional commitment and availability of skilled and competent health care professionals. This paper examines the commitment of district-level health officials in the new state of Chhattisgarh in India. Since development-oriented human resource practices are powerful tools that commit health professionals to enhance the quality of care, we believe that health sector reforms should concentrate on human resource issues and practices more than ever. This paper attempts to examine the following issues: (a) the status of professional and organisational commitment and the technical competencies of health officials managing the sector; (b) the characteristics of human resource management practices in the health sector in Chhattisgarh; and (c) the linkage of these management practices with professional and organisational commitment. Finally, the paper discusses the implications of these issues in the health sector reform process.

Indian public-private partnership for skilled birth-attendance.

www.thelancet.com Vol 371 February 23, 2008 631 cities that provide short courses for public-health workers with supervision provided by Chinese trainees and graduates of the training programme in fi eld epidemiology. These provincial programmes had trained over 200 public-health workers by the start of 2008. There is new funding for categorical programmes to combat priority diseases, including the US President’s Emergency Plan for AIDS Relief, the Global Fund to Fight Tuberculosis, AIDS and Malaria, and the GAVI Alliance. His torically, creating a legacy of health systems that sustain their goals has been diffi cult for categorical programmes. These programmes might now increase contributions to public health and strengthen human capacity by supporting initiatives such as training programmes in fi eld epidemiology. Thus, the training programmes can meet and sustain their goals with an added positive eff ect on countries’ abilities to improve health in many areas. The resulting public-health systems, led by competently trained public-health workers, will increase the host country’s ability to fi ght AIDS, tuberculosis, and malaria— as well as diarrhoeal diseases, maternal mortality, and chronic diseases, and to address the International Health Regulations and other disease priorities of the ministries of health.

Insurance Industry in India: Structure, Performance, and Future Challenges

With the liberalization and entry of private companies in insurance, the Indian insurance sector has started showing signs of significant change. Within a short span of time, private insurance has acquired 13 per cent of the life insurance market and 14 per cent of non-life market. However, there is still a huge untapped demand for insurance. Insurance companies have a pivotal role in offering insurance products which meet the requirements of the people and, at the same time, are affordable. Some of the challenges faced by the insurance sector pertain to the demand conditions, competition in the sector, product innovations, delivery and distribution systems, use of technology, and regulation. To understand the growth and development and the future prospects of this sector, this colloquium addresses the following issues: What will be the demand for insurance? What types of innovative strategies of insurance education and awareness will we require to encourage the Indian consumers? With the changes following bank participation in insurance, will the nature of competition in this sector intensify? What kind of competitive and risk pressures will the insurance businesses experience? What are their implications for profitability, margins, and efficiency? The average size of the polices will continuously decline as the insurance companies increase the geographic coverage. As a result of this, the intermediation costs will go up. What are the implications of these on average costs? What will be the product market scenario? Has the insurance sector benefited from the knowledge base of global companies? To what extent have the technology gains in telecommunications, computer information, and data processing contributed to increased efficiency and productivity of insurance companies? The following key points emerged from the responses of the panelists: The future in life insurance will be determined by the increase in pure protection products, a refreshing look at unit-linked plans, launch of customized plans, and improved service levels. The insurance sector will grow steadily rather than rapidly. While the law and regulations are in place to ensure financial strength and solvency of insurers, the regulators challenge lies in monitoring compliance. The opportunity for financial services is increasing all over the world. Big domestic companies with significant market shares in the local countries will have the opportunities to commence business in other markets. Keeping in mind the complexities of the industry, multi-product, multi-channel, and multisegment route needs to be followed for growth. The challenge of successfully implementing bancassurance lies in training the staff, integrating the insurance products, and ensuring best quality service. Agents in the insurance sector are critical for its success and, in order to gain competitive advantage, quality people are needed but attracting and retaining agents is a challenge.

Hospital Efficiency: An Empirical Analysis of District Hospitals and Grant-in-aid Hospitals in Gujarat

This study focuses on analysing the hospital efficiency of district-level govern ment hospitals and grant-in-aid hospitals in Gujarat. The study attempts to provide an overview of the general status of the health care services provided by hospitals in the state of Gujarat in terms of their technical and allocative efficiency. One of the two thrusts behind addressing the issue of efficiency was to take stock of the state of health care services (in terms of efficiency) provided by grant-in-aid hospitals and district hospitals in this state. The motivation behind addressing the efficiency issue is to provide an empirical analysis of the governments policy to provide grants to not-for-profit institutions to ensure the provision of hospital care in the state. The study compares the efficiency of grant-in-aid hospitals and public hospitals. This comparison between grant-in-aid hospitals and district hospitals in terms of their efficiency has been of interest to many researchers in countries other than India, and no consensus has been reached so far as to which category is more efficient. The relative efficiency of government and the not-for- profit sectors has been reviewed in this article. It is expected that the findings of the study would be useful to evaluate this policy and help policy makers to develop benchmarks in providing grants to such institutions.

Management of Claims and Reimbursements: The Case of Mediclaim Insurance Policy

The Mediclaim scheme run by the government- owned General Insurance Corporation (GIC) of India is currently the only private voluntary health insurance scheme available in India. This scheme has been in operation since 1986 and from time to time a number of revisions has been made to address the needs of its clients. The analysis of claims and reimbursements under this scheme is scanty. This paper analyses 621 claims and reimbursements pertaining to policy initiation years 1997- 98 and 1998-99 of the Ahmedabad branch of GICs subsidiary. The study estimates that about a third of claims amount increase is due to the problems of adverse selection or provider- induced demand. The analysis of breakup of reimbursements suggests that more than one-third of reimbursements are made towards doctors fees, followed by diagnostic charges which account for about one-fourth. The findings also suggest that the insurance company took on an average 121 days to settle the claim.

Evaluating Financing Options to Strengthen Ambulance Services

The provision of ambulance services in remote areas is an important policy inter vention to strengthen the referral system and improve the quality of emergency care. The financial requirements resulting out of capital costs and operating expenses are considerable. Given the financial constraints facing state govern ments in India, departments of health need to explore alternative options. In this article we discuss the options of owning, leasing or hiring of vehicles. We also examine that if the facility has to be self-sustaining, what should be the fees col lected from the users of these services. We also discuss policy implementation issues of protecting the poor from high financial burdens and suggest an overall cap on total charges and exempting indigent patients. The role of local govern ments such as panchayats in creating contingency funds to meet the needs of the poor and developing appropriate exemption policies is considered important to sustain these services. The approach suggested in this article is an illustrative one and results would change depending on what numbers are used in analysis. These numbers are also expected to change from situation to situation. The spreadsheet used in this analysis can be obtained from the author on request.