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Indian Journal of Community Medicine

C. M. E. - Health Sector Reforms: Relevance in India

Author(s): D. Agarwal

Vol. 31, No. 4 (2006-10 - 2006-12)

D. Agarwal

The importance of working on sector reforms and the important elements of health sector reforms is paramount in Indian context. It is important to pause and ponder about the ultimate and intermediate outcomes of health systems. What are the reforms, what do we mean by reforms in the health sector? Do we really need reforms in the health sector in the India and how critical it is to build a consensus for a reforms agenda for the country? I intend to share some key conclusions towards the end of my presentation. As far as the composition of the health system in the country is concerned, we know that the health system is highly heterogeneous and ,complex with multiple actors, the large number of treatment providers belonging to different pathies and in different settings. We have a wide range of providers: formal and non formal, qualified and less than qualified, registered medical practitioners etc. They are working in the outreach, home settings, stand alone dispensaries, nursing homes and corporate sector world-class hospitals. We have preventive and promotive care services in terms of immunisations, family planning, maternal health services, vertical disease control programme to name the few. We have a range of fi nancing mechanisms to support health care. The Government spending on health is an attempt to subsidize health care. Large chunk of population has to make out-of-pocket expenditures to access health care. Health insurance is gradually growing and more players along with new products are going to be in the market given the conducive policy environment. Last decade has been witness to phenomenal growth in numbers of the medical colleges, nursing colleges and other similar training institutions. There are multiple institutional players in organizing health care. We have the panchayat system who are responsible for providing primary health care, the State Governments providing predominantly budgetary support, Central Government for setting broad policy frameworks and also budgetary support and several autonomous institutions, railways, army, ESI, etc Also one can not ignore very impressive presence of private sector players especially as most states are promoting what they call as “medical tourism” to attract patients from neighboring countries. We have 21 percent of global burden of disease. Twenty five percent of all maternal deaths takes place in our country and same may be true for neonatal mortality.

Politics infl uence health systems in signifi cant manner. The goals, priorities, and the strategies, variations in the commitment are largely decided through the political contingencies. There are competing demands on the health systems. The evolution of the health systems is largely shaped by the culture, history, and norms.

Any health system would have 3 important goals. Health sector or health system should work for improving the health status, but we know its difficult to measure. Indicators like life expectancy, DALYs etc. are there. There are legitimate questions regarding use of these indicators and the inclusiveness. Averages mask the equity such as, the regional equity and the gender equity parameters and also the income quintiles.

Another goal of health system is customer satisfaction, which WHO refers to the health systems responsiveness. Health systems have to be responsive to the needs of the clients and the community. It is difficult to measure the customer satisfaction and gauze responsiveness of health systems. We don’t have firm handle in terms of what are the client satisfaction level with private services. Client satisfaction also depends on non-clinical aspects of care. One would expect that the customer satisfaction would largely depend on the clinical outcomes of care, but non clinical outcomes of care do infl uence the customer satisfaction and that’s what the health system have to worry about. Financial risk protection is another goal of health systems. We need to start thinking about how health systems are covering for the fi nancial contingencies and fi nancial risk. Are people protected against the high cost of medical care? So any health system should see to it that the fi nancial protection is extended against the catastrophic illnesses and the poor people who are really worst affected with the high cost, are not constrained to seek care.

It is useful to pause and take stock of Indian health sector. We have improved life expectancy considerably from 49 years in 1970 to 63 years in 1998. Yet averages mask the equity dimensions. Clearly there are class and regional inequities. We also have high mortality and the burden of disease amongst the poor. An analysis of coverage with preventive and promotive interventions with special reference to income quintiles will highlight huge differentials. Several studies have indicated that poor don’t seek care on account of poor purchasing power.

Client satisfaction is very high. As per NFHS-2 data, an overwhelming majority of clients are satisfi ed by the services delivered by the public systems. May be the expectations are low or may be our people are so courteous. But on the hand, we have the report from Transparent International, ranked the health system in India is the most corrupt system.

It will be useful to see as how we are doing in terms of spending? Overall, Government spending is 0.9% of GDP, which is very low. WHO has pointed that we are really in the bottom quintile in the world in terms of public sector spending in the health care? Though the policy documents are explicit for increasing public spending to 2% and then 5% within next 10 years. It is also worrying that post liberalization,one is seeing the greater decline of investment in social development sector including health sector since 1990 to 2000 or 2003 in the real terms. In terms of private expenditures 80 percent of all spending is on health from the private sides, it’s kind of out-of-pocket expenditures because the health insurance is yet to catch imagination of masses. There are wide interstate variations in terms of utilization of health care and out-of-pocket expenditures including risk of falling in debts after hospitalization.

This is important in context of taking forward the agenda of the reforms. Coming to delivery of public health services, it is important to know as who are the users? Who uses the services? We thought the subsidy, which is given by the state would ultimately go to meet the needs of poor. What is happening? The richest quintile consumes three times more public health resources as compared to poor. It is poor who are subsidizing for rich in terms of uses of public health resources in the country, richest quintile consuming three times more services, more public health services as compared to poor. We have the data in terms of OPD care, as 80%-85% going in the private sector. Same is true for indoor care. So it is largely private sector which is dominating, in utilization of services and also largely unregulated. Health needs of urban poor, marginalized groups, tribal population, fringe populations, and other disadvantaged and vulnerable communities need to be addressed.

What are the intermediate outcomes, those health system should pursue in order to achieve ultimate outcomes. There are issues in terms of efficiency, quality, and access related issues.

What do we mean by efficiency? What are the outputs, which we are producing? If we wish to provide 100% coverage for antenatal care, how we are going to produce such an output. Are we going to achieve it through the mobile services? Are we going to do it through out reach services? Are we going to engage the private providers in deliveries of antenatal care? Are we going to talk of some paramedic model or some alternate service delivery or franchising model? Thus it is important to assess technical effi ciency of our interventions. Allocative effi ciency on the other hand will help us to know what do we produce, do we need to produce 100% antenatal care or do we need to produce 100% institutional delivery if our goal is to reduce maternal mortality. So those are the questions, which health systems and health sector need to answer, in case they are going to improve the health status and bring down the mortality and mobility burden. So what is being suggested here is look into technical effi ciency of interventions and also look into allocative effi ciency i.e. where are you putting your money, Is your money in the right place? Technical efficiency, the essence of management and allocative effi ciency is linked to political economy of health. So more decisions are taken at the context of political parameters in terms of political economy and not with reference to evidence base. So that’s the kind of situation that we are still struggling whether we should train “Dais”, or we should do 100% antenatal care, promote emergency obstetric care, do institutional deliveries, engage communities in safe motherhood etc

What is quality? Again quality is most abused term in health systems There are several defi nitions, lots of frameworks, different approaches and institutional mechanisms. There are multiple players in the quality. The management systems, the insurance companies, providers, third party administrators, health management organizations, clients, community are the different stakeholders. Quality influences both health status and satisfaction. If you provide good quality services, are you looking for the good clinical outcomes, improved health status or you are also looking for the client satisfaction? It is crucial to understand quality from the providers, management, and from the client and community prospective. The clinical and service quality dimensions of quality are important to focus and there are different budgets for different quality. If you have lower level allocation, lower level of budget, there is a quality curve, you are going to miss out either in the clinical quality or you are going to miss out in service quality.

There is very limited information on QOC in health systems. Lately there are some efforts to incorporate quality monitoring in the programme designs. There have been some initiatives in the donor projects to work on the quality of care but apparently it has not gone much ahead. We are still monitoring coverage. We still monitor coverage for immunizations which is critical but we don’t know, adverse events after immunizations. Service quality issues are important again but we really don’t know how the privacy and confi dentiality are addressed in the service delivery settings?

Access is another important element that needs to be considered Access is dependent on availability of services such as physical availabilities of services i.e. availability of providers. “Ghost PHCs” and sub centres are common especially in remote districts. The women would come from all the way from a distant village to a sub center or PHC, to only fi nd out the sub centers are locked. So there is no effective availability of services. There are socio-cultural issues, gender of providers, the language, the jargon, which is used by providers, which makes it diffi cult for the poor women to access services. Economic barriers in access in terms of opportunity costs coming to a city seeking services with 2-3 relatives are also going to be quite signifi cant. Utilization, which is a marker of demand, is also related to access and there are several factors, which infl uence utilization. Are outreach visits regular and predictable? So what is happening to the access for the primary reproductive health care services to the women? What is the package of services? Are we offering a complete package of say RCH services at one point? Can poor women negotiate the use of higher level health care services ? Can she communicate to the providers in big hospitals?

Now after saying all that, what is the national context of health reforms which we should look forward? We all know that India is passing through demographic transition. There is very significant shift from high fertility and mortality to low mortality and fertility. We see there is a window of opportunity for India in terms of demographic bonus in case our adolescents are provided adequate skills and interventions are in place to promote their reproductive and sexual health. We also see the epidemiological transition taking place in country as we are still having communicable diseases, burden of malnutrition,, which have been controlled, eliminated from many other countries but we also have the lifestyle diseases the cardiovascular, the endocrinal diseases. So we have that kind of disease pattern, a double burden of disease. A responsive health system will incorporate this distinct shift. We also see the social transition-taking place. High literacy rates, the mobility is increasing, the expectations of the people of the health systems are going up. Technological transitions are also taking place. We are coming with the rapid diagnostic, auto disabled syringes, genetic engineering, IVF and emergence of non invasive technologies is also putting new demands on the health systems.

Both National health policy documents, National population policy document, and several other Government documents talk of increasing allocation for health care in future. Clearly this is very much needed. What do we mean by reforms? Reforms encompass a range of those purposeful efforts to change the system for improving its performance. This is what the reforms would mean. You should make deliberate efforts, and conscious choices so that the changes in the system would lead to the improved performance in terms of those goals. Reforms have to be rational and logical, it can’t be quick fix and knee jerk reaction. They have to rational, they have to be logical, they have to be specifi ed. Do we have limited reforms with small changes here and there and just tinkering with the system, which is again possible and many countries had all these small reforms and have been successful. Or we go with a big bang theory with a big ticket reforms and change the way you financed the health care, organize services and delegation of technology etc.

What should be the focus of reform in India. Decentralization is going to be the key element of the reform process. One size doesn’t fit all is clearly the mantra. Alternate ways of fi nancing health care should receive policy attention in a major way. Clearly there is scope of formulating demand side fi nancing mechanisms so as to provide access to poor. Private sector should be seen as a national asset and alternate service delivery systems e.g. social franchising should be considered. It is also critical to work with private sector in terms of certifi cation and accreditation systems.

D. Agarwal
UNFPA, India.
Presentation made at 31st National IAPSM Conference,
Chandigarh, on 27-29 February 2004
E-mail: [email protected]

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