Prasanta Mahapatra | The Institute of Health Systems (original) (raw)

Papers by Prasanta Mahapatra

Monitoring Vital Events (MoVE) writing group* Vital statistics generated through civil registrati... more Monitoring Vital Events (MoVE) writing group* Vital statistics generated through civil registration systems are the major source of continuous monitoring of births and deaths over time. The usefulness of vital statistics depends on their quality. In the second paper in this Series we propose a comprehensive and practical framework for assessment of the quality of vital statistics. With use of routine reports to the UN and cause-of-death data reported to WHO, we review the present situation and past trends of vital statistics in the world and note little improvement in worldwide availability of general vital statistics or cause-of-death statistics. Only a few developing countries have been able to improve their civil registration and vital statistics systems in the past 50 years. International efforts to improve comparability of vital statistics seem to be effective, and there is reasonable progress in collection and publication of data. However, worldwide efforts to improve data hav...

While preparing for this day, I have pondered, how can medical statistics help improve the state ... more While preparing for this day, I have pondered, how can medical statistics help improve the state of medical care? The potential for better medical care is dependent on the scientific temper of our medical profession. The question is how can we improve the scientific temper? The search for evidence is fundamental to the practice of modern day medicine. There is now a movement towards evidence based medicine. But evidence does not come neatly. How do we get past the veil of perception, and how do we tease out reality from illusion? Random noise is a fact of life. We do not have access to all aspects of any experience. Our cognitive stance affects what we perceive and how we process those inputs. Hence, in general, we like to start with skepticism, and look for evidence to improve our understanding. The search for a criterion of truth and knowledge prompted Descartes to start with a system of doubt. Our search for explanations and the quest for knowledge uses strategies, commonly refer...

Health Policy Research in South Asia. Building Capacity for Reform., 2003

Quality of care delivered by health care institutions is a matter of public concern. Any differen... more Quality of care delivered by health care institutions is a matter of public concern. Any differences in quality of services by ownership of health care institutions have significant policy implications. Evidence from health-seeking behavior studies suggests that people who can afford to tend to use private health care institutions. It is assumed that the private health care institutions must be providing better quality of services. Otherwise, why would the rich and middle class access the private health care sector? Such an argument relies on the observed pattern of utilization as a proxy measure of quality of care. Instead, it would be desirable to rely on more direct measures of quality of health care services. But the concept of quality health care tends to have different meanings depending on one's viewpoint. This chapter first discusses the concept of quality in health care and presents a framework for assessing health care quality. Evidence is then presented on the quality of care in the private sector in India. Quality Health Care in Private and Public Health Care Institutions This is followed by findings about structural and process quality issues from a study in Andhra Pradesh to illustrate the structure and dynamics of the private health care sector. Finally, some opinions are presented about quality-of-care measures obtained from owner-managers of private health care institutions in Andhra Pradesh.

This paper analyzes government expenditure on health and related services from 1980/81 through 19... more This paper analyzes government expenditure on health and related services from 1980/81 through 1993/94 in the Indian state of Andhra Pradesh. First it looks at the total health expenditure for health and health-related services from different perspectives. This is followed by an analysis of expenditure on the principal components of health services: public health services, hospital-based services, and education and training. The expenditure on public health services is further broken down into its components. The composition of expenditure on hospital services is analyzed from the perspective of the role of hospitals. Expenditure on education and training is then analyzed in relation to the service components. Per capita expenditure on health and health-related services increased from Rs43 in 1980/81 to Rs120 in 1993/94 calculated at 1980/81 prices. However, as a proportion of state domestic product (SDP) - an indication of the state's overall economic situation - health services expenditure stagnated around 1 percent and health-related expenditure services expenditure increased from 3 to 4 percent. The increase in health expenditure was a result of growth in the economy rather than any change in allocative emphasis. The increase in health-related services was mainly contributed by education and community development. Water supply, sewerage and sanitation did not benefit as much. The structure of allocations within the health service sector provided some reassuring trends and a few disturbing features as well. Government expenditure on public health services viewed as a share of total government health services expenditure, by and large, increased during the 1980s and early 1990s. This is reassuring. Composition of the hospital sector, however, continues to be biased in favor of the tertiary-level institutions. Composition of the expenditure on education and training also needs to be altered to favor training of health workers and nurses. Sewerage and sanitation services have been particularly neglected. These are disturbing. A look at the hospital subsector is particularly illuminating. The share of hospital services expenditure in Andhra Pradesh is lower than what has been from most developing countries. During the 1980s the shift in allocative emphasis away from hospitals was almost equally shared by secondary and tertiary level hospitals. The actual share of secondary and tertiary level hospitals during the 1980s has been 50:50 against a suggested norm of around 66:33. Correcting the initial imbalance in resource distribution between the secondary and tertiary level hospital may take many years if it is done solely through changes in allocation at the margin. Deliberate, one-time investments to increase the secondary level hospital stock may be necessary if the imbalance is to be corrected in reasonable time.

Utility of standardisation in planning and development of hospitals in public sector; (i) to dire... more Utility of standardisation in planning and development of hospitals in public sector; (i) to direct public resources towards provision of the prescribed minimum range and level of services, (ii) to discourage investments for introduction of any facility outside the maximum range and level until and unless the range are themselves fully satisfied, (iii) offer to the public a minimum guaranteed range and level of services, and (iv) to act as an administrative tool for planning, execution and monitoring of hospital services. Utility of standardisation in planning and development of hospitals in private sector; (i) to act as a tool of accredition for conofrmity to minimum standards, (ii) a tool of financial analysis and project planning, (iii) to offer to the clientele a minimum guaranteed range and level of services, and (iv) to help management in monitoring the range and level of services. The paper describes (table-2) the system of classification, nomenclature and normative range of ...

Certain methodological characteristics appear common to all priority-setting exercises in public ... more Certain methodological characteristics appear common to all priority-setting exercises in public health, namely (a) some form of quantification of disease burden; (b) feasibility and cost-effectiveness of the interventions; and (c) reliance on consensus among experts. The role of disease burden estimates in priority-setting needs elaboration. Evidently a disease burden estimate is only one component of a priority-setting exercise. Faced with disease burden estimates, people quickly recognize the main causes of illness and develop a motivation to reduce them. This motivation to apprehend the main causes of disease burden inevitably leads one to search for appropriate technologies and their cost-effectiveness. Considerations of technical and practical feasibility and the cost-effectiveness of interventions play a crucial role in the minds of policy-makers (along with social, political and ethical considerations) in determining which causes of the disease burden are targeted by the hea...

This is a brief note about a project report for development of secondary level hospitals during t... more This is a brief note about a project report for development of secondary level hospitals during the 8th Five Year Plan. The project seeks to develop the District and Sub-district hospitals, so as to make medical care facilities available to people nearer their home. At present people have to travel from far-flung areas to a few regional towns to seek medical care. The existing facilities for the medical care in rural areas are not commensurate with the needs. As against the 7th Five Year Plan norm of 70% of hospital beds, the District an Sub-district hospitals in Andhra Pradesh at present account for only 43% of the total hospital beds in the State. The project covers about 200 locations spread all over the state and seeks to add about 11960 hospital beds at the District and Sub-district level. The current availability of Maternity and Child Health hospitals in the State is very poor. Hence a major component of the project consists of the establishment of MCH hospitals. Govt. propos...

Demography India

Valid and reliable statistics on cause of death is an essential input for setting up of prioritie... more Valid and reliable statistics on cause of death is an essential input for setting up of priorities in the health sector. Developing countries like India are making efforts to operate cause of death reporting systems that are feasible within the given constraints of partially developed registration of vital events, and poor availability of medical facilities. In the rural areas medical certification of cause of death is usually not feasible since a lot of deaths happen without any prior medical attendance. So India depends on a system of lay reporting of cause of death using what is called a verbal autopsy methodology. Until December 1999 cause of death data for the rural areas used to be collected under the Survey of Cause of Death (SCD) Rural scheme, from a sample of primary health center (PHC) headquarters villages by a lay diagnosis and reporting system. From January 1999 the a cause of death component has been added to the SRS (SRS-COD component). Certain general design features...

Journal of evidence-based medicine, 2014

Broad outline of this paper was presented at the Evidence Aid Symposium, on 20 Sep 2014, at Hyder... more Broad outline of this paper was presented at the Evidence Aid Symposium, on 20 Sep 2014, at Hyderabad, India, before the 22nd Cochrane Colloquium. Survey of the field and review of literature. Response to disasters is usually vulnerable to myths and misconceptions. Effective healthcare response requires evidence and information to meet various and often unpredictable eventualities. The knowledge base should facilitate rapid assessment of adverse health outcomes, availability healthcare infrastructure, appropriate organizational strategies, and selection of feasible medical interventions to deal with any given disaster. Most rapid surveys have to adopt some stratification and a cluster sampling design for representativeness. Qualitative research methods are useful to study organizational challenges. Adequate and accurate description of the context is important for interpretation of organization behavior studies. Testing efficacy of medical interventions by randomized trials is usuall...

and (d) Indirect estimates from the National Family Health Surveys (NFHS). The SRS is the most re... more and (d) Indirect estimates from the National Family Health Surveys (NFHS). The SRS is the most regular source of demographic statistics in India. It is based on a system of dual recording of births and deaths in fairly representative sample units spread all over the country. The SRS provides annual estimates of (a) population composition, (b) fertility, (c) mortality, and (d) medical attention at the time of birth or death which give some idea about access to medical care. The population composition from SRS coupled with the decennial census counts, enables fairly reliable estimate of population in the intercensal periods. Average time to publication of SRS annual reports is about two years. SRS estimates are generally valid and reliable for the country as a whole and for bigger states with more than 10 million population. Recently the sample size of SRS has been increased to allow for estimates by natural divisions within the bigger states. Evaluations during 1970s and 1980s showed...

Valid and reliable statistics on the cause of death is an essential input for setting of prioriti... more Valid and reliable statistics on the cause of death is an essential input for setting of priorities in the health sector (Mahapatra, 1999). As is generally known, most developed cause of death reporting systems rely on medical certification of cause of death using a well defined system of classification. The International classification of causes of death (ICD) released by WHO from time to time is usually followed as such or with suitable adaptations to specific country settings. The 10th revision of the ICD (ICD10) is the latest instance of this kind (WHO, 1993). Most developed cause of death reporting systems have invariably achieved near total coverage. In other words a cause of death report is invariable filed by the medical attendant for all deaths in such countries. Developing countries like India have to depend on lay reporting of the cause of death for rural areas, where adequate medical facilities are not available. However, usability of the cause of death statistics is que...

When we ask a person to value time spent in a health state without any information about the key ... more When we ask a person to value time spent in a health state without any information about the key domains of health, (s)he must guess a description of the health state. The description visualized by the valuer would usually be implicit in the valuation task. This will inevitably introduce measurement error and a potential for bias in the results. Another consideration is how to convey relevant information about a hypothetical health state to the individual undertaking the valuation, who might not have personally encountered the state. Disease labels are short and parsimonious, but do not convey adequate information about functional status. Moreover, disease labels are vulnerable to different interpretations based on cultural and personal settings. Here we report the 6D5L description system developed and used by the Andhra Pradesh Health State Valuation Study 1999 (APHSV99). Results from this study are presented in chapter 9.4. More details of design, methods, data collection and anal...

The National medical journal of India, 2017

BACKGROUND Equity in health and equitable access to healthcare has been at the core of health pol... more BACKGROUND Equity in health and equitable access to healthcare has been at the core of health policy in India. The key policy challenge has been how to make that possible? Various health insurance schemes such as the Rashtriya Swasthya Bima Yojana and Arogyasri seek to improve poor people's access to specialist medical care in the public and private sectors. On the other hand, access to primary medical care has been left to the supply side interventions. METHODS We did a focused review of evidence on equity aspects of primary medical care versus specialist medical care. We selected relevant publications from the Cochrane Library, PubMed and Google Scholar searches and articles snowballing out of them. RESULTS Higher primary care physician-to-population ratio is invariably associated with better health outcomes. Primary care may partly protect the poor from adverse effects of income inequality on health status. On the other hand, populations do not necessarily benefit from an ove...

Vital statistics generated through civil registration systems are the major source of continuous ... more Vital statistics generated through civil registration systems are the major source of continuous monitoring of births and deaths over time. The usefulness of vital statistics depends on their quality. In the second paper in this Series we propose a comprehensive and practical framework for assessment of the quality of vital statistics. With use of routine reports to the UN and cause-of-death data reported to WHO, we review the present situation and past trends of vital statistics in the world and note little improvement in worldwide availability of general vital statistics or cause-of-death statistics. Only a few developing countries have been able to improve their civil registration and vital statistics systems in the past 50 years. International efforts to improve comparability of vital statistics seem to be effective, and there is reasonable progress in collection and publication of data. However, worldwide efforts to improve data have been limited to sporadic and short-term meas...

A.The Problem: The natural birth process is generally safe for mothers and babies. However, trial... more A.The Problem: The natural birth process is generally safe for mothers and babies. However, trial of natural labor in the presence of certain risk factors & medical conditions may be dangerous for the mother and/or the baby. A Cesarean section (C-section/CS) is an operation to deliver a baby through the abdominal route, instead of the natural vaginal route. When medically indicated, C-sections save lives and enhance perinatal outcome of high-risk pregnancies. C-sections reduce the risks of operative vaginal delivery for the mother. C-sections can be performed only in medical institutions and hospitals equipped for surgery. Specialists and healthcare workers skilled in comprehensive emergency obstetric care (CEmOC) ought to be available. Therefore, C-sections rates has been advocated, occasionally, as a process indicator of the quality (WHO 1994; Gichangi et al, 2001) and equitable access to maternal care (Stanton & Holtz, 2006; Thomas, 2006; Cavallaro et al, 2013; Irani & Shad, 2015...

INTRODUCTION Real operations of a health system, on a daily basis, treat certain problems, meet c... more INTRODUCTION Real operations of a health system, on a daily basis, treat certain problems, meet certain requirements and bypass others. Priorities are set explicitly or implicity. It is important to recognize that health sector priorities are ultimately set through social and political processes. Linkages between the health policy and the social and political processes have been well documented.l? Analytical approaches to priority setting operate within the sociopolitical environment and modify it by changing people's information set. On the other hand, social and political interests may engender the development of specific analytical approaches. Although expressions such as 'priority setting techniques' and its minor variants are used in health policy literature, they actually refer to technical and analytical aids to priority setting. This semantic distinction is important, since some criticism of specific aids to priority setting arise from an apprehension that they a...

Human Resources for Health, 2010

Background: Ensuring health worker job satisfaction and motivation are important if health worker... more Background: Ensuring health worker job satisfaction and motivation are important if health workers are to be retained and effectively deliver health services in many developing countries, whether they work in the public or private sector. The objectives of the paper are to identify important aspects of health worker satisfaction and motivation in two Indian states working in public and private sectors. Methods: Cross-sectional surveys of 1916 public and private sector health workers in Andhra Pradesh and Uttar Pradesh, India, were conducted using a standardized instrument to identify health workers' satisfaction with key work factors related to motivation. Ratings were compared with how important health workers consider these factors. Results: There was high variability in the ratings for areas of satisfaction and motivation across the different practice settings, but there were also commonalities. Four groups of factors were identified, with those relating to job content and work environment viewed as the most important characteristics of the ideal job, and rated higher than a good income. In both states, public sector health workers rated "good employment benefits" as significantly more important than private sector workers, as well as a "superior who recognizes work". There were large differences in whether these factors were considered present on the job, particularly between public and private sector health workers in Uttar Pradesh, where the public sector fared consistently lower (P < 0.01). Discordance between what motivational factors health workers considered important and their perceptions of actual presence of these factors were also highest in Uttar Pradesh in the public sector, where all 17 items had greater discordance for public sector workers than for workers in the private sector (P < 0.001). Conclusion: There are common areas of health worker motivation that should be considered by managers and policy makers, particularly the importance of non-financial motivators such as working environment and skill development opportunities. But managers also need to focus on the importance of locally assessing conditions and managing incentives to ensure health workers are motivated in their work.

Health Policy Research in South Asia. Building Capacity for Reform., 2003

Demography India

Journal of evidence-based medicine, 2014

The National medical journal of India, 2017

Human Resources for Health, 2010