In 2011-12, more than 50 percent of deliveries in nine of 10 Telangana districts were caesarean section deliveries (C-sections), according to an analysis of district-level health data.

In comparison, none of the districts in Rajasthan, Uttar Pradesh, Madhya Pradesh and Bihar had C-section rates of more than 25 percent.

The healthy rates of C-section should range from 10 percent to 15 percent, according to this April 2015 World Health Organization estimate, while a December 2015 study led by Ariadne Labs, a joint center of Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, suggested that optimal C-section rate could be as high as 19 percent.

At the national level, while India lies near the healthy range, around 8.5 percent as per WHO data, it is deceptive of the underlying inequalities and variations.

In many districts in India, the C-section rate is either too low or too high, according to the analysis we conducted at Evidence for Policy Design of district-level estimates for C-section rates across the country – in both public and private healthcare institutions – from the District Level Household Survey Round 4 and the Annual Health Survey.

Also read: Hospitals Will Now Have to Share Data of All Caesarean Deliveries

What is Driving High C-Section Rates?

Higher than necessary C-section rates can be presented as a case of “market failure”, an economic term used to describe cases where allocation of goods or services is not efficient.

Combine that with potential incentives for doctors to provide expensive treatments, and you are looking at a healthcare market that is inclined to over-treat.

In several districts in south India, we found high rates of caesarean deliveries even in public institutions.

For instance, C-section rates in public institutions were higher than 20 percent in all the districts of Telangana, which is a rare example of extremely high C-section deliveries overall.

Also read: Home Births: Why Are More Women Choosing It Over C-Section?

C-section Rates Proxy of Healthcare System Performance

India spent 1.4 percent of its gross domestic product on public healthcare in 2014.

In comparison, Organisation for Economic Co-operation and Development (OECD), a group of 35 advanced economies, spent an average of 7.7 percent.

The answer to this is not a blanket approach of investing in healthcare facilities and personnel.

The outcome budget of the ministry of health and family welfare follows this as a solution with an overarching emphasis on quantity: the underlying assumption being that more public health facilities would lead to increased access to public facilities, which would be followed by more people accessing public facilities, and eventually better health outcomes.

There is a need to indulge in preliminary diagnostics to determine site-specific needs and strategies.

Challenges in the low C-section districts are quite different from those with very high rates, and the healthcare policy should reflect such differences.

For districts with low rates, there is a possible case for greater investments in public healthcare infrastructure and facilities, and more qualified medical personnel.

It is not clear if this approach would be appropriate for some of the regions with high C-section rates.

For one, it ignores the critical role of the private sector, which is the more dominant health service provider in India.

Across India, for treatment of most ailments, citizens prefer private healthcare service providers approximately 70 percent of the time, an analysis of National Sample Survey Round 71 data shows.

When asked why they chose a private facility over a public facility, the dominant response was the quality of facilities, which is not satisfactory in public institutions.

More appropriate solutions for these areas could be to invest more in quality of care rather than quantity, and to design regulatory frameworks to ensure that healthcare institutions – both public and private – are held more accountable.

For instance, there are not enough data that can help us gauge quality of care, without which we do not have a clear sense of what drives perception of quality. Building on that, we will need more robust evidence on what works in different contexts.

Cross-country and cross-region lessons in attempts to improve overall quality of healthcare can serve as preliminary evidence to determine the direction in which investments in the health sector in India. Only then can we be sure that we get the most out of our limited resources.

((The article was first published on IndiaSpend. The author is a Senior Research Associate for EPoD India at IFMR, a joint initiative by Evidence for Policy Design at Harvard Kennedy School and the Institute for Financial Management and Research. Singh is a former Research and Training Manager for EPoD India at IFMR and current Project Manager at International Food Policy Research Institute.)

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