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Universal coverage for all? Health inequalities in MCH and health systems reforms in Brazil and India

Paper presented at the 2013 IUSSP international meeting, Busan-Korea. Not to be cited without authors’ consent.

Tiziana Leone, LSE Amos Channon, University of Southampton TR Dilip, WHO Geneva Kenya Noronha, UFMG Abstract Emerging economies are showing signs of health improvements with average levels of key health outcomes increasing. Post-MDG agenda has increasingly turned its attention to inequalities in health with the concern being that the improvements might not be even across wealth groups. Focussing on maternal health care (MHC) we use the National Family Health Surveys (1992, 1998, 2005) and the District Level Household Survey (2007) for India and Household Demographic Surveys (PNDS) (1986, 1991, 1996, 2006) in Brazil to analyse how the stages in health reforms in both countries have progressed at a time of health improvements and how health inequalities have evolved in both countries at regional and urban/rural level. The aims are:

To chart the evolution of decentralisation in both Brazil and India and of universal coverage in Brazil.

To assess how inequalities in MHC have fared in this period.

To understand how the Brazilian lessons can be useful in order to map out steps and future directions some of the Indian states might wish to take.

We focus on access indicators (eg: % of caesarean sections, skilled attendance at delivery) by wealth groups Results show a convergence of use of services in Brazil towards universality with rural areas catching up at a faster pace with the exception of caesarean sections. The progress is apparent in India as well but at a much slower pace with wide variations between states. While the Indian case presents more challenges in the interpretation, it is clear that state disparities need to be addressed as well as the increasing rise of the commodification of c-section in both countries. Introduction A recent Lancet special issue on India (Balarajan, Selvaraj, & Subramanian, 2011; Reddy et al., 2011) calls for universal health coverage at a time where numerous health reforms have not achieved the level of health equalities that were acceptable. This seems to be particularly true in maternal and child health where the slow progress

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towards the MDGs has been particularly slow given the effort and resources put in (MMR=200 in 2010, World Bank). India underwent a series of health reforms in the last two decades which included a progressive decentralisation of the system (Paim, Travassos, Almeida, Bahia, & Macinko, 2011) and several initiatives within MCH which we will explore later on (Lim et al., 2010). Brazil, an equally growing economy underwent a similar decentralisation process at the same time. However, Brazil has moved to universal health care access starting a national health system in 1988 (Sistema Unico de Saude, SUS). The Brazilian case has been hailed as successful at least on the surface., mainly in terms of widening the access to health services. On paper both countries experienced similar reforms in their health systems. But while reforms in Brazil were driven by civil society at the same time of democratisation after military regime, in India they were led by the central government or international organisations (Paim, et al., 2011). The way that reforms were pushed through in Brazil might be the key to many of the successes achieved in the last decade (Victora, Aquino, et al., 2011; Victora, Barreto, et al., 2011; World Health Organisation, 2008). However, despite an increasing high level of access to health services, the strong between and within inequalities still persist and OOP is still high at 30% of the overall health expenditure and the level of maternal mortality still not acceptable with an MMR of 56 (Victora, Barreto, et al., 2011). Persistent inequalities in several health services are often blamed on quality of care and lack of funds to get an adequate coverage of the services for the whole territory. To date most studies look at national inequalities and don’t go in depth into the regional differences in Brazil which would be key in order to understand the progress made. On the other hand in India, uneven distribution of access is probably the key cause when it comes to health services as it remains among the countries with the highest level of out of pocket expenses in the world (Reddy, et al., 2011) (60% of the overall health expenditure, World Bank 2011). Overall both countries have experienced similar economic growth and health reform with India lacking a proper universal health coverage push. While Brazil took on major overall health reforms India concentrated more on single initiatives which have been focussed strongly in the area of maternal and child health and other key diseases. We want to therefore understand how these two experiences have developed over the last 25 years in an area of development (maternal health) which has received a lot of attention at national level but has not had enough research into the inequalities in outputs and outcomes.

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Table 1 Brazil and India background

Brazil India

GDP per capita $4,400 $717

Gini index 55 35

% tot gov spending on health

6.0 4.1

Private exp on health as % of tot expenditure on health

52.1 75

Out-of-pocket ex as a % private h. expenditure

64 94

Donor spending as % of spending

0.1 0.7

The aim of this paper is to explore the changes in health inequalities in the two countries at a time of health reforms and to understand the mechanisms if possible of persisting or changing inequalities in maternal and child health care. More specifically we will address the following points:

To chart the evolution of decentralisation in both Brazil and India and of universal coverage in Brazil.

To assess how inequalities in MHC have fared in this period.

To understand how the Brazilian lessons can be useful in order to map out steps and future directions some of the Indian states might wish to take.

To the best of our knowledge this paper ithe first to compare access to MHC in these two countries and more specifically it is the first study to look at regional as well as urban and rural differences across time for both India and Brazil. Most studies looking at inequalities have concentrated their attention on national overall trends and have ignored both residence as well as state variations. The paper will firstly analyse the health system’s functions and structures in both countries. It will then review health policies that have occurred in both countries in the last two decades alongside decentralisation’s initiatives.

In the first stage we look at the inequities in public subsidy and its impact on health care utilisation looking at a review of studies in both countries on economic burden of health expenses inequalities and the reforms in health financing in the last three decades. Key health outcomes that we will focus on are access to services and outcomes maternal health care.

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Secondly using nationally representative surveys, we will analyse the inequalities in key access indicators. using the concentration index to assess the level of wealth. The key challenge and strength of this study is the comparison of largely government funded Brazilian Health System with a private sector dominated Indian Health System. The aim of this exercise is not to create new theory or frameworks but is to generate new ideas, identify gaps in knowledge and to identify policy implications/lessons which could be beneficial to both countries. Why MH as a study case Maternal health care was chosen as they receive much international attention because of the Millennium Development Goals (MDGs). In a recent Lancet series (Grépin & Klugman, 2013) the MDGs have been accused of ignoring the health systems and its linkage to universal health coverage. There is therefore a clear need to go beyond the indicators set by the MDGS and look at progress within the health systems. The post-MDG agenda is increasingly focussing on inequalities within indicators as both the countries analysed in this study show that if there is progress it is often uneven. We believe by addressing both key indicators and inequities within the systems we are addressing many of the concerns raised by the recents calls in the global maternal health agenda (Grépin & Klugman, 2013). In India, since 2009 the institutional birth attendance or birth by trained personal has reached above 90 percent because of interventions such as the conditional cash transfers to poor pregnant women for institutional delivery (e.g.: JSY – Janani Suraksha Yojana). State-level variations notwithstanding, the JSY has resulted in an increase of the overall number of women using institutional delivery facilities between 2005-06 and 2009-10 (Lim, et al., 2010). Within this, the provision of cost-effective, evidence based services is critical to translate the increased demand for maternal health care services into an accelerated decline in maternal mortality. However, lack of regulation and planning has meant that delivery services have not kept pace with increased demand. In public facilities, there are no clearly agreed indicators to measure service quality at either the national or the state level. Recent research points out that a targeted programme like JSY has helped in reducing maternal and neo natal mortality. In Brazil the most notable improvements have occurred following the introduction of the SUS in 1988 as well as conditional cash transfers to improve water and sanitation in the 1980s (Victora, Aquino, et al., 2011). In general, both countries have made an increasing effort in trying to decrease levels of mortality. They are two of the most affected by inequalities and also among the most easily treatable when it comes to interventions. Lastly the availability of data made the comparison relatively easily. Finally, there are very few studies that look at health systems factors and their impact on maternal health services (Parkhurst et al., 2005). One of the most relevant is the one by Parkhurst et al (2005) which reviews case studies in Bangladesh, South Africa, Russia

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and Uganda. It found that the most common important system issues influencing maternal health care were human resource structures, the public-private mix of service provision. However it came short of looking at time trends in process indicators. Health system reforms Several recent studies have focused the attention on financial access to care with the abolishing of user fees and the implementation of a true free national health care system as previously mentioned being among the key gold standards. User fees have long been a contentious issue when it comes to increase access and decrease inequalities in care (Yates, 2009). It has been highlighted that user fees can increase the poverty trap and free access to services can be beneficial to read just inequalities in access to services (Whitehead, Dahlgren, & Evans, 2001). Removing users’ fees only removes one barrier to access and not completely as administrative and geographical access might still be cumbersome. There is still lack of evidence in Low Income Countries (LIC) around the other costs of maternal and child health care which is mainly determined by the lack of data. The call in India is for an integration of the private sector into the national health-care system (Reddy, et al., 2011). However, the modalities of how this might work are still to be seen mainly in light of the fact that India has had in theory a NHS since the 70s. Parkhurst et al. (2005) study showed that the impact of health reforms such as changes in fees’ charges, would make a difference only according to what the rest of the health system performance is. In particular the balance between private and public is another factor which have a significant impact on maternal health in particular (Parkhurst, et al., 2005). We want to highlight in this paper how did the Brazilian cope when the SUS was set up and finally implemented. Lastly, decentralisation if often hailed as the best way to improve health systems in developing countries (Bossert, 1998). This started as an administrative process but was later seen as a way to increase democratisation and involvement of local authorities and communities into decision making. Decentralisation starts with governance and it makes local authorities more accountable and efficient (Faguet, 2013). Local authorities are often thought to be best placed to know the needs of the communities. However evaluation of the real impact of decentralisation of the system is still cumbersome and in need of more structured research (Bossert, 1998). Decentralisation would improve inefficiency and make the health sector accountable for (Bossert, 1998). Obviously the decentralisation term can refer to different dimensions: devolution, delegation, de-concentration and privatisation (Saltman, 2007). Each of this could influence the final outcome. Brazil and India experienced different trajectories but yet the final aim was the same. What needs to be highlighted within decentralisation is the impact at state level. While the national figure might be positive, often more in depth analyses of state level inequalities show a completely different impact of decentralisations.

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Costa-i-Font (2005) for example showed that devolution did not create inequalities in Spain but in regions with more private health care it increased it. In general regions with a higher concentration of private healthcare show higher levels of inequalities. This could be the case in both countries given the disparity in availability of services and of private health insurance (Costa-Font & Rico, 2006; Costa-i-Font, 2005). The jury is still out on what is the real impact of decentralisation on health systems and no generalisation is yet possible (Costa-i-Font, 2012).To the best of our knowledge there hasn’t really been a study looking at the effect of decentralisation and its impact on access to services in particular in MHC. Ultimately, the structure of the system and the way the reform is initiated will shape the availability and access to health services. The Brazilian and Indian case studies represent an excellent example of how reforms can go in different directions. Health reforms in Brazil

The concept of health for all in Brazil started at the end of the military dictatorship in 1988 (Paim, et al., 2011). The National Health Service (SUS) was established in 1988 based on the 1978 Alma Ata declaration of health for all. The SUS struggled in the first few years and was probably not implemented until 1994 when the family health planning was rolled out. IN 1996 a further reform established a decentralised universal system, with municipalities providing comprehensive and free health care to each individual in need financed by the states and federal government (World Health Organisation, 2008).

To complicate things in the Brazilian health sector is the mix of private and public services which complement and overlap each other. The public funding given to the private sector by the municipalities further reinforces the challenge of analysing the impact of health reforms on health care access.

The level of access has undoubtedly increased in Brazil since the establishment of the SUS and this is particularly true since the implementation of the family health reforms (Victora, Barreto, et al., 2011). However what is less clear is the level of inequality in access to the services. Previous studies have shown that outpatient care has been more affected than inpatient care by inequalities (Channon, Andrade, Noronha, Leone, & Dilip, 2012; Noronha & Andrade, 2002). However it is still unclear how maternal helath care might be affected.

Health reforms in India Despite the call for universal health coverage in India the first attempt to free health care occurred in the 1970s after a heavy reliance on user fees. Key reforms have often been

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pushed by international calls and more in general by the general reliance up until a few years ago on exogenous donors. Few of the inputs included the World development report 1993 on investing in health. The 1992-97 five year plan is first real attempt to tackle economic management of HS with levying user fees to above poverty line population and increasing access to poorest strata. In 1992/93 decentralisation of powers in health sector with federal government funds states according to their requests. At the same time of the 5 year plan in 1992 the child and mother survival programme was implemented. In 1994 the Cairo conference on Population and Development-family planning and MCH gave a further input in the MCH reforms which included the 1997 Reproductive and Child Health programme where many user fees lifted Other reforms that followed included the 5 National Rural Health Mission in 2005;Social health insurance (voluntary) and several other local initiatives, vertical mainly, often not sustainable. Data and methods: We used data from the National Family Health Surveys (1992, 1998, 2005) and the District level Household Survey (2007, not shown here) for India and Household Demographic Surveys (PNDS) (1986, 1991, 1996, 2006) in Brazil. More specifically to account for state/regional variations we have selected 6 states from India to represent a progressive more public funded orientation (Tamil Nadu, Karnataka and Punjab) and three with a low public expenditure budget (Bihar, Uttar Pradesh and Madhya Pradesh) (Government of India, 2009). For Brazil we concentrate on two different regions with different levels of development in terms of economy and health systems as well with the Northeast being the least developed and the South East (Sao Paulo, Rio and Minais Gerais) being the wealthiest and those regions where the health reforms where implemented more quickly (ref. ). All the surveys considered are stratified sample survey comparable across time and countries which used stratified sampling at household level to select eligible women in reproductive age (15-49 years old). We concentrated on process indicators related to maternal health which would be a mix of basic services as well as more advanced emergency ones. In addition they were also chosen as they form part of target indicators to measure the progress of the Millennium Development Goal 5 (maternal mortality). These included the percentage of institutional deliveries, skilled attendance at delivery (def), any antenatal care and more importantly as recommended by the WHO sufficient ANC which corresponds to 4 visits+ regardless of who conducted the visit. Lastly we looked at whether the birth was delivered normally or via c-section. This last indicator is possibly the most controversial as it is used as a measure of the level of emergency services but at the same time if the percentage reaches high levels (e.g.: above 15%) it is often used as a proxy for overmedicalisation of births. We have chosen to 4 or more ANC visit as an indicator of access to basic maternal care and c section delivery as access to higher level of health technology in the area of maternal health.

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As a measure of inequality we considered the asset index of wealth measured through a series of asset variables summarised by factorial analysis (for more information see Filmer and Pritchett, 2001). The quintiles were calculated separately for urban and rural areas and by region/state at household level to account for unequal weights within and between regions. The measurement of the progress in tackling inequalities was done with the concentration curves as function based on covariance of health variable and wealth distribution. The interpretation of the curves is as follows: a concentration of the variable above the equity line (negative CI) would mean more common among poor people and below (positive CI) among rich. A CI equal to 0 means no inequalities. Where the x axis is the cumulative share of children and the Y axis the cumulative share of the indicator. We also considered the numerical equivalent of the concentration index (O'Donnell, Doorsslaer, Wagstaff, & Lindelöw, 2008) which is based on the concentration curve: twice the area between the equity line and the curves. The key strength of this measure is that it is independent of the measurement of wealth, and can therefore be standardised across time and place. In addition we can perform a dominance test on whether the differences were statistically significant. In order to evaluate the changes in inequalities across time, within region and between place of residence we have looked at trends across time and regions of those indicators by wealth quintiles and concentration indices and curves to identify whether socio-economic inequalities have changed across time between rural and urban areas within the same region. The time span of the data allows us to look at pre and post reforms as well as in between changes such as the decentralisation of the Brazilian system in 1996. Results Trends Figure 2 shows a clear picture in both countries. Not many changes across wealth groups in the rural areas of India and if anything a slight worsening of antenatal care access in urban areas. What is most interesting is the gap between wealth groups remains the same. On the other hand in Brazil the real winners are the rural areas who show an increase across all wealth groups. Urban areas remain more or less even. Figure 2 Percentage of mothers with sufficient antenatal care (4 or more visits) in Brazil and India by residence group 1992-2006 India Brazil

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Births in facilities are almost universal in Brazil and they show a strong convergence and low level of inequalities across the period considered (figure 3). Whereas India’s gap is still strong with most improvements reported in the wealthiest groups. Rural are areas catching up with urban areas slightly improving. Figure 3 percentage births in facilities by residence and wealth in Brazil and India 1992-2006 India Brazil

For the sake of brevity we will show more in depth results for two key outcome indicators: sufficient antenatal care and % of C-sections. The overall discussion will also include skilled attendance and institutional deliveries. While we looked at South East Brazil and other Indian states we will only show the results for Northeast of Brazil, Tamil Nadu (to represent progressive health system) and Uttar Pradesh (less progressive). The trend in sufficient antenatal care in India is definitely upward (fig 4). This is the case for UP and TN. However from this first look it seems clear TN has had a convergence of

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the access to the services in both rural and urban areas. Whereas UP shows striking disparities in urban areas as well as a worsening of the service access. Figure 4 sufficient antenatal care (at least 4 visits) in India and selected states 1992-2005 India Tamil Nadu Uttar Pradesh

Concentration curves Moving onto the concentration curves inequalities in basic services such as ANC have worsened in India (mainly in Rural areas) and in low public spending states such as UP (Mainly in urban areas) (fig 5 and 6). Whereas in high public expenditure states (with the exception of Punjab possibly due to sample size) inequalities in sufficient ANC have declined over time dramatically (Fig 7). Figure 5 concentrations curves India Sufficient ANC (4+ visits) 1992-93 1998-99 2005-06

Figure 6 concentrations curves Uttar Pradesh Sufficient ANC (4+ visits) 1992-93 1998-99 2005-06

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Figure 7 concentrations curves India Sufficient Tamil Nadu (4+ visits) 1992-93 1998-99 2005-06

Sufficient ANC has increased dramatically in all wealth groups in Brazil as well as in the Northeast where the progress has been much slower as expected given the slow speed of the reforms in the 1990s. This first result shows the clear impact of firstly free access but secondly with the 2006 dramatic increase we get an idea of the further reforms for families implemented by Lula. Figure 8 sufficient antenatal care Brazil and Northeast 1991-2006 Brazil Northeast

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Figure 9 Concentration curves Brazil 1996-2006 sufficient ANC (4+) Brazil 1996 2006

The concentration indices for India show a different picture when we look at c-section. (Fig XX). While improvements have been reported in key services such as institutional deliveries or antenatal care, the disparities are strong and even worsening across time when it comes to access to c-sections. This is particularly striking for Tamil Nadu (Fig XX) and Karnataka where the level of inequalities is particularly pro rich in particular in urban areas (while in Punjab is in rural areas) where they keep on being at the same level while they decrease in rural areas (not significant in 1998). India, Bihar, Madhya Pradesh and TN show instead a worsening in rural ones. Figure 10 India concentration curves % c-section 1992-2006 1992-93 1998-99 2005-06

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Figure 11 Tamil Nadu % c-section 1992-2006 1992-93 1998-99 2005-06

The same picture is reported in Brazil and the Northeast where although access to c-section has increased over time the level of access has not been even across wealth groups with the wealthiest quintile reaching above 70% (fig xx) a clear sign of overmedicalisation. Figure 12 C-section in Brazil and Northeast 1986-2006 Brazil Northeast

As for the progressive states in India while there seems to have been an improvement in basic services, the gap is still persistent and at times worsening for caesarean sections. Given the nature of c-sections in Brazil where they are taken as a commodity rather than an emergency service, we need caution in interpreting this result. More in the discussion!

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Figure 13 concentration curves c-section Brazil 1986-2006 1986 1996 2006

Limitations Firstly we were not able to assess the causality given the limitations of the data but as we said in the introduction this paper was not set to assess the impact but to explore the changes in coverage and inequalities across key access indicators in maternal health care. Municipal/district level of information would have been useful to assess the smaller areas to get a better idea of decentralisation where often the reforms are made. As with every analysis of policy reforms it is challenging to pin down the actual impact. In addition as several of the studies on decentralisation of services have demonstrated (Costa-i-Font, 2012; Faguet, 2013) the complexity of the process is such that not a single event could be accounted for when looking at effects. If anything this study sheds further light into the complexity of the issue. We have no appropriate information on implementation. The data points are so few that we cannot distinguish between the effect of decentralisation and of the overall impact of the family health reforms in the 1990s. However breaks in between the data-points can give us hints on various reforms. Finally the demarcation between rural and urban is part of the limitations of the data we are using as some individuals may live near cities and benefit from their services, but be classified as rural. These can be wealthy individuals. Discussion and future work The study shows some clear differences by region/state and place of residence – this is overlooked if solely country analyses are done. We have confirmed an increase in access to services in Brazil after the creation of the SUS. It is particularly evident that there has been a progressive smoothing of inequalities in access occurred when the implementation of the SUS finally went ahead in the latter part of the 1990s. The further push by Lula during his 8 years government has finally further addressed the inequalities in access but it is not clear whether it has done so in the tertiary sector, outpatients and in quality of care as well as in primary care. In both

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countries it is clear that basic level of services are more easily equal. It may be that the reforms increased the quality of care in Brazil, encouraging greater use. However given the type of data we have we could not really ascertain this. The data show two speeds (or more) for India between and within states where there is a higher access to services with higher inequalities at country level. In addition for some states while basic services’ access increases for other (i.e: CS inequalities grow) such as in Tamil Nadu and Karnataka where particularly strong effort has been put on universal coverage. Decentralisation in India may be a way forward, although there is a lower level of service to start with which may mean that inequalities has to get larger before it gets smaller. There is still a problem with the standard of care in the Indian public sector. Whatever be over all inequality in the society, a decentralized health system offering universal health security can ensure equitable access to basic and essential health care needs. Low coverage in a health system without universal outreach, gives scope for high inequities in access to MHC (ANC visits). As Amos mentioned and can be seen in case TN and UP, the inequities has to increase during the phase when utilization of maternal services improves, in before it converges to a no inequality situation. Implementation of NRHM and universal health coverage (UHC) might help India to cross this high inequity situation at faster pace as seen in Brazil. Inequity in access to emergency delivery care/ C-section delivery remains high in Brazil and India: this is an example indicating impact of overall inequity in the population returns in the case of services beyond the scope of UHC. Data shows the role of overall income inequality in a population remains in the case of access higher levels of health care and in situations involving use of expensive health care technologies which are beyond the scope of universal coverage. Commodification of health care too has contributed to this scenario.

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