Publications and Papers
Publications and Papers


Working Paper 1: A Guide to Applied Political Analysis for Health Reform
By Michael R. Reich and Paola Abril Campos
August 2020
Creating health system change requires a combination of technical solutions and political skill. Understanding the political context of health policies is crucial to improving the chances of effectively designing, adopting, and implementing health reforms that can achieve their intended objectives. This guide seeks to help reformers navigate the political processes involved in changing and implementing health policies that will improve societal health and well-being. Policy reform is a profoundly political process, and advocates need to manage the politics of change, through careful political analysis and innovative political strategies. It is important to note that this guide is aimed to assist in applied political analysis—not in advancing theory, but in supporting practitioners. We seek to provide guidance that will help in the art of policy reform, through step-by-step suggestions for analysis. (See Appendix 1 for a glossary of some terms used in this guide.) Various forms of applied political analysis exist. This particular form is a core component of the Flagship Approach to Health Reform that has been developed since the mid-1990s by a team of researchers at Harvard University in collaboration with the World Bank and other institutions. This guide can be used in conjunction with the Flagship Approach, but it is also designed to be used independently, to provide policy makers and policy analysts with instructions on how to manage the political processes of reform. The guide helps identify political, fiscal and institutional constraints that need to be addressed by political strategies that can improve the adoption and implementation of health reform. With an Introductory Message from Arti Ahuja, Additional Secretary Ministry of Health and Family Welfare, Government of India.
Resources: Download the current version of the Guide here.

Working Paper 2: Delivering primary healthcare with quality and accountability in India: the case of Swasth
By Anuska Kalita, Sundeep Kapila, and Michael R. Reich
October 2020
Abstract: Mumbai’s health system faces several challenges, as in many other parts of India, and both the public and private sectors have failed to deliver a broad set of good quality primary healthcare services in a patient-friendly way. Swasth, a not-for-profit social enterprise, was founded in 2009 with an aim to address many of these gaps by delivering primary healthcare services to low-income populations in Mumbai through a network of health centers. Using both primary and secondary data, this paper presents the interventions that Swasth has undertaken to address key health system challenges in Mumbai: (1) providing a broad set of primary healthcare services, including preventive-promotive and curative care, as well as dental care, diagnostics, and drugs; (2) delivering easily accessible and patient-friendly care, through conveniently located and timed clinics; (3) assuring accountability to patients for services, by issuing warranties for timely and lowest-priced services, and for treatment outcomes in dental care and hypertension management; and (4) promoting provider behavior that prioritizes quality and accountability, through incentives, technology systems, and careful recruitment, training and monitoring of their staff. We conclude the paper with a discussion on the challenges of financial sustainability and scalability that Swasth confronts today. We also present an examination of potential lessons for Health and Wellness Centers under India’s Ayushman Bharat program, specifically, lessons for expansion of primary healthcare services, for making public sector facilities more accessible to people, for introducing measures of accountability to patients, and for designing mechanisms to ensure quality of care by public sector providers. This paper is intended to inform PHC interventions in both public and private sectors and is envisioned to be useful for readers involved in designing PHC reforms at the central and decentralized government levels.
Resources: Download this Working Paper here.

A Case Study on the Use of Pay-for Performance Contracts in Turkey to Reduce Geographic and Social Disparities in Access to Primary Health Care
By Ece Amber Özçelik
August 2020
Abstract: Turkey is one of the few countries that explicitly relied on primary health care (PHC) provider payment reforms as part of a much larger health system reform process known as the Health Transformation Program (2002-2013) to address inequitable access to health services. This case study reviews Turkey’s PHC provider payment reforms (2005-2007) that entailed the introduction of performance-based contracts for all PHC providers to derive lessons that may be applicable to India’s ongoing efforts to redesign the existing payment arrangements for its own PHC providers. This analysis uses the Flagship Framework to understand how changes in PHC provider payment methods can lead to changes in the geographic distribution of health professionals and in the use of PHC services. It compares the traditional salary-based provider contracts used prior to the reform with the new performance-based contracts, with a focus on the design features that provide explicit financial incentives for (1) deployment in areas with low levels of socioeconomic development and (2) increasing the number of PHC consultations for certain segments of the population, particularly for maternal and child health care. The case study derives three lessons from Turkey’s experience in designing and implementing PHC provider payment reforms. First, redesigning provider payment arrangements at the PHC level is an important policy lever that can lead to better health system performance. Second, relying on provider payment mechanisms to boost provider availability in areas with low socioeconomic development alone does not guarantee significant increases in provider density in these areas due to the other underlying factors that drive geographic maldistribution of health professionals. Third, the design choices for identifying performance indicators in provider contracts can encourage providers to prioritize certain kinds of healthcare services, but not others that may also be needed.
Resources: Download this Working Paper here.

Women’s Agency
By Jan Cooper
Abstract: We propose a new method to design a short survey measure of a complex concept such as women’s agency. The approach combines mixed-methods data collection and machine learning. We select the best survey questions based on how strongly correlated they are with a “gold standard” measure of the concept derived from qualitative interviews. In our application, we measure agency for 209 women in Haryana, India, first, through a semi-structured interview and, second, through a large set of close-ended questions. We use qualitative coding methods to score each woman’s agency based on the interview, which we treat as her true agency. To identify the close-ended questions most predictive of the “truth,” we apply statistical algorithms that build on LASSO and random forest but constrain how many variables are selected for the model (five in our case). The resulting five-question index is as strongly correlated with the coded qualitative interview as is an index that uses all of the candidate questions. This approach of selecting survey questions based on their statistical correspondence to coded qualitative interviews could be used to design short survey modules for many other latent constructs.
Citation Jayachandran, Seema, Monica Biradavolu, and Jan Cooper. 2021. Using Machine Learning and Qualitative Interviews to Design a Five-Question Women’s Agency Index. w28626. National Bureau of Economic Research.

Our research featured at AcademyHealth Annual Research Meeting
Members of the India Health Systems Project team will present several areas of work at the upcoming AcademyHealth 2021 Annual Research Meeting, June 14-17, 2021.

Our research featured at iHEA Congress 2021
The India Health Systems Project team will present several areas of work at the upcoming 2021 Congress of the International Health Economics Association (iHEA), July 12-15, 2021.

Working Paper 4: Procurement of Medicines in Sri Lanka: A Case Study
For many decades, the nation of Sri Lanka has been providing for the health of its citizens at a level that exceeds what most other countries with similar economic situations have attained. Among other indicators, Sri Lanka has assured relatively good access to medicines while controlling prices. Sri Lanka spends about 1.6% of GDP on health, with about one-quarter of the total health budget spent on medicines. Its achievements in access to medicines stem from the government’s well-established system for procurement and distribution of medicines. For health systems in low- and middle-income countries, Sri Lanka’s example demonstrates the benefits of investing strategically and extensively over long periods of time in building a strong system for the procurement of necessary medicines, in useful formulations and appropriate quantities. The case study provides details on Sri Lanka’s model, which offers lessons for other governments working to improve medicines procurement policies and practices. In order to procure medicines effectively, a list of required medications must be drawn up, manufacturers or suppliers of each medicine must be identified and vetted, funds must be provided to pay for them, and the physical commodities must be purchased, received and their quality verified. Then they must be transported to the facilities in time to be available to patients who need them. Each step in this process is complicated on its own—and coordinating the various steps to work in concert with each other adds complexity to the system. While Sri Lanka’s system is far from perfect, it is overall relatively strong and has proven to be flexible enough to adapt and improve over time while maintaining its commitment to improving health equity in the country. The system has developed and changed over time, with key principles and goals related to providing for access to medicines for all Sri Lankans made clear from the outset. Structures established early on to support the vision remain in place, most notably the State Pharmaceuticals Corporation (SPC), through which all purchasing of pharmaceuticals for use in Sri Lanka is conducted. Having a single, government-controlled, purchaser does create bottlenecks that can slow down timely procurement. However, by issuing worldwide tenders and enabling bulk purchasing, SPC manages to control its own costs and the prices paid by consumers. Sri Lanka’s long-standing insistence on using the generic names of medications when prescribing has also contributed to bolstering the use of cheaper generics. By controlling costs, Sri Lanka has managed to expand its Essential Medicines List and formulary in order to supply a wide array of products to citizens. Thanks to its long tradition of principled health care delivery, Sri Lanka is well-positioned to build on its previous successes as it continues to develop its approaches to health care delivery overall and access to quality medicines in particular. It also provides an informative example for other health systems seeking to rationalize their pharmaceutical policy and delivery systems to better serve populations in need.
Download this Working Paper here.

EPW: Evaluating Health Insurance Programmes – An Insurance Cascade Framework
Faculty member Dr. Sebastian Bauhoff published a piece recently in Economic and Political Weekly providing an insurance cascade as a framework to understand and assess bottlenecks in accessing public health insurance in India. An array of bottlenecks has ensured that the numerous health insurance schemes introduced over the years have failed to make any significant dent on the health sector. This article tries to assess these problems by using the “insurance cascade,” a framework that traces the steps from enrolling eligible households to ultimately delivering their benefits. The existing evidence suggests substantial bottlenecks across all cascade steps, with especially large gaps in beneficiaries’ awareness of how to enrol in schemes, what the schemes covers, and how to access scheme benefits.
Resources Bauhoff, S. & Sudharsanan, N. Evaluating Health Insurance Programmes. Economic and Political Weekly 56, 7–8 (2015), available here.

Report: Reform Options for Odisha and other Indian States with Similar Conditions Reform Options for Odisha and other Indian States with Similar Conditions
By Winnie Yip, Anuska Kalita, Bill Hsiao, and Michael Reich
January 2022
Abstract: This report presents three broad reform options that the government of Odisha (or other similar states) could consider to address the areas of poor performance in their health system. This report is designed for policymakers at the state and national levels to assist in making critical choices to improve the performance of the state’s health system, and also for analysts and donor institutions who are involved in providing technical assistance to governments on health systems reforms. The report proposes three reform options to consider. Option 1 continues current policies for the health system in the state of Odisha and does not include any new initiatives to address critical problems in the state’s health system. Option 2 and Option 3 are intended to address critical problems in the state’s health system, as identified through a comprehensive assessment of Odisha’s health system conducted in 2019-2020 (the Assessment), based on ten new field surveys on the performance of the state health system. The reform options are based on three Guiding Principles that articulate core goals of the state health system: Extend financial risk protection in the state health system by covering primary health care through pooled public or private resources, Increase value-for-money in the health system and thereby increase efficiency and quality, and ultimately improve health conditions (especially for vulnerable groups), by restructuring the organization of the delivery system and improving provider payment incentives, regulation, governance, and data systems, and Adopt a comprehensive approach to improving the health system by incorporating both public and private sectors in state policies. By “primary health care” (in the first principle), we mean the provision of basic curative health care and essential drugs for the most common health conditions in the population and population-based care, including prevention, health promotion, and chronic disease management.
Resources: Download the report here.

Publication: Catastrophic Health Expenditure on Private Sector Pharmaceuticals: A Cross-Sectional Analysis from the State of Odisha, India Why does out of pocket expenditure remain high in India?
We assess variation in financial risk protection in Odisha, India. Our novel study is the first to investigate the in-depth role of the private sector—especially private chemist shops—in providing outpatient care and also contributing to financial hardship due to healthcare costs. Introduction India has high rates of catastrophic health expenditure (CHE): 16% of Indian households incur CHE. To understand why CHE is so high, we conducted an in-depth analysis in the state of Odisha – a state with high rates of public sector facility use, reported eligibility for public insurance of 80%, and the provision of drugs for free in government-run facilities – yet with the second-highest rates of CHE across India (24%). Methods We collected household data in 2019 representative of the state of Odisha and captured extensive information about healthcare seeking, including the facility type, its sector (private or public), how much was spent out-of-pocket (OOP), and where drugs were obtained. We employ Shapley decomposition to attribute variation in CHE and other financial hardship metrics to characteristics of healthcare, controlling for health and social determinants. Results We find that 36‧3% (95% Uncertainty Interval: 32‧7-40‧1) of explained variation in CHE is attributed to whether a private sector pharmacy was used and the number of drugs obtained. Of all outpatient visits, 13% are with a private sector chemist, a similar rate as public primary providers (15%). Insurance was used in just 6% of hospitalizations and its use explained just 0‧2% (0‧1-0‧4) of CHE overall. 86% of users of outpatient care obtained drugs from the private sector. We estimate that eliminating spending on private drugs would reduce CHE by 56% in Odisha. Discussion: The private sector for pharmaceuticals fulfills an essential health system function in Odisha – supplying drugs to the vast majority of patients. To improve financial risk protection in Odisha, the role currently fulfilled by private sector pharmacies must be considered alongside existing shortcomings in the public sector provision of drugs and the lack of outpatient care and drug coverage in public insurance programs.
Resources: Webinar: The role of private sector pharmacies in financial hardship in India: a health system analysis in the state of Odisha (August 24, 2022), held with the World Bank, Health Nutrition and Population; Health Financing Global Solutions Group; and Joint Learning Network.
More info here. Haakenstad, A., Kalita, A., Bose, B., Cooper, J. E., & Yip, W. (2022). Catastrophic Health Expenditure on Private Sector Pharmaceuticals: A Cross-Sectional Analysis from the State of Odisha, India. Health Policy and Planning. https://doi.org/10.1093/heapol/czac035