Improving the quality of health care in any country can be challenging. However, doing it in a country with diverse culture, ethnicities, religion and languages such as India, is extremely difficult. Professor Grant Miller, Director of the Stanford India Health Policy Initiative, and also Director at Stanford Center for International Development (SCID), talks about the challenges of bringing unconventional insights and solutions for health policy in India.
Q. You have been leading research on Indian health policy initiatives for the past two years. What is your approach to tackling Indian health policy issues?
GM: One of our guiding principles is that we don’t start with a preconceived notion of what the right challenges to work on are. We spend a lot of time talking with health policy leaders, government decision makers, practitioners, and entrepreneurs to understand what they consider the top priority issues to be. We invite them to our annual roundtable to decide which issues we could work on together during the year.
Q. Having local partners to be involved in setting your research agenda seems to be a critical part of your approach. How do you motivate your stakeholders such as policy makers, healthcare providers, and patients so that they actively share their thoughts on different health policies?
GM: One approach that we use is to present research as a conversation-starter. Hints and clues about people’s views emerge from their reactions to presentations. Second, our students work closely with our local partners who have spent a lot of time in the area. They are very good at establishing the right kind of relationship with the people that we would like to engage with in our research. Finally, Stanford’s reputation helps both to bring people together and to make them interested in sharing their views.
Q. How do Stanford students participate in the research project?
GM: It’s been about two years since we launched the Initiative and we have taken students to India for intensive summer-long fieldwork each of the two years. This field experience comes in the middle of a three-quarter commitment that we ask of our students. During a spring quarter, we work with students to prepare to go the field. Then they spend a full summer in India maximizing their time being focused on field research such as data collection. For the fall quarter, we develop a report based on their data analysis and observations.
"We approach what we are doing with a lot of humility. We also expect to make a lot of mistakes. We try to be extremely honest with ourselves about our mistakes and use them to improve as we go."
Q. What do you think are some of the most challenging issues in Indian health policy?
GM: I can identify three of them. One of the critical challenges is motivating high level political decision makers to do what communities or constituents demand – which is about governance and accountability.
The second issue is about incentives within organizations. Conditional on a political or administrative decision to mount a new program, organizations implementing them sometimes of course suffer from tight resources, constraints or lack of training/skills – but importantly, they also lack strong incentives to perform to the full ability of their knowledge or skill. For example, since public sector employees often cannot be fired public sector managers are unable to hold their employees accountable. Also communities have difficulty judging whether or not they are actually receiving good quality services, and therefore, service providers have weak incentives to be responsive to them.
Third, we often erroneously assume that what communities or patients want is always what is best for their health. In other words, people care about health but they care about other things as well. Even if you can deliver a good quality package of health services, you may not be delivering what a community really wants. There are numerous reasons why people may not want to participate in a program that maximizes their health. Without fully understanding these patient, consumer, or community perspectives, well-meaning and effectively implemented policies can fail.
Q. How do you collaborate with ISERDD? Why do you think they are ideal for your research?
GM: I couldn’t say enough positive things about the Institute on Socio Economic Research on Development and Democracy (ISERDD), a key in-country partner - we have been extremely lucky to work with them. ISERDD has a very strong combination of top-notch leadership, including a renowned anthropologist at Johns Hopkins and leaders at several top Indian universities. Their highly skilled staff have extensive experience conducting field research in remote areas under challenging circumstances.
Q. What are some of the challenges you have been dealing with while conducting field research?
GM: We approach what we are doing with a lot of humility. We also expect to make a lot of mistakes. We try to be extremely honest with ourselves about our mistakes and use them to improve as we go.
I think one of the challenges is that a policy-making community in India is a constant moving target. It is common that government officials are transferred around from position to position after short postings and with little notice. We may work hard to build a relationship with a person or a group of people, but when they are transferred to a different region or position, we have to start all over again. Another challenge is that the process of getting permissions to conduct fieldwork is not straightforward. You have to identify all the relevant stakeholders and groups that you need to be supportive of your work.
Q. What are some of specific health policy issues that you have been focusing on for the Academic Year of 2014 and 2015?
GM: This year, we have been focusing on the role (and potential role) of informal healthcare providers in the current climate of changing health policies in India. About three quarters of primary healthcare services in rural India are delivered through informal practitioners. While some people think informal healthcare providers should be forbidden from practicing because they don’t have formal training, others think that they actually don’t perform much worse than providers in public facilities - and that they provide some valuable services in the absence of a high quality formal healthcare system. The reality is that they still exist regardless of their legality (they are illegal right now). We have been trying to understand the nitty-gritty of who these informal practitioners are, what they do, what motivates their activities – and to understand how the reality of their existence should fit with various strategies for improving the delivery of health care.
* Get to know more scholars at Freeman Spogli Institute for International Studies who are devoted to understanding and solving global health issues: http://fsi.stanford.edu/impact/global-health