Inside Healthcare Policy


Much like research in science, Humanities and Social Sciences research is multifaceted and can be approached from a variety of perspectives, methodologies and tools. To offer a glimpse into research in the social sciences, this piece explores the research work carried out in the area of Health Economics and Public Policy by Prof. V. R. Muraleedharan (or Prof. VRM) from the Humanities and Social Sciences department in IITM.


In a career spanning three decades, Prof. V. R. Muraleedharan (or Prof. VRM) has contributed a lot to research on public health policy. In order to learn more about what policy research entails and understand the complexities involved in the field of healthcare policy, I found myself stepping into Prof. VRM’s office one sunny evening for an interview about his work and extensive research experience in this field; in particular, his several recent and very exciting projects.

Policy Research: The Big Picture

Policy refers to a broad set of decisions, plans and actions undertaken to achieve specific goals in a region or nation. In the field of healthcare, formulating effective policies is crucial as good policies can have profound effects on the state of health in a particular area.  For example, a policy subsidizing contraceptives in HIV-prone areas could in the long run lead to drastically reduced rates of disease. To ensure that there is a high level of quality and access to healthcare, it is necessary to have well thought out, effective healthcare policies. Coming to what policy research is: it involves examination of the design and process of policy making and implementation, evaluation of  policy outcomes, and also an analysis of factors that constrain the effectiveness of policy, including figuring out exactly how and why particular policies worked or may work under certain circumstances. “Normally, a policy is viewed as a black box: the interest lies in the inputs or elements that form the policy, and the output or outcomes of the policy”, Prof. VRM points out. “But working on policy research means being interested in what goes on inside the black box – understanding the pathways and dynamics that make particular policies work. So, for effective policy analysis, you have to open the box and correlate the two”.

Is there any one broad theme that reflects the essence of policy-oriented research taking place across the projects that Prof. VRM has been involved in? “Our focus across several projects has centred on one single question, one I am very fond of”, Prof. VRM says thoughtfully. “The first part of this question is the realization that every rupee spent on one person is a rupee denied to another – as someone working in the development field, this is a daily chant. But the second part is the critical economic question from the public point of view: is that rupee well spent, given that someone else is being denied it?” This really is a very interesting and tough question. To illustrate: the government budget this year for Tamil Nadu on health is about 8000 crores – and this money was spent with a view to certain benefits and their distribution. “But what we’d like to know,” Prof. VRM says, “is how it was distributed across different socioeconomic spectra, the particular benefits of public spending on healthcare, how equitably the benefits of government spending are distributed, how can it be improved with a sense of equity and how much of the pie do the poor get in terms of benefits.

A Deeper Look at Policy Oriented Healthcare Research

Across Different Time Periods and Regions

A large part of Prof. VRM’s work has focused on studying the costs of, access to and coverage of healthcare in Tamil Nadu, especially by comparing healthcare interventions and health indicators in TN to those in other regions/states of India and countries, and using the research findings to craft constructive healthcare policy. For example, one project, carried out between 2009 and 2011, is titled ‘Good Health at Low Cost, 25 Years on: What Makes a Successful Health System?’. It carried forward a research project on comparing healthcare across a particular set of countries which was carried out in 1985 and seeks to analyse, 25 years later, how and why each of these and other countries accomplished substantial improvements in health or access to services or innovative health policies relative to economically comparable regions or countries . In India, only the state of Tamil Nadu was studied because the scale of diversity in India makes it difficult to generalize such a study for an entire country based on a few states.

This project necessitated analysing the past 30 years of healthcare in Tamil Nadu and was carried out by Prof. VRM and Prof. Umakant Dash from the HSS department. This was done using their past extensive experience and research in the field as well as more than 30 interviews with higher level officials who could explain policy changes, and had worked at the district level before and were closely involved in the implementation of various programmes. Speaking to higher level officials who had worked in different states was the best way to get a comparative perspective relative to other Indian states and find out how TN made use of certain financing measures and central government program features to achieve a higher level of healthcare. The project found that Tamil Nadu had not spent lavishly on healthcare until 2005 and even after 2005, when the National Rural Health Mission was instituted. “We wanted to look at the 30-year period before that to see how places that spent relatively little on health managed to bring out better health outcomes ”, Prof. VRM explains.

“We have several programs in India, targeted for particular diseases for example, and the same programs in every state. But some do better than the others. How does one explain that?”

One way is to construct the story behind these events: all 5-6 central secretaries interviewed during this project gave the impression that “Tamil Nadu is good at seizing money fast when there’s a big pool of money for allocation”. But the other question to be asked is what percentage of the allocated money is spent effectively, that could have positive impact on health outcomes. Many states don’t spend a high percentage, as effectively, but instead underspend the allocated funds and attribute the relatively poor outcomes to a lack of capacity. “This is a very interesting point. Tamil Nadu spends relatively more effectively than others. If 70% of the money is spent effectively, and say 30% goes through other hands (meaning, down the drains), that 70% is still quite well spent. But it’s the other way round in other states, as we found after distilling our observations and interview responses over several years,” Prof. VRM explains. But this leads to a third, even more interesting point. “If I have spent 70% of the allocated money well, and you have spent 40% of your allocated money well, this 30% difference in spending, cumulated over 30 years, makes a huge difference in terms of outcomes.” This difference, if repeated consistently, and aided by other factors such as an efficient bureaucracy, a diligent work ethic, supported by other systemic factors such as good roads and transportation, and media, add up to a cumulative difference that counts for a lot. This offers one explanation for the relatively positive health outcomes in the state.

Consortia for Comparative Research

Comparing different health systems to arrive at better policy practices for a particular region can be carried out in several ways. In recent years, Prof. VRM has been involved with at least two research consortia that seek to do just this. The first, the Consortium for Research on Equitable Health Systems (or CREHS), carried out comparative research between 2005 and 2011 in six countries India, Nigeria, South Africa, Thailand, Kenya to generate knowledge on how to strengthen health system policies and interventions in ways that would “preferentially benefit the poorest”, such as by examining the impact of mobile health units on access to care. The second consortium, which evolved from CREHS, is called RESYST (Resilient and Responsive Health Systems), and aims to enhance the resilience and responsiveness of health systems to promote health and health equity and reduce poverty.

Working in a consortium necessarily means that a lot of time is spent in sharing and discussing each stage of the research process across countries and teams. This involves regular meetings, time spent to structure the content and regularity of the meetings, arriving at common questions, developing a methodology and research instruments (the questionnaires) together, and interpreting and sharing the findings. Comparative studies take up a lot of time because all the teams involved have to reach a consensus on common questions that are meaningful in each country and are comparable across them as well, and they must establish clearly what each country gets out of the exercise. Each step of the research process for one team must be in tandem with the steps taken by the other teams, and it can be difficult to maintain an equitable rhythm and balance while carrying out the work over a long period of time. There are internal checks and balances and timelines to ensure that the work proceeds relatively smoothly and sub-groups that keep moving back and forth before arriving at a satisfactory conclusion.

How does international comparative research help craft good policy at country / state level? Prior experience shows that learning from the experiences of other countries as well as our own history helps construct efficient and well-constructed infrastructure and delivery structures. “The impact of research on policy here is not a linear, direct or clear relationship because it is difficult to predict exactly where, when and how does research influences policy” Prof. VRM remarks, “but we have very interesting ways of capturing this relationship”. One aspect of this is the engagement between researchers and policymakers, which builds gradually and takes off over time. “For example, each of the hundred odd meetings and talks I have had with the government the past year is evidence of my physical and mental engagement – and its impact is different from handing in policy reports that that nobody has time to read anyway (even if they want to). It is important to find ways to engage as researchers with policy makers in your own way and style”, says Prof. VRM.

Insights from Grounded, Participatory Policy Research

 

The Thottapattu sub-centre, or lowest unit in the healthcare delivery system (serving 5,000 - 6,000 people), in Tamil Nadu. (From right to left) Prof. Umakant Dash, the head nurse who manages the entire sub centre, and Prof. VRM (2013).
The Thottapattu sub-centre, or lowest unit in the healthcare delivery system (serving 5,000 – 6,000 people), in Tamil Nadu. (From right to left) Prof. Umakant Dash, the head nurse who manages the entire sub centre, and Prof. VRM (2013).

 

However, policy oriented research work has its own complexities. One way to illustrate them is through Prof. VRM’s ongoing project on Universal Health Coverage (UHC), which seeks to pilot this concept in Tamil Nadu for the state government in two districts, one of which is Krishnagiri. In this district the research is being carried out specifically in the block of Shoolagiri. The project has been ongoing for around six months.

Piloting the UHC involves a large number of household surveys, facility surveys, group discussions and focus group discussions across villages and intense discussions with field functionaries. This is with the objective of collecting ground level knowledge of illnesses, learning the expectations of the villagers, and keeping track of the facilities that are currently functional on ground. “For this, the complete mapping has been done to first assess what is present on the ground. Next, it is important to find out how much people are spending out of pockets for healthcare (this was captured through a large survey of 5000 households) and recording health seeking behaviour of the villagers of the last one year, including for deliveries, prenatal, postnatal care, immunization, access to public or private facilities, out of pocket expenditures for various illnesses, and so on”, explains Prof. VRM. Further, state level consultations take place on developing an Essential Health Package or EHP, including its contents and ways to guarantee its distribution through a publicly financed system. “Coming up with the EHP involves an intricate set of negotiations which include consultations with state level officials, field functionaries and people living in the villages. Thus, the bottom-up views are collected along with the expectations residents have from the EHP”, says Prof. VRM. This material, which reflects people’s voices and their needs, is used to then reflect on what is doable and what is expected. It helps negotiate different meanings and consequences of the EHP and proceed forward to arrive at a package that combines the needs and expectations of all in an equitable way.

 “For policy to work out effectively in practice, the research must also incorporate the psyche, ecology, terrain, geography and multitude of other factors surrounding the region”, Prof. VRM emphasizes. For example, one peculiarity particular to Shoolagiri is that people speak 3 languages, with different languages used for different activities. Thus, taking this into account, particular areas and policy recommendations have to be treated with sensitivity: for example, as Prof. VRM argues, “you cannot place someone from Tirunalveli as a Village Health Nurse (VHN) into Shoolagiri – she would speak not just Tamil but a different dialect of Tamil”. Thus, even just the process of recruitment in public systems is one that is fraught full of problems. Such issues may arise at different parts of the research work or policy implementation and must be anticipated (or at least, mechanisms for swift redressal conceived) in order to ensure smooth functioning of policy.

Research Narrative: Coming Full Circle

My last question is one that perhaps should have been the first. How did Prof. VRM find himself in this field? “After completing an MA in Economics from BITS Pilani followed by a two year break”, Prof. VRM says, “I found myself engaged in two research projects across Maharashtra and later as a research assistant on a project on assessing PHCs in Orissa in 1981. Around this time, aided by two wonderful research guides, I travelled all across five districts of Orissa and developed an interest in healthcare. Studying healthcare systems in Orissa in that time was very tough, and that project, the field work and the travelling stimulated my interest in the field. So I really owe a lot to Orissa!” I am surprised to find out that Prof. VRM is an alumnus of IIT-M, having completed a PhD here on the history of  healthcare in South India under a renowned economic historian, Professor S Ambirajn, who taught at HSS IIT-M from 1981 till 1995. Prof VRM’s thesis, and subsequent research, was based on archival work. After a one year sabbatical at Harvard in the 90s, Prof. VRM’s focus shifted more towards more recent policy, and this has shaped his current research interests and work. In a similar vein, he also enjoys guiding research scholars from diverse disciplines, though the general rule is that scholars whatever be their disciplinary background, should have an interest in public health policy issues.

Speaking about how all facets of policy research tend to come together, Prof. VRM says, “Right now, we are working towards using our work in RESYST to help inform the UHC project; especially for increased exposure”. In fact, the UHC project itself has also tied into yet another project funded by USAid, where 5 research institutions in India are trying to pilot UHC in eight Indian states (and this is just one component out of three, of this project). “By now, it’s difficult to say what one thing I am working on by way of a funded subject, because as you can see all these projects are an organic evolution, and are connected in essence. And as Prof. VRM points out, “You know, despite doubts about how meaningful your work is, you continue your research and keep pushing the frontiers of policy studies through your engagement with policy makers…and , naturally, there is no end to this process.”

 


IIT_8939In a research career spanning over three decades, Prof. V.R. Muraleedharan has held several different roles in the field of public health, some of which include: Member of the Mission Steering Group of the National Rural Health Mission, Govt. of India; Senior Researcher for national and international bodies such as DFID; co-Vice President of the Health Economics Association of India; Member on the Editorial Board of “Medical History”, a journal published by Cambridge University Press; and full Professor since 2000 (and between 2004 and 2011 as the HoD) in the Humanities and Social Sciences department.


Isha (1)

Isha Bhallamudi is a fourth year Integrated M.A. student of the Humanities and Social Sciences majoring in Development Studies. She has been involved in writing about research and innovation through Immerse and T5E. Her research interests (at the moment) lie in policy research and its cross connections with health, poverty and gender. She is currently exploring an interest in contributing to increased awareness and interest in social sciences research. Isha can be reached at b.isha.ravi@gmail.com for comment, criticism or discussion!


Cover image: Image of Public Health Centre (PHC) in Tumkur, Karnataka. Courtesy Prashanth NS, via Wikimedia Commons.