Location, Location, Location: Residence, Wealth, And The Quality Of Medical Care In Delhi, India

Abstract

There are seventy medical care providers within walking distance of every household in Delhi. However, inequalities in health outcomes persist among the rich and poor, which might reflect differences in the quality of available care. This paper shows that providers visited by the poor were indeed less knowledgeable than those visited by the rich. There is strong evidence of inequalities in access, with lower competence among privateand public-sector providers in poor neighborhoods, but no evidence of inequalities in choices. Practical policy options include targeted information to patients on provider competence and improving the allocation of public doctors across poor and rich neighborhoods. [Health Affairs 26, no. 3 (2007) I n d i a s p e n d s 6 p e r c e n t o f i ts g r o s s d o m e s t i c p r o d u c t (GDP) on health-three times the amount spent by Indonesia or Philippines and twice the amount spent by China. 1 Surveys show that 60 percent of health spending is for primary care; of this, households contribute more than 80 percent. 2 It is usually assumed that a large proportion of spending devoted to acute illnesses reflects the prevalence of morbidities with high case-fatality ratios (such as tuberculosis) or diseases leading to permanent disability (such as leprosy).The problem of health care is often assumed to be low availability; increasing availability is thought to reduce the delays in seeking care and therefore the cost of treating illnesses. This point of view is not unique to India. The influential 1978 Alma-Ata Declaration, for instance, identified better health outcomes with increased availability of primary care: w 3 3 8 2 7 M a r c h 2 0 0 7 Q u a l i t y V a r i a t i o n s

Impact of the Elderly on Household Health Expenditure in Bihar and Kerala, India

“…Alternative medicine is often cheaper than modern medicine so poorer populations (such as in Bihar) would be expected to use alternative medicine more often. It has been shown that the quality of health services used by the poor (whether public or private) are of less good quality than those used by the rich in Delhi (Das & Hammer 2007 Returning to our hypotheses, we saw that there was more CHE in Kerala than…”

Money for nothing: The dire straits of medical practice in Delhi, India

“…22 20 Technically, the exercise is valid as long as the there is payoff-equivalence among the doctors visited and not-visited, the market is competitive, and the observed day was random. 21 Poor and rich patients visit the same private doctors, conditional on living in the same neighborhood (Das and Hammer 2005b). This could indicate that poor patients are, on average, sicker when they visit the doctor and thus their willingness-to-pay is higher than what their income indicates.…”

“…Provider characteristics for different samples are in Table A1. 12 These 35 doctors are no different from the remainder of the sample in observable characteristics, including competence. Details are in Appendix 1.…”

Analyzing the Determinants of Health Worker Performance

“…Many authors have addressed the variation in quality-some explicitly looking at the gaps outlined earlier and others addressing the elements within the gaps directly. Das and Hammer (2007) and Leonard, Masatu, and Vialou (2007) examine the variation in the can-do gap across different institutions, showing that the can-do gap is much larger in the public sector than it is in the private or charitable sectors. Whereas Das and Hammer (2007) examine the difference between public and private, Leonard Masatu, and Vialou (2007) show that the gap is related to the degree of decentralization: facilities that are more decentralized in management have smaller can-do gaps than facilities with centralized decision making.…”

“…Das and Hammer (2007) and Leonard, Masatu, and Vialou (2007) examine the variation in the can-do gap across different institutions, showing that the can-do gap is much larger in the public sector than it is in the private or charitable sectors. Whereas Das and Hammer (2007) examine the difference between public and private, Leonard Masatu, and Vialou (2007) show that the gap is related to the degree of decentralization: facilities that are more decentralized in management have smaller can-do gaps than facilities with centralized decision making. Das and Sohnesen (2007) consider the variation in quality across types of patients, looking for evidence of discrimination (which they do not find).…”