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Quality improvement and its impact on the use and equality of outpatient health services in India


  • Krishna Dipankar Rao

    (Department of International Health, Johns Hopkins Bloomberg School of Public Health, New Delhi, India)

  • David H. Peters

    (Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA)


This paper examines the impact of quality improvements in conjunction with user fees on the utilization and equality of outpatient services at a range of public sector health facilities in India. Project impact on outpatient visits was estimated via the difference-in-difference method using pooled time series visit data from project and control facilities. The results indicate that the quality improvements significantly increased visits at all facility types. The project effect was largest at primary health center (PHC) and community health center (CHC), followed by district hospital (DH) and female district hospital (FDH). Pro-rich inequalities in outpatient visits increased at DHs and FDHs while at CHCs and PHCs the distribution remained equitable. This suggests that quality improvements at public sector health facilities can increase utilization of outpatient services in the presence of nominal user fees, but can also promote greater inequality favoring the better-off. At the referral hospital level, quality improvements should be made in conjuction with programs which encourage utilization by the poor. In contrast, the benefit of quality improvements at PHCs and CHCs is equitably distributed. Copyright © 2006 John Wiley & Sons, Ltd.

Suggested Citation

  • Krishna Dipankar Rao & David H. Peters, 2007. "Quality improvement and its impact on the use and equality of outpatient health services in India," Health Economics, John Wiley & Sons, Ltd., vol. 16(8), pages 799-813.
  • Handle: RePEc:wly:hlthec:v:16:y:2007:i:8:p:799-813
    DOI: 10.1002/hec.1194

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    References listed on IDEAS

    1. Ashenfelter, Orley & Card, David, 1985. "Using the Longitudinal Structure of Earnings to Estimate the Effect of Training Programs," The Review of Economics and Statistics, MIT Press, vol. 67(4), pages 648-660, November.
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    3. Filmer, Deon*Pritchett, Lant, 1998. "Estimating wealth effects without expenditure data - or tears : with an application to educational enrollments in states of India," Policy Research Working Paper Series 1994, The World Bank.
    4. David H. Peters & Abdo S. Yazbeck & Rashmi R. Sharma & G. N. V. Ramana & Lant H. Pritchett & Adam Wagstaff, 2002. "Better Health Systems for India's Poor : Findings, Analysis, and Options," World Bank Publications, The World Bank, number 14080, September.
    5. Kakwani, Nanak & Wagstaff, Adam & van Doorslaer, Eddy, 1997. "Socioeconomic inequalities in health: Measurement, computation, and statistical inference," Journal of Econometrics, Elsevier, vol. 77(1), pages 87-103, March.
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