Odisha Health System Assessment: Key Findings


Over the past few years, India has introduced several major healthcare reforms like the National Health Mission (NHM), Pradhan Mantri Jan Aarogya Yojana (PMJAY) and the Health and Wellness Center (HWC) Programs, and the recent National Digital Health Mission (NDHM). In addition, India has implemented various state-level initiatives on health financing and healthcare delivery—all seeking to improve the health system’s performance. There have, undoubtedly, been some significant achievements, especially in increasing access and utilization of health services. However, India continues to face challenges in achieving better health system outcomes such as assuring financial risk protection, affordable and equitable access to quality healthcare, efficiency in service delivery, and citizen satisfaction about how the health system performs.

To design effective solutions for these persistent challenges, we first need deep and comprehensive diagnoses of their root causes – a systemic analysis of the health system. With this aim, the Harvard T.H. Chan School of Public Health (Harvard) in 2019-2020 undertook the Health System Assessment Study in Odisha, one of the poorest states in India, with a population of ~40 million. This study is a part of the Odisha Health System Project led by Harvard T.H. Chan School of Public Health (Harvard) with support from the Bill and Melinda Gates Foundation (BMGF). The project’s overarching goal is to design evidence-based solutions for Indian states to improve affordable and equitable access to quality care while avoiding major financial risks and improving citizen satisfaction.

The study provides a comprehensive and evidence-based assessment of Odisha’s health system. It diagnoses the underlying causes of the strengths and challenges, measured in terms of UHC goals like financial risk protection, access, quality of care, and citizen satisfaction. As the first large-scale health system assessment in India, the lessons from the study apply not just to Odisha but to the comparable Empowered Action Group (EAG) states, which together represent more than 52% of India’s population.

Like many other states in India, Odisha has made progress in maternal and child health (MCH) and nutrition. These advances reflect the government’s priorities and donor support for vertical programs in MCH. However, as India aspires to move towards UHC, many challenges lie ahead and its health care system requires revisioning and redesigning, especially given the additional challenges in the context of the COVID-19 pandemic.

Overview of Study

With preliminary analysis completed at the end of 2020, the Odisha Health System Assessment Study illustrates how Odisha’s health system is performing and highlights strengths and challenges, measured in terms of a set of final and intermediate outcomes based on the Control Knob framework (Roberts et al., 2008). The study represents a systematic analysis of Odisha’s health system using new key data gathered through a novel survey conducted in Odisha 2019-2020 and linked with existing data sources where appropriate.

Due to gaps in existing data (National Sample Survey, National Family Health Survey, Economic Survey, and Rural Health Survey), the Harvard team concluded that existing data cover only a subset of the Indian health system and therefore are not adequate for a systemic analysis. The team therefore designed an innovative and new package of surveys for a comprehensive assessment of Odisha’s health system. This package included ten different surveys with over 33,000 respondents including households, patients, over 2,000 individual providers, public and private sector health facilities at various levels of care, and chemist shops. The surveys concentrated on knowledge gaps such as linking demand with supply-side characteristics; providing a more comprehensive understanding of the private health sector; collecting geospatial data to allow public-private market analyses; and going beyond physical access and quantity of service to assess quality and effectiveness of care.

Key Findings

  • Current public insurance program in India does not address the main cause of financial hardships: Residents in Odisha experience high financial risks, with out-of-pocket spending on medicines from the private sector contributing up to 69% of all expenses, even for people who seek care at public sector health facilities. Most health expenses and financial hardships were due to spending on drugs, especially for outpatient care, rather than on hospitalizations. Existing government health insurance programs provide limited protection against these financial hardships as it covers only hospitalizations and not outpatient care or medicine expenses, which are the primary source of high health spending. Similar levels of financial hardships are faced by both insured and uninsured families, and at both public and private sector hospitals.
  • The private sector, formal and informal, constitute a main source of care: The majority of residents (54%) seek outpatient care from the private sector, including from chemist shops. A larger number of people go to chemist shops and solo providers (both qualified and unqualified), rather than to public sector primary healthcare facilities, like PHCs, Sub-Centers, and Health and Wellness Centers (HWCs). Even when people seek care at public sector facilities, ~70% buy their medicines from private chemist shops. This is due to 1) the poor availability of drugs at public sector facilities: only 38% of essential medicines were in stock at PHCs and a mere 18% at Sub-Centers and 2) inconvenient locations and opening hours of the public sector.
  • Quality of care is very poor across all providers: Low quality of care is one of the most significant challenges for Odisha’s health system. Ours was the first study to assess the quality of care from both patient and provider perspectives at a state level. We found poor competence among providers to diagnose and treat common conditions, poor patient safety culture in public sector hospitals, and low levels of patient satisfaction, especially among vulnerable groups. Only 2.4% of outpatient care providers knew the correct treatment for common conditions, including illnesses like TB, diarrhea, and pre-eclampsia, which have been national priorities for decades. All providers, irrespective of their qualifications, in rural and urban locations and across public and private sectors, prescribed incorrect and unnecessary treatments. Over 90% of public hospital staff have never reported adverse events and medical errors, which are critical for improving patient safety. These worrisome findings raise the question: are people getting value for their money spent?
  • The public delivery system suffers from inefficiencies: Public sector facilities in Odisha have lower than recommended occupancy rates, sub-optimal staff mix, and idle capacity of doctors. There is a lack of backward referrals from hospitals to primary care facilities even for simple illnesses. This result indicates that public hospitals are not being used to their full potential and that scarce and more expensive resources like specialist care and hospitals are inefficiently used for cases that could be managed at lower-level facilities.
  • Citizens are dissatisfied with the health system: Our assessment of citizen satisfaction, the first in India, can help inform policymakers and political leaders about how the public views the health system and the new health reforms. We found that 91% of the surveyed respondents expressed that the health system needs improvement and 33% felt that the health system needs to be completely rebuilt. Confidence in the health system was lower among people in rural areas, those belonging to lower castes and tribal groups, those without insurance coverage, and among households with low income and educational attainment, raising concerns about equity of health system performance for different population groups in Odisha.

Funding from the Bill and Melinda Gates Foundation (OPP-1181215 and OPP-1181222) is gratefully acknowledged.