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HEALTH SECTOR REFORMS
Presenter Moderator
Dr M A Bashar Dr Tarundeep Junior Resident Assistant Professor
04/18/2023
Reforms
o ‘Fundamental rather than an incremental change, which is sustained rather than one off, and also purposive’
(Cassels1997)
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Health System
• Health system means the "combination of resources, organization, financing, and management that culminates in the delivery of health services to the population"
(Roemer 1991)
• The key institutional components of the health system are: – State or government institutions– Health care providers– Resource institutions– Purchasers of health care such as insurance agencies – Other sectoral agencies e.g., education, water supply, sanitation– Consumers or population at large
Background
• Health sector reforms have generated much debate in India, especially in the context of economic liberalization.
• The World Bank intensified this debate in 1993 when it tried to redefine the role of the public and private sectors in healthcare.
• There is no consistent and universally accepted definition of what constitutes Health Sector reforms thereby leading to varied meaning and connotations.
Definition
• “Sustained purposeful change to improve the efficiency, equity and effectiveness of the health sector”
– Peter Berman (1995)
• “Defining priorities, refining policies and reforming the institutions through which those policies are implemented”
– Cassels (1997)
Definition
• Health sector reforms is a sustained process of fundamental change in policy and institutional arrangements, guided by government and designed to improve the functioning and performance of health sector and ultimately the health status of the population.
-WHO
Introduction
o Changes that affect at least two of these elements: o health financingo Expenditureo Organization regulationo Consumer behavior.
• If we change only health financing its not health
sector reform
(William Hsiao)
Introduction
• In recent years, economic pressures on the government and specifically on the health sector have forced the governments of developing countries to initiate health sector reforms.
• This thrust is made to ensure that an appropriate share of public funds is spent on health care, especially at local levels (allocative efficiency).
• It is designed to improve the organization and management of health systems and ultimately to achieve overall health policy objectives.
Introduction
• The users should also be satisfied with the form and content of health services offered (improved health status and client satisfaction), and that the benefits of publicly-funded health care are equitably distributed (improved equity of access to care).
• These health sector reforms varied in social, economic and political environments, as well as in development stages of health care systems.
HSR Components • HSR deals with – Equity – Effectiveness – Efficiency – Quality – Sustainability – Defining priorities – Refining the policies – Reforming institutions for policy implementations.
Types of Reforms
o Changes in financing methods
o Changes in health system organization and Management
o Public sector reforms
(Reforms Thomason Jane A, Health Sector Reform in Developing Countries :A Reality Check http://www.sph.uq.edu.au/acithn/conf97/papers97/thomason.htm Site last assessed on September 25, 2014)
Problem Definition
Diagnosis
Implementation
Policy Development
Political Decision
Evaluation
Health-Reform Cycle
POLITICS
ETHICS
(Getting Health Reform Right. Roberts, Hsiao, Berman, Reich,2004)
Challenges to reforms
• Unclear who has the power and responsibility. • The minister for health?• The medical association?• The health insurers?• The citizens?• Power divided among groups - interests ?• Doctors want more freedom and more resources• Health insurers want more control and less spending• Ministers want quick changes• Public health specialists’ focus is health promotion
Health Sector Reforms In Developing Countries
HSR in China
• Economic changes began in 1978• Rapidly dismantled the socialized mechanism
of financing the healthcare• Sudden introduction of market forces in
previously state organized system• Primary level services lost their collective
funding base in much of rural china• State budget were inadequate to support urban
hospitals
HSR in China
• These changes unleashed a variety of subsequent changes. They were
Privatization of village doctor practicesIntroduction of financial autonomy for
hospitalsCost escalation, as prices were liberalized and
providers were free to increase revenues.
HSR in Africa
• African countries faced major financial crisis in 1980s and early 1990s
• Major programs of structural adjustments led by international financial institutions i.e. World Bank And IMF included
Allowing local currencies to be devaluatedReducing govt expenditures(including social
expenditure) and debt Cutting back on civil service
HSR in Africa
• Zambian reforms initiated in 1991-92 included an innovative institutional restructuring of govt health care
• Created a Central Board of Health to oversee health care delivery matters external to Ministry of Health
• Also involved significant decentralization to district health management teams and health boards
• Introduction of user fees• Development of nationally defined benefit packages
Origin of Reforms in India
Need for Reforms
Fiscal Constraints Poor social indicators
Need for reforms
Òil ShockEconomic crisis of 70s and 80s
‘Investing in Health’ WDR, 1993
‘Financing Health Services in Developing Countries’WB, 1987
(Health Sector Reforms in India, Initiatives from nine states. GOI. Vol 1. Aug 2004)
Fiscal ConstraintsEconomy committed
to socialism•Planned economic development•Strong import substitution
Economic crisis •No Balance of Payment Crisis•Slack in foreign exchange flow
Oil Crisis •Import dependent growth strategy•BOP crisis post gulf war
18/04/2023
Fiscal deficit – Had to go for WB loan under the Structural Adjustment Programme
(www.idrc.ca/en/ev-118491-201-1-DO_TOPIC.html)
Need for Reforms
o Financing Health Services in Developing Countries, World Bank, 1987o User feeo Insurance or other risk coverageo Effective use of non government resourceso Decentralization
o Investing in Health, WDR, 1993o Fostering an ideal environmento Increased Govt. spendingo Promoting diversity and competition
(Health Sector Reforms in India, Initiatives from nine states. GOI. Vol 1. Aug 2004)
04/18/2023
Privatization
• Regulating Private Health Care in India• • - COPRA 1986 - Pharmacy Act• - IMC Act - Nursing Home Act• - Code of ethics - Bureau of Indian Standard• - Drugs & Cosmetic Act - Public Nuances Act• - Dangerous Drug Act• - Drug Price Control Act
Regulating the private health care sector: the case of the Indian Consumer Protection Act Health policy and planning; 11(3): 265-279
23/49
Financing of Healthcare
04/18/2023 25
Financing of Health Care
Bangladesh
India
Sri Lanka
China
Thailand
0 50 100 150 200 250 300 350
17
19
88
122
207
40
81
101
193
116
Public SpendingPrivate Spending
Per Person Total Expenditure in Health, PPP $(2005)
Financing health care for all: challenges and opportunities A K Shiva Kumar, Lincoln C Chen, Mita Choudhury, Shiban Ganju, Vijay Mahajan, Amarjeet Sinha, Abhijit Sen. The Lancet 2011
Financing of Health Care
o 10 % of households – medical insurance 1
o Ailments that went untreatedoRural 28%oUrban 20%
o Slow increase in insurance • ( National Commission for Enterprises in the Unorganized Sector )
o93% population in unorganized sectoro77% population - poor and vulnerable
o CBHI – very few studies, little information on impact 2
Financial Protection
1. NFHS 3 2. The landscape of community health insurance in India: An overview based on 10 case studies. Devadasanad et al Volume 78, Issue 2, Pages 224-234 (October 2006)
Financing of Health Care
S.no Efficiency of Health Spending Rural (%) Urban (%)
1 Not satisfied by govt doctor or facility 41 45
2 Large distance 21 14
3 Non availibility of services / facilities 30 26
4 Private providers for OPD care 78 81
5 Private providers for in patient care 58 62
• Proportion of Respondents Quoting Poor Efficiency
• High cost of careFinancing health care for all: challenges and opportunities A K Shiva Kumar, Lincoln C Chen, Mita Choudhury, Shiban Ganju, Vijay Mahajan, Amarjeet Sinha, Abhijit Sen. The Lancet 2011
18/04/2023
04/18/2023
Demise of Alma Ata Declaration
Failure of PHC
1
• Cut in soft sector budget• Inefficient allocation
Replaced by HSR
1
• based on market forces
Poverty trap
2
• Most OOP in India for primary care through pvt
Health inequity
1. Health for all beyond 2000: the demise of the Alma-Ata Declaration and primary health care in developing countries John J Hall and Richard Taylor2. Equity and health sector reforms: can low-income countries escape the medical poverty trap? Margaret Whitehead, Göran Dahlgren, Timothy Evans
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04/18/2023 29
The Poverty TrapCharacteristics of the
poorPoor
utilizationUnhealthy practices
Poor health
outcomesIll health
MalnutritionHigh fertility
Diminished income
Loss of wagesCatastrophic
OOP
Poor health provision
Lack of income knowledge
Excluded from health finance system
Bad environment
(Poverty and health sector inequalities. Adam Wagstaff )
Health Sector Reforms in India
HSR IN INDIA
• Health sector reforms have come center stage since 1980s essentially from frustration of the citizens in receiving any semblance of health care from the public system. By 1990s the process had taken concrete shape.
• In India, the health sector reforms broadly cover the following areas :– Re organisation and restructuring of existing health care system
– Involving Community in health service delivery
– Health Management Information System
– Quality of care
All aspects of the sector from manpower to infrastructure to logistics to monitoring to participation of stakeholders are subject matter of this process
EIGHTH FIVE YEAR PLAN (1992-97)
• Concept of free medical care was revoked• Levying user charges for people above poverty line for
diagnostic and curative services. • Ensured commitment for free / highly subsidized care for the
needy / BPL population. • Promote social welfare measures like improved healthcare,
sanitation• Check the population growth by creating mass awareness
programs • Private sector promotion
NINTH FIVE YEAR PLAN (1997 - 02)
• Convergence and increase involvement of public, private and voluntary health care providers.
• Enabling Panchayat Raj Institutions (PRI) in planning and monitoring health programmes.
• Emphasis on basic infrastructural facilities including safe drinking water and primary health care.
• Inter-sectoral coordination and utilization of local & community resources.
• Greater emphasis on accountability
TENTH FIVE YEAR PLAN (2002 - 07)
• Reforms focused on primary, secondary & tertiary health care level.
• Emphasis was on equity and financing health care • Social Health Insurance for BPL population – Universal
Health Insurance Scheme. • Human resource development• Capacity building• Quality assurance• PRI empowerment• Focus on public private partnership
Policy Shifts in Five Year Plans
8th • Free medical care revoked• Encouraged initiatives with private
sector
9th • Profit/non-profit NGO in health
care • Inter sectoral coordination of
health programmes• PRI in planning and monitoring
10th • Address issue of equity
(Adjustment and Health Sector Reforms: the Solution to Low Public Spending on Health Care in India? DelampadyNarayanawww.idrc.ca/en/ev-118491-201-1-DO_TOPIC.html)
NATIONAL RURAL HEALTH MISSION
• Health care is now one of the thrust areas for the Government of India.
• The Government mandates an increase in expenditure in health sector, with main focus on Primary Health Care from current level of 0.9% of GDP to 2-3% of GDP over the next five years.
• The National Rural Health Mission (NRHM) which is the main vehicle for giving effect to the above mandate was launched in April 2005.
NATIONAL RURAL HEALTH MISSION
• NRHM is an overarching umbrella initiative which subsumes the existing programmes of Health and Family Welfare and seeks to be the omnibus vehicle for sector wide reforms in India.
• The NRHM (2005-2012) in recognition of the needs of the urban poor population has constituted a task force on urban health to recommend strategies for improving health of the urban poor.
The National Urban Renewal Mission (NURM) launched by the Government of India in 2005 has a sub-mission on basic services for the urban poor covering sixty cities in India.
NATIONAL RURAL HEALTH MISSION
• Architectural corrections in delivery systems in reforms agenda– Promote equity, efficiency, quality and accountability– Enhance community based approaches to health– Ensure public health focus– Promote new innovations, methods & new approaches– Decentralize and involve local governing bodies
• District health societies• NGO involvement• Integration of ISM (AYUSH)
ELEVENTH FIVE YEAR PLAN (2007-12)
• To achieve good health for people, especially for the poor and the underprivileged
• Time-Bound Goals for the Eleventh Five Year Plan– Reducing MMR to 100 per 100,000 live births.– Reducing IMR to 28 per 1000 live births.– Reducing Total Fertility Rate (TFR) to 2.1.– Providing clean drinking water for all by 2009 and ensuring no
slip-backs.– Reducing malnutrition among children of age group 0–3 to half– Reducing anaemia among women and girls by 50%.– Raising the sex ratio for age group 0–6 to 935 by 2011–12 and 950
by 2016–17.
HSR: AREAS
• Decentralization
• Human Resources
• Financial reforms
• Reorganization and restructuring of the existing health system
• Health Management Information Systems
• Communitization
• Quality assurance
• Convergence
• Public Private Partnership
DECENTRALIZATION
• Devolution of authority and responsibility• Delegation of responsibility and functions• Shifting power from the central offices to peripheral offices• Merger & formation of Societies, VHSC, RKS• Decentralization of Planning Process• Decentralization of Financing mechanism• NGO participation in National Health Programs
HUMAN RESOURCES
• IPHS norms– 2 ANMs/sub-center and 1 male MPW.– 3 nurses/ANMs per PHC, 2 MO– 9 nurses/CHC plus 5 specialists & 3 to 4 MO– AYUSH staff
• Expanding available skilled human resource• More medical UG & PG seats in govt. & private medical
colleges• Reviving ANM and MPW training centers
HUMAN RESOURCES• Compulsory rural postings• Contractual appointments• Incentives for difficult areas• ‘Pooling’ of medical officers• Multi skilling option for existing staffs
FINANCIAL REFORMS
• “We are now aspiring to taking the total allocation for the health sector to 2-3 per cent of our GDP in the 12th (Five Year) Plan period” : Mr. Ghulam Nabi Azad (union Health and Family Welfare Minister) at Pune (8th May 2011)
• New financing mechanisms of untied funds, breaking the traditional Treasury route
• Untied grants to village, subcenters, PHC, block, district
FINANCIAL REFORMS
• Alternative financing of health care, such as – user fees/charges, – community finance, – health cards or voucher systems, – contracting services, – social insurance schemes and – private insurance
FINANCIAL REFORMS
• Demand side financing through Insurance (RSBY) • Conditional cash transfers (JSY)• Flexible financial resources to ensure service
guarantees• State Government’s increase their allocation by
10 % every year and also contribute 15% to NRHM.
STRUCTURAL RE-ORGANIZATION
• Creation of Societies- bypass regular government Procedure
• National/ State level technical support organization like– NIHFW, SIHFW, NHSRC, SHSRC (State Health Systems Resource Centre)
• Emergency response systems- 108 or 102• Emergency Management and Research Institute
(EMRI)
STRUCTURAL RE-ORGANIZATION
• Procurement initiatives – TNMSC (Tamil Nadu Medical Services Corporation ), KMSC, PHSC (Punjab Health Systems Corporation) etc.
• National HMIS• Meaningful partnerships with the non-governmental
providers for reaching quality health care• Co location of AYUSH in PHCs/CHCs/District
Hospitals
COMMUNITIZATION
• Community accountability through RKS/ RMRS (Rajasthan Medicare Relief Societies)
• monitoring process by community stakeholders • Community Health volunteer – ASHA• PRI involvement in health care• Village health & nutrition days (VHND)
Quality Assurance
• New standards for government facilities• IPHS• NABH standards (National Accreditation Board for
Hospitals & Health care providers) & • NABL standards (National Accreditation Board for Testing
and Calibration Laboratories)• Focus on service guarantees
CONVERGENCE
• Envisaged horizontal and vertical linkages within Health sector
• Intrasectoral and Intersectoral integration• Mainstreaming of AYUSH
PUBLIC PRIVATE PARTNERSHIP
• Involving the private sector in service provision• Private sector should be seen as a national asset and
alternate service delivery systems e.g. social franchising should be considered.
• Outsourcing of services• Contracting-in options –– Specialists (Haryana, MP, Rajasthan etc.)
• Contracting-out options –– Karuna trust in Karnataka, Punjab (village level
dispensaries)
Newer High-Potential HSR Initiatives Government initiatives
Purpose Issue(s) addressed
Telemedindia Combines information and communication technologies(ICT) with Medical Science for clinical records, diagnostic tests, video consultations and medical education(several govt and private healthcare network established)
To increase healthcare services and education to rural(and remote) parts or under emergency conditions
Compulsory licensing
Grant non- patent holder(s) permission to manufacture patented drugs not available at an affordable price (first grant to cancer drug Nexavar in March 2012)
To increase accessIbility to medications
Bachelor of Rural Health Care(BRHC)
A 3 &1/2 year rural health care course( proposed inn Rajya Sabha)
To increase rural healthcare professionals
Newer High Potential HSR Initiatives Govt initiative Purpose Issue(s) addressed
National Programme for Healthcare of the Elderly(NPHCE)
To be test –launched in 100 districts of the country in 2012-17
To reduce the incidence of non-communicable diseases (NCDs)in elderly
National programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke(NPCDCS)
To be test-launched in 100 districts of the country in 2012-17
To reduce the incidence of major non-communicable diseases through lifestyle modifications
Free Medicines for All Rs 28,560 crore plan to provide 348 medicines for all and must-prescribe generic drugs mandate to doctors (proposed 2012-2017
To increase accessibility to medications
Healthcare for All by 2020 All residents will have healthcare coverage via a combination of public, employer and private sources
To uphold the fundamental right of all citizens to adequate health care
WHO'S ROLE
• The World Health Organization, through its various
collaborative programmes at all levels, is involved in
capacity building in the member Countries to take care of
the evolving reforms in the health sector, mainly in the areas
of planning and human resources.
• To support the reforms processes in countries, a series of
publications, both at regional and global levels, have been
issued.
WHO'S ROLE
• An international "Forum on health sector reforms" has been
established to share and disseminate information on the
scope and nature of WHO's current and planned activities in
support of health sector reforms and in identifying priority
issues, reviewing country experiences and also the
approaches of different agencies in the field.
• WHO is also supporting institutional strengthening to
promote expertise in the developing countries.
Way Forward for effective HSR
Effective HSR
Incentive system to
states
Taxation
Regulation of pvt sectorRisk pooling
Strengthening of HMIS, Social
audits, Community monitoring,
Capacity building, Prioritization, Cost
effective policy
Increased public
spending on health
Financing health care for all: challenges and opportunities A K Shiva Kumar, Lincoln C Chen, Mita Choudhury, Shiban Ganju, Vijay Mahajan, Amarjeet Sinha, Abhijit Sen. The Lancet 2011
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CONCLUSION AND POINTS FOR CONSIDERATION
• Reforms encompass a range of purposeful efforts to change the system for improving its performance
• You should make deliberate efforts, and conscious choices so that the changes in the system would lead to the improved performance in line with the desired goals.
• reforms have to be rational, logical and specific.
CONCLUSION AND POINTS FOR CONSIDERATION
• Health sector reforms is a political process.
• Radical reforms is impossible without robust political
leadership, informed by sound technical advice.
• reforms should take place as a sustained process of
fundamental change in health policy and health institutional
arrangements.
CONCLUSION AND POINTS FOR CONSIDERATION
• Improvements in the functioning of the public sector and
civil service systems in general will occur in parallel with,
and sometimes in response to, other aspects of institutional
reforms, such as increasing privatization.
• Sustained information and education are needed to generate
wider political and public understanding and support.
• Health system research and other forms of research studies
will provide evidences to strengthen the processes and
mechanisms for health sector reforms.
CONCLUSION AND POINTS FOR CONSIDERATION
• Health sector reforms demand an explicit link between researchers, planners and decision-makers for the optimal use of research findings.
• While every reforms experience is country specific, there are always important lessons to learn from comparing options, identifying common issues addressed and the tools used, and evaluating effects of various reforms initiatives.
THANKS
