Heathcare in Rural India: What Doesn’t Work (Policy 360 Podcast)

What happens when there are very high hopes for a particular policy idea, and then researchers conclude the results are not as promising as they once seemed? Are there lessons to be learned from this?

A widely hailed initiative that combines franchising business models and telemedicine to deliver better quality health care in rural India has failed to improve care for childhood diarrhea and pneumonia, found a large-scale study by Assistant Professor Manoj Mohanan and researchers at Stanford and University College London.

​Listen to Mohanan talk with Sanford’s Dean, Kelly Brownell:

Interview Highlights:

Kelly Brownell: Your work is really groundbreaking in interesting ways, and I’m not the only one that’s noticed this. Your research showed that an acclaimed social program, that seemed at first glance to be having tremendous impact, in fact failed. The telemedicine project combined the business model of a franchise, say like McDonald’s, with new media and healthcare. So let’s start off, if you wouldn’t mind, by describing the Bihar region and what it’s like.

Manoj Mohanan: Bihar is a northern central state in India, one of the largest states in India with a population of over 110 million. It’s a rural state, a very rural state, and has some of the worst population health indicators globally. It has been one of the largest challenges for development and health in India. One of the things that this project hoped to do when it was rolled out was to really address the question of improving quality of care available to its population.

Kelly Brownell: Let’s take the case of childhood diarrhea. There is a standard protocol for addressing this. They know about it, but only 20% of them actually provide it. What do they do instead? What happens to the children?

Manoj Mohanan: This is the sad part. A lot of children get unnecessary antibiotics without even establishing that this is a case of diarrhea that needs antibiotics. A lot of them get steroids. We have a spreadsheet listing thousands of different types of drugs that are prescribed, some of which are frankly scandalous, because there are chemotherapy drugs that are on that list. It’s a very disturbing scenario where we see systematic under-provision of correct, appropriate care. At the same time, the market forces are driving these guys to prescribe drugs that are likely harmful, not just unnecessary.

These two members of a family in Bihar participated in the research study. Photo credit: Anna Maria Barry-Jester

Kelly Brownell: Let’s return to the study that you have done recently. Could you describe the concept of telemedicine and how this franchising idea works?

Manoj Mohanan: After six decades of various health policies in India trying to train, recruit, and staff doctors in rural areas, the experience has been generally that it’s really hard to do so. Most of the care, about 80% of care in rural India, is provided by healthcare providers who have no medical training whatsoever.

So when the government of Bihar entered into a very strategic partnership with the Gates Foundation, one of the ideas on the table was to see what technology could do to help leapfrog this problem. Rather than trying to recruit, staff, and train doctors in these areas, work with the existing set of healthcare providers and see what we can do to improve the quality of care that they provide. This idea is not without merit. In some sense, even if they can improve the care that is provided a little bit, that could have massive effects for the population.

There were two parts of the business model. One was to work with franchising clinics. The idea was, you create a standardized set of protocols for standard operating processes, supply chains, the kind of drugs and supplies that you receive, and also provide some training so that they do the right thing, they adopt better diagnostic processes. The diagnostic technology through telemedicine was to help refer more complicated patients, and in addition to that, when I as a telemedicine operator or a small healthcare provider observe the doctor sitting in a large city the way the doctor is interviewing his or her patient, I might learn in that process as well. And then there’s of course the market competition, that when a neighboring doctor starts providing better quality care, by technology or by franchising, then I as another doctor in that same market might start improving my quality as well. That was the overall concept.

Kelly Brownell: You did a very careful evaluation of how the program was being implemented and what it’s impact was. What did you find?

Manoj Mohanan: First, we found that none of the population level outcomes which the program was targeting, mainly childhood diarrhea and childhood pneumonia, had any effect at all. It raised the question, well, if you don’t see any effects on the main outcomes, then why might that be the case?

We find several answers that I think are really important in this context. One is we did not find that the market penetration is very high. This was one of the fundamental assumptions of the program. They assumed that by the end of three or four years of implementation, the program would be able to serve about 10% of the population in these areas. What we find is it’s closer to 3%. When you’re able to touch only about 3% of the population, to accomplish any significant change in the population health level is just not going to happen.

The question was, well, why is that population level reach so low? Two reasons why. One is that not too many health care providers signed up for the system. A franchise program essentially requires me as a healthcare provider to pay a certain amount of money to join the system. My decision to join might depend upon how well I’m doing. If I’m a healthcare provider with a thriving practice, I don’t have any reason to invest more money and join the network, or my reasons to join might be lower relative to someone else who is new in the business or who is seeking to really expand their market clientele. That’s what we find: some of these doctors are younger, relatively newer, and have less experience. We had, however, hoped that the introduction of better quality care would mean that patients would be drawn to better quality providers. Ironically, there is no empirical evidence we know of in developing countries which says something about the market level response to quality improvement. This was a big assumption that everyone was working on, and what we find is there’s no evidence, at least in this study, where we can see the patient level responses are actually in favor of the demand. That is, we do not find evidence that patients are going to these healthcare providers a lot more often than other providers.

Kelly Brownell: If you were a funder like the Gates Foundation or other people who were supporting some of this work, would you be in favor of expansion of this, further testing of it, would you give up on it? Where do you think that it all stands now, given what you’ve found?

Manoj Mohanan: I don’t think it’s time to give up. I say that for two reasons. One is, this was a unique project that brought together two promising ideas, telemedicine and social franchising. Independently, each one has its own value. We still need to find significant studies that show the empirical evidence in favor of whether or not each one works. That’s work that has not yet happened. It’s a little early to make the call on whether this works or not. If I had funding decision to make, I would start slow. First ask implementing agencies to demonstrate evidence on a small scale, but not so small that you cannot replicate this, and not in a manner that is purely driven by selection. Do small studies, but do it very carefully and demonstrate it can happen, and then scale it up in phases.

Watch a video about Mohanan’s study: