health sector reform in India

7/30/2019 health sector reform in India

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A Policy Analysis of the Health

Sector Reform Process in India

Dr. Rama Baru

Associate Professor, JNUIndia Habitat Center, March 7th, 2003


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A policy analysis of the HSR

process in India

The overall objective of this study is to explore

the perceptions and experiences of health sector

reform at the national levelIt specifically explores the definition, content,

process, and sustainability of the health sector

reform process in India.

It seeks to understand both the internal andexternal forces that are shaping the health sector

reform process.


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Definition of Health Sector

Reform

The definition of health sector reform used in thisstudy is that it is a fundamental rather than anincremental change, which is sustained rather than

one-off, [and] purposive in nature(Cassels:1997).

According to Cassels (1997) health sector reformincludes:

Improving the performance of civil service

Decentralisation of power and resources

Improving function of national health ministries

Broadening health financing mechanisms

Introducing managed competition


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Data Source: Interviews

Actor Numbers

contacted

Numbers

interviewed

Bilaterals (EEC, DfID,

SIDA roundtable)

7 7

World Bank 2 2

Ministry of Health and

Family Welfare

6 3

Tamil Nadu state level

policy makers and

academics

3 2


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Motivation for the Analyses of

Health Sector Reforms

Health Sector reforms are bound to influence the

provisioning, financing, manpower, drugs and

technology in the health service systemReforms will have a bearing on the effectiveness

of National Health Programmes.

Reforms will also have an impact on the

availability, accessibility, quality and cost ofhealth services-both general and specifically for

reproductive and child health


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Questions Pursued in the

Analyses

Varying definitions of health sector reform -Indian

government and major donor agencies

Motivation for reforms of different donor agenciesand the government

Content of health sector reforms

Implications of HSR for health services delivery

Sustainability of the reform process

Implications for equity


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Methodology

All who were involved in the health sector

reform process were contacted and key

persons were interviewed from the majormultilateral and bilateral agencies and the

Ministry of health and family welfare. The

donor agencies included The World Bank,DFID, SIDA, and the European

Commission


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Methodology

Elements of HSR that got special emphasis during

the nineties with loans/grants from multilateral

and bilateral agencies were reviewed; Loans to communicable disease control programmes

with focus on specific diseases viz. tuberculosis,

malaria and HIV/AIDs

Loans for the Reproductive and Child Healthprogramme

Loans to state governments for the state health systems

projects for primary, secondary and tertiary levels


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Plurality of definitions

Health sector reform is nothing more than projectsthat have been put together and it is tied to loans

from the World Bank. (Interview former Secretary

of MOHFW May 2002).During negotiating for the loans, the Bank told usthat unless we accepted conditionalities for powerreform they would not give us loans for health. We

told them that we did not want to be tied down bysuch conditionalities and would rather not get theloan. Then they came back to negotiate with us onthe terms set by us. (Interview with senior officialin the health ministry, Delhi, March 2002)


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A senior official of The World Bank views health

reforms as a group of projects that includes

communicable diseases, Reproductive and Child

Health programme and Health Systems The

motivation for health sector reform as seen by the

World Bank is to promote economic efficiency,

quality, reform of public sector (Interview withSenior Bank Official, The World Bank Delhi

Office, March, 2002). .


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The European Commission on the other hand arguesthat health sector reform is nothing more than a mixedbag of donors, projects and the government of India.

Overall there is a singular lack of vision among allthese actors when it comes to health sector reform.(Interview with Senior Official, EuropeanCommisssion, Delhi office, March 2002). They

consider the World Bank to be setting the agendaguided by some North American consultants tointroduce privatisation and have designed thecomponents of the health sector reform agenda for the

country. (Interview with Sr. official, EC Delhi office,March 2002


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Some academics and researchers (based on recentstudies) on health sector reforms regard them aslargely driven by the World Bank, though

accepted by the national government in order toget loans to overcome the fiscal crisis, without acorresponding vision of the national government.

Some academics have pointed that it is the lack of

a vision of health sector reform within the ministrythat results in the identification of HSR with donorled initiatives (Interview with a senior healthresearcher, Chennai, April,2002).


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Space for negotiation

According to the European Commission the governmentdoes have space for negotiations in terms of theprogramme content and the choice of technology. Space

defined by vision, technical intellectual capacity ofgovernment officials and political will of stategovernments For example, user fees in Kerala and AP.

The role of the bureaucrats has been a mixed picture withthose who have a vision, some who collude with

foreign agencies and others who want to pursue theirown pet ideas ( Interview with Senior Official of the

European Commission, Delhi, March 2002)


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Space for negotiation

The bureaucrats from the health ministry opined that eventhough the World Bank was the major actor it did notdetermine the priorities for the country since the quantum offunding is small and not an additionality to the existingbudget.

Although the outlay is insignificant, a senior bureaucrat inthe health ministry argued that, we negotiated with theWorld Bank based on our needs. There was no element in

the disease control programme that was seen as unnecessaryby the Indian government. (March, 2002) The onlyprogramme that was pushed by the World Bank was forHIV/AIDS but the other disease control programmes namelytuberculosis and malaria were seen as important internally

and were endorsed by the Indian technocrats themselves.ibid .


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Space for Negotiation

At the state and central levels the push factor for

taking loans is the fiscal crunch faced by the

states. Given the poor state of finances, the state

governments opt for loans and see it as a way of

tiding over a financial crisis.


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World Banks Review of the Health

System Reform Project

The Banks image of itself as a provider of hardware and

infrastructure rather than a developer of human resources.

Resistance from Indian counterparts to address systemic

issues.

Shortages of resources and effective managers.

Focus on the public sector and on expanding the public

health system

Application of a single model to areas with very different

characteristics.


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Ownership of Reforms

The process of reform has been a top down with very littleinvolvement from the community. The plans are made at thecentral and state levels with very little input from the communitys

needs.As a result the ownership of reforms at the state and lower levelshas been weak.

Capacity weak at the state, districts levels

Resistance of public sector doctors to give administrative powersto Panchayats

Governance of public institutions unaddressed


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Implications for equity in access

and utilization

Privatization

Corruption

Rising cost of care, increasing cost of drugs,

user fees


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Sustainability of Reforms

Most state governments are not in a position toincrease allocations

In addition to sustaining these programmes, the stateswill have to also pay back the loans, which will onlyincrease their financial burden.

Frequent transfers of bureaucrats and technocrats asnegatively affect the implementation of the reforms.

Lack of civil service reforms

Corruption within the health services as an additionalimpediment to sustainability of reforms

Need for more effective donor coordination


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Major Issues

Definitionincremental not fundamental

The project approach to health sector reform

spaces are available for negotiations at both the centraland state levels with multilateral agencies.

Since nearly all state governments are facing a fiscalcrisis and health is not a high priority area of

investment, most of them have been applying for loansto the Bank.

The interviews suggest that the entire reform process isa top-down approach. There is little consultation

with the personnel at different levels of the health


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Major Issues

There is very little co-ordination among donors onhealth sector reform. There are situations where twoor three donors are operating in the same state with

their own priorities and agendas. This has raised theproblems of duplication and adhocism when it comesto programme implementation.

In the RCH programme the government has adopted

the Rights Based Approach after ICPD but this hasnot been effectively transferred to the different levelsof providers.

New budget?

Documents

health sector reform in India