1. What do we know about improving health in Punjab? And some lessons from India Dr. Jeffrey Hammer Princeton University IGC – CDPR Seminar, Islamabad February 12, 2015

2. What do we know? Possible answers First is “not a lot” Second is: Maybe something from India? Or from theory and logic? Third is: Maybe something from surveys done in Pakistan? Fourth is: Not really. as I undercut answer three above with examples of peculiarities in Pakistani data. Can we start getting some reliable data by establishing collection systems? 2

3. Talk in three parts Some evidence from rural areas in India on the relative effectiveness of public and (publicly provided) private goods. Some meager (and debatable) evidence on the same thing in Punjab, Pakistan Complaint about the state of statistics and a suggestion or two on new opportunities for data sources, collection methods and organization. 3

4. The Total Sanitation Campaign in Maharashtra Program: change behavior to get rid of open defecation, don’t just build latrines Evaluation: Randomized Control Trial of promotion of 100% safe defecation practices at village level. Chaudhury, Ghosh Moulik et al; Hammer and Spears (2014) 4

5. Challenges of initial design Secretary, Rural Development, wanted to try this out in the hardest possible conditions – very poor, very isolated, heavily tribal areas. He bet that if it could work there, it could work anywhere. Unfortunately, he lost. Only in 1 District out of 3 (Ahmednagar) did officials do anything 5

6. Lessons (before we even start) On Intent to Treat grounds it obviously failed. Implementation constraints are critical BUT, on Treatment on Treated grounds, things look much better So, it might work. But only where it works. 6

7. Effect of program on latrine coverage – only in Ahmednagar 7

8. So addressing sanitation (with big externalities) could work! How about publicly provided primary health care?... not so much 8

9. How can this be? How can publicly provided medical care NOT help? Vacancies (A budget, not an implementation problem) Absenteeism Low levels of knowledge and ability of public MBBS’s (sometimes relative to untrained – sometimes not) Abysmal effort exerted by public providers such that they can’t possibly find out what’s wrong with you Substitutability of small (ish) public sector with a much larger private sector around it 9

10. All leading to the question: What is the marginal impact of an expanded public system on the market as a whole? On overall usage (quantity)? On the accuracy of medical advice (quality) in the market as a whole – public and private? This is a very hard problem – we can only address bits and pieces of it 10

11. “Weak links” in our knowledge India Absenteeism – about 40% in 2003, not much change about a decade later Quality of care (knowledge)- Das et al, Das and Hammer – next slide Pakistan ??? – one very good but small study (Hasanain et al) based on an IT intervention, not a national picture ??? Not that I know of 11

12. How bad can quality be? Madhya Pradesh: Public doctors know more than anyone but put in so little effort, they give the worst advice and treatment 12

13. Diagnosis and Treatment Asthma In Madhya Pradesh Right Wrong 13

14. BUT NONE OF THIS IS KNOWN OR EVEN ASKED IN PAKISTAN 14

15. Reasons to doubt effectiveness of public sector - almost no one uses it Punjab20122006 Place of treatmentDiarrheaCough / FeverDiarrheaCough / Fever Government Hospital7.897.976.618.61 RHC/BHU/FWC1.971.619.929.27 Lady health worker0.610.092.480.66 All public sector10.479.6819.0118.54 Private hospital24.5826.0919.8313.25 Private doctor36.1236.4331.4039.07 Other private13.2012.0512.4011.92 All private sector73.9074.5763.6464.24 Not treated15.6315.7517.3617.22 Total100 Public sector if treated12.411.52322.4 Private sector if treated87.688.57777.6 PDHS reported in Afzal, Hammer and Ghaus (2015) Public shrinking? 15

16. Even in villages where a facility is certainly available Place of treatment in villages with a public facility available, PDHS 2012 (Punjab) DiarrheaCough / Fever Government hospital7%9% RHC / BHU / FWC7%9% Lady health worker2%1% All public sector17%18% Private hospital / clinic20%13% Private doctor31%39% Other Private12% All Private Sector64% Not Treated20%18% Total100 Private share of those seeking treatment79%78% Down from 88% 16

17. What shows up as possible correlates with child health in the Punjab? Education (of mothers for sure – maybe fathers) Standard of living (measured by possessions – not even a direct measurement) Maybe, just maybe, open defecation (but not nearly as convincing as we’d like to see) 17

18. Why is it so hard to show anything? Serious data quality issues “Errors in variables” larger than variance of variables 18

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20. Correlation of levels of “Open defecation” 2006 versus 2012 by district (PDHS) 2008 2012 20

21. Plea for better data Massive changes in rich world in type, sources and sizes of available data Organized in ways that are either easy to use or, at least, publicly available Much is being organized geographically – a continuously lengthening panel of routinely collected data 21

22. Can we start now to develop general use statistics? Could we request donors to ask questions in their surveys that policy makers in Pakistan have discussed and considered important? And maybe ensure quality? Could we request researchers to format data so that it can be absorbed into a larger system? Could we request ministries to do the same? 22