Radical Journal of Health 1998 Vol. 3, No. 2, April – June
Item
- Title
- Radical Journal of Health 1998 Vol. 3, No. 2, April – June
- Date
- June 1998
- Description
-
Determinants of health: some issues
State’s response to fiscal crisis: implications for health – A Kerala study
Focus group discussions: A methodological note
National health insurance and financing: An international review - extracted text
-
April-June
1998
A SOCIALIST HEALTH REVIEW TRUST PUBLICATION
New Series VOLUME III
DETERMINANTS OF HEALTH:
SOME ISSUES
STATE’S RESPONSE TO FISCAL
CRISIS: IMPLICATIONS FOR
HEALTH - A KERALA STUDY
FOCUS GROUP DISCUSSIONS:
A METHODOLOGICAL NOTE
NATIONAL HEALTH INSURANCE AND
FINANCING: AN INTERNATIONAL REVIEW
Rs 25
Consulting Editors’.
Amar Jesani,
CEHAT, Mumbai
Binayak Sen, Raipur, MP
Dhniv Mankad,
VACHAN, Nasik
K Ekbal,
Medical College, Kottayam
Francois Sironi, Paris
Imrana Quadeer,
JNU, New Delhi
Leena Sevak,
London School of Hygiene and
Tropical Medicine, London
Manisha Gupte,
CEHAT, Pune
V R Muraleedharan,
Indian Institute of
Technology, Madras
Padmini Swaminathan,
Madras Institute of
Development Studies, Madras
Sandhya Srinivasan,
Hat vard, USA
C Sathyamala, New Delhi
Thelma Narayan,
Community Health Cell,
Bangalore
Veena Shatrugna, Hyderabad
Irudaya Rajan, CDS,
Trivandrum
The Radical Journal of Health is an
interdisciplinary social sciences
quarterly on medicine, health and
related areas published by the Socialist
Health Review Trust. It features
research contributions in the fields of
sociology, anthropology, economics,
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management, technology and other
emerging disciplines. Wcll-rescarchcd
analysis of current developments in
health care and medicine, critical
comments on topical events, debates
and policy issues will also be
published. RJH began publication as
Socialist Health Review in June 1984
and continued to be brought out until
1988. This new series of RJH begins
with the first issue of 1995.
Editor. Padma Prakash
Editorial Group’. Aditi Iyer, Asha
Vadair, Ravi Duggal, Sandeep
Khanvilkar, Sushma Jhavcri,
Sunil Nandraj, Usha Sethuraman.
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Socialist Health Review Trust.
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Volume III
New Series
Number 2
April-June 1998
Editorial: Under a Cloud Padma Prakash
Rationalising Immorality Amar Jesani
Determinants of Health: Some Issues
Mohan Rao
XI
Expenditure Trends in Government Sector
in Health. Kerala, 1977-78 to 1992-93:
State Response to Fiscal Crisis
and Its Implications for Health
V Raman Kiitty
89
National Health Insurance and Financing
Review of International Scene
K Balasitbramaniam
105
Communications
Focus Group Discussions:
A Methodological Note
Alex George
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Under a Cloud
The nuclear tests of May, in India and Pakistan, legitimise
the nuclear establishment’s sustained irresponsibility towards
the health and safety of people.
THE story of modern civilisation has been all about amassing
power; about controlling the forces of nature, devicing ways and
means of harnessing natural resources and potentials for human
progress which is synonymous with being powerful: powerful
nations, powerful classes, powerful caste, race and sex. That much
is hardly a revelletion; philosophers and political scientists have
written al length about it. It is however, important to record
another homelruth: that in its search for instruments which allow
it to capture power human civilisations and their components
have rarely thought of the consequences of such technologies.
The scientists who first found the means to release the forces of
nature, the inventor who harnessed these forces and elaborated a
technology, the entrepreneur who installed it and controlled it, and
the slate which benefited because the dominant class did so, never
has it been the norm or practice for them to inquire into the
consequences of the new developments. Such querying has
occurred only rarely, as for instance, in the development of phar
maceuticals.
Il is now well-documented lhai early atomic scientists working
in the Los Alamos secret laboratory in New Mexico in the US in the
1940s to develop the bomb did not quite comprehend the devastat
ing effect of radiation exposure. Their mandate, issued by the state
that they served, an America in the throes of war, was to develop
a mighty weapon and they didjusl that. Subsequently, with the
Atoms for Peace programme the objective was to harness the
energies released from within the uranium atom to ‘peaceful’
purposes for humankind’s porogress. Even then, the tremendous
risks involved as a consequence of this new lechlogy was hardly a
matter of concern. Even after the horror of Hiroshima was revealed
to all the realisation that exposure to low levels of readiation would
have long-term highly disruptive consequences for biological
RJH
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75
systems was slow in coming. And when radiation effect studies
began to he conducted they were inevitably, influenced by the
consideration that nuclear energy appeared to be a cheap and
efficient source of power. A high risk appeared to be acceptable
and the general consensus was to undcrplaj radiation effects and
its potential for damage among those who worked with such
technologies or those who lived close to these plants. In the
decades that followed the build-up of nuclear arms, their testing
and development look a heavy loll of human health and ecology, all
of which was long ignored. Only in the vibrant 70s did ordinary
people’s protest coalesce forcing a greater attention to such fall
out.
Not surprisingly, nuclear establishments in south Asia borne in
the throes of a modernising ethos, have enjoyed a great degree of
protection by the state. This cloak has been all the more effective
because of its connection, albeit carefully concealed, with the socalled security issues. Thus has grown one of the most irrespon
sible establishments with little public accountability.
Il is in this context lhal one must perceive the series of Indian
nuclear tests conducted in May in the desert of Pokhran, and those
by Pakistan. There can be no hesitation in condemning this move
towards the nuclearisation of the subcontinent. While it is of course
obvious lhal India had gone a long way towards developing nuclear
devices well before May, the act of testing the devices amounts to
a declaration that India does not see nuclear armament as abso
lutely. inarguably undesirable. This being the bottom line, argu
ments about the need for a dctcrrance fall flat. Ol even greater
concern here is the manner in which the department has dealt with
the people of the area before and. during and after the tests which
is symptomatic of its attitude to people’s safety in all its institu
tions and projects. Incredible as it sounds, the atomic energy
establishment has never deemed it necessary to conduct base line
health surveys al any of its power projects or other installations. In
sum this means lhal there is no way of knowing if indeed people
I
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76
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(New Series)
Vol III 2
/9(AS’
around have been affected by radioactive contamination. Studcs
which have been conducted, as the one around the thorium plant in
Kerala, arc not recognised by the establishment and have acquired
the label of ‘activists* research, which by definition is question
able. Recent protests by workers at the Jaduguda uranium mines
reveal the extent of damage that has been caused and also the
unimaginable negligence on the part of the establishment of work
ers’ health. The May explosions have legitimised this
irresponisbility on the part of the atomic energy establishment.
Thus is it is necessary to bring undercritical review the entire range
of operations of the atomic energy establishment. Protesting India’s
entry into the nuclear club is not sufficient; the question we must
raise is whether and to what extent we need to expand the civilian
nuclear empire as well.
-Padma Prakash
Rationalising Immorality
By its carefully w orded protest supporting the protest of Bihar
doctors against the government resolution banning private practice
in government, the Indian Medical Association is once gain bury ing
its head in the sand with regard to ethical issues in medical practice.
THE documentation of moral degradation of medical profession in
India would read like a horror story. While medical associations
keep blaming few black sheep within the profession for unethical
and negligent medical practice, these few sheep arc evidently too
many. We arc fed with daily stories of doctors misdemeanours: of
denial of medical care to tribal or dalil patients, of medical
bureaucrats messing up the hospital emergency rooms so well that
the crowd attack the hospital and its staff, or of doctor's collusion
with torturers, criminals and politicians. While the medical asso
ciations have certainly refused to commend such actions by indi
vidual doctors (and that is the real ray of hope), at the same lime.
as the organised medical force they have done nothing to weed out
these black sheep by initialing concrete steps within the associa
R.IH
(New Series)
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1998
77
tions or in the medical councils where they have a strong pre
sence. What is al the root of the medical immorality in our
country? An aberration, an individual straying from the ethical
norms, etc, could be taken care of easily by the vigilant profes
sional bodies. But what can be done when professional bodies arc
pre-occupied with protecting the unethical and rationalising the
immoral?
The malady afflicting medical profession is that its members
have become traders and their practice commercialised. No doctor
can survive in the present medical market unless s/he makes peace
with the unethical norms of the market which invariably marginalises
those who do not have money to purchase medical care. And their
number is not small in India, they are in fact in the majority. In
addition to these vagaries, the medical market is also without any
control and accountability. Interestingly, no developed free market
economy in the world from where the ideology of free market
comes, has a medical system which is as free as ours. The US has
the largest number of laws and regulations over the medical market
while many countries in western Europe have established stringent
control and reduced the space for the medical market. Indeed, they
do not practise what they preach through the World Bank and other
institutions. This they have done simply because they know that
universal access to health care is not possible unless the market is
brought under stringent control.
The tragedy of the professional associations in India is that they
act more like self-serving guilds rather than professional bodies
having their morality and ethics committed to people’s welfare. As
a consequence, the associations have exerted their energies to
protect vested interests of their members, refused to have account
ability and accepted private practice as the best mode of delivering
medical care.
We witnessed a typical example of such an attitude in July 1998
when much maligned Bihar government took a bold step of ban
ning private practice by the government doctors. It is hardly
necessary to amass evidence to show that private practice by
government doctors is one of the major reasons why our public
health system has declined and the poor masses find it difficult to
access the government health care. Even in Mumbai city, in big
teaching hospitals, a simple survey would bring out that many full
78
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1998
time doctors hardly attend their hospital duties for more than a few
hours. They spend rest of their lime in private practice. Indeed, this
is not confined to medical care and doctors— the college teachers
in every discipline appear to be interested in giving their best in
coaching classes than in the college lectures. Some attempts are
now being made to weed out such practices. And there is general
public support for ensuring that teachers give their best in their
bona fide jobs and not in private practice.
However, in Bihar, the medical profession has come out with a
different approach. And this is supported by the Indian Medical
Association at the national level. No less a person than the national
president and general secretary of the IMA rushed all the way to
Patna to provide support to the private practising government
doctors who where agitating against the government order to slop
private practice. Il is worth mentioning that such important and
busy IMA office bearers did not rush to Sural when their members
were abandoning the plague afflicted patients, or did not lake any
concrete steps when the press published accounts of doctors giving
false medical certificates to Chadraswamy to help him escape
incarceration in prison or when the press reported that in Tamil
Nadu doctors had provided sanctuary in hospital to politicians
facing criminal charges. But indeed, the government attack on
private practice by government doctors was a serious matter, it
affected a very large constituency of doctors in government surviv
ing on double benefit - the salary and private fees.
The IMA was careful in its pronouncement of support. Il said
that “the IMA was not opposed to ban on private practice of
government doctors”. However, the ban was ‘‘highly illogical, ill
limed and unthoughtfur because the government should have
‘‘enforced a ban after creating adequate facilities in public sector
hospitals. The health facility presently available in government
hospitals (in Bihar) was worse than the hospitals in Meghalaya”.
Thus, this attempt to be ethically correct and yet support the
unethical seems to be a hallmark of the way IMA functions. The
point is, if the IMA is opposed to the private practice by the
government doctors and is in favour of improving conditions of
public hospitals, why isn’t it agitating against the government in
the same way as it is doing against the Consumer Protection Act?
Quite simply, it is difficult to practice medicine ethically if the
RJH
(New Series)
Vol 111: 2
1998
79
tions or in the medical councils where they have a strong pre
sence. What is at the root of the medical immorality in our
country? An aberration, an individual straying from the ethical
norms, etc, could be taken care of easily by the vigilant profes
sional bodies. But what can be done when professional bodies arc
pre-occupied with protecting the unethical and rationalising the
immoral?
The malady afflicting medical profession is that its members
have become traders and their practice commercialised. No doctor
can survive in the present medical market unless s/he makes peace
with the unethical norms of the market which invariably marginalises
those who do not have money to purchase medical care. And their
number is not small in India, they are in fact in the majority. In
addition to these vagaries, the medical market is also without any
control and accountability. Interestingly, no developed free market
economy in the world from where the ideology of free market
comes, has a medical system which is as free as ours. The US has
the largest number of laws and regulations over the medical market
while many countries in western Europe have established stringent
control and reduced the space for the medical market. Indeed, they
do not practise what they preach through the World Bank and other
institutions. This they have done simply because they know that
universal access to health care is not possible unless the market is
brought under stringent control.
The tragedy of the professional associations in India is that they
act more like self-serving guilds rather than professional bodies
having their morality and ethics committed to people's welfare. As
a consequence, the associations have exerted their energies to
protect vested interests of their members, refused to have account
ability and accepted private practice as the best mode of delivering
medical care.
We witnessed a typical example of such an altitude in July 1998
when much maligned Bihar government took a bold step of ban
ning private practice by the government doctors. Il is hardly
necessary to amass evidence to show that private practice by
government doctors is one of the major reasons why our public
health system has declined and the poor masses find it difficult to
access the government health care. Even in Mumbai city, in big
teaching hospitals, a simple survey would bring out that many full
78
RJH
(New Series)
Vol 111: 2
1998
time doctors hardly attend their hospital duties for more than a few
hours. They spend rest of their lime in private practice. Indeed, this
is not confined to medical care and doctors— the college teachers
in every discipline appear to be interested in giving their best in
coaching classes than in the college lectures. Some attempts are
now being made to weed out such practices. And there is general
public support for ensuring that teachers give their best in their
bona fide jobs and not in private practice.
However, in Bihar, the medical profession has come out with a
different approach. And this is supported by the Indian Medical
Association al lhe national level. No less a person than the national
president and general secretary of lhe IMA rushed all lhe way lo
Patna lo provide support lo lhe private practising government
doctors who where agitating against the government order to slop
private practice. Il is worth mentioning that such important and
busy IMA office bearers did nol rush to Surat when their members
were abandoning the plague afflicted patients, or did not lake any
concrete steps when the press published accounts of doctors giving
false medical certificates lo Chadraswamy to help him escape
incarceration in prison or when the press reported that in Tamil
Nadu doctors had provided sanctuary in hospital to politicians
facing criminal charges. But indeed, lhe government attack on
private practice by government doctors was a serious matter, it
affected a very large constituency of doctors in government surviv
ing on double benefit - the salary and private fees.
The IMA was careful in its pronouncement of support. Il said
that “lhe IMA was nol opposed lo ban on private practice of
government doctors”. However, lhe ban was “highly illogical, ill
limed and unihoughtful” because the government should have
“enforced a ban after creating adequate facilities in public sector
hospitals. The health facility presently available in government
hospitals (in Bihar) was worse than the hospitals in Meghalaya”.
Thus, this attempt to be ethically correct and yet support the
unethical seems lo be a hallmark of the way IMA functions. The
poinl is, if lhe IMA is opposed lo the private practice by the
government doctors and is in favour of improving conditions of
public hospitals, why isn’t it agitating against the government in
the same way as il is doing against the Consumer Protection Act?
Quite simply, il is difficult to practice medicine ethically if the
RJH
(New Series)
Vol 111: 2
1998
79
ddeqnate facility is not available in rhe hospital. This single moo
impoiiant issue lor advocacy and agitation would bring more relief
in the patients (han by abandoning them and going to the market
place foi practice. Besides, isn't it unethical not to lake responsi
bility to put one’s own hospital in order and to abandon the poor
patient in the hospital waiting for the doctor's attention?
No doubt the government has responsibility and it has abdicated
it. Bui the unethical act ol one cannot he used tor rationalising
anothet ‘s immorality and lack of ethics. There is no moral basis foi
the IMA's moralising of the government unless the IMA stalls
taking the issue of morality for its own members seriously.
Besides, the larger ethical and human rights issue lacing the
profession is making health care universally accessible to people
ol this country. When we have one doctor (qualified in all systems
of medicine) lor 800 persons, the gross lack access to basic health
care for a majority of people must worry the IMA the most. The
very basis of the existence of doctors is caring for those who need
it. Il would be difficult to argue without undermining the moral
authority of the profession that the doctors exist for I heir own
commercial interest and not to care for people.
-Amar Jesani
Note to Contributors
We invite contributions to the RJH.
Original research
articles, perspectives. Held experiences, critiques of policies
and programmes in health care, medicine and allied areas are
welcome. Please send manuscripts, preferably typed in
doublespace. If the material is on a word processor please
send us a hard copy along with the matter on a diskette
preferably in WS-4 Address all communications to the editor
ai the address on the inside front cover.
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Determinants of Health: Some Issues
Mohan Rao
Current historiography of health care is dominated h\ the tra
jectories of medicine and disease, quite ignoring the social, political
and economic roots of health and ill health. This has had negative
consequences for state interventions in health care, which have
focussed entirely on devising technological answers fa problems.
THE historiography of health is frequently conflated with that of disease
and medicine. The latter history is then marked (ml in terms of milestones
for the identification of microbes, the discovery of medical technologies
and their application to human populations. Thus the word health
immediately conjures up images of doctors, medicines and the triumphant
medical conquest of germs. God is then in His heaven and all’s well with
the world. This historiography of medicine, however, seriously distorts
an understanding of health and its determinants. As a consequence, health
policy planing not only limits its vision of intervention hut also gravely
undermines the possibilities of such intervention itself.
Thomas McKeown, a medical doctor less well known than he ought
to be both among health professionals and policy makers, offered us
startling new insights into the rcmrkable advances in human longevity
and health made over the last two centuries. His revelatory findings in the
1970s, as a historian of health, have profound implications for health
policy and planning.
Surveying the decline of the death rate in England and Wales during
the registration period, he noted that significant and long-term declines
in deaths had occurred due to a decline in infectious and communicable
diseases, the quintessential diseases of poverty and hunger. More
remarkably, that medical technology had little to do with this decline of
mortality with the possible exception of small pox which was hardly a
major cause of deaths.
Tuberculosis, that while plague of diseases, offers a striking
McKcowenite example. By the time the tubercle bacillus was identified by
Koch, the giant of bacteriology in 1865, the death loll due to tuberculosis
had shown a long-term secular decline as revealed in the accompanying
figure. By the lime effective chemotherapy was discovered in the 1940s,
tuberculosis had ceased to be a major public health problem in the west.
The declines in infectious diseases were unlikely to be related to
changes in the virulence of the infectious agents over so short a period of
lime. Nor could it be attributed to salubrious changes in the environment.
which indeed had deteriorated due to industrialisation and urbanisation
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Excluding these possible causes for the decline of infectious diseases,
McKeown went on to conclude that this dramatic decline could only have
been a consequence of increased general resistance to infectious diseases
through improvements in the nutritional status of the population as a
result of wide-ranging changes in the agrarian economy.
McKeown acknowledged that the public health revolution of the
late nineteenth century played an important role in reducing exposure
to water-borne diseases such as diarrhoea, dysentery and cholera but
that these could account for, al the most, a quarter to a third of the
mortality decline. Even in the case of this group of diseases, the
underlying cause for the decline of lethality may well have been the
same, viz: increasing human resistance due to improvements in
nutrition [McKeown 1976].
McKeown's thesis has been a matter of controversy but has received
support from a number of other studies noting that a host of other
countries in the west had a similar trajectory in health as living standards
improved. Further, the period also witnessed a secular increase in heights
accompanied by a reduction in class differentials in heights, both attesting
to declines in chronic hunger.
In short then, the economic, political and social changes accompany
ing what Hobsbawn called ‘The Age of Capital’, leading to increasing
employment and food availability in the population was what underlay
the epidemiological transition. Il might not be completely amiss to note,
incidentally, that over this period there occurred a significant and sustained
increase in population, accompanied by significant and marked increases
in per capita income. This phenomenon, hardly unique to England,
completely undermined the scientific credibility of Malthusianism.
More recent and dramatic data on the impact of employment and food
security is provided by Dreze and Sen [Dreze and Sen 1993] noting the
increase in life expectancy at birth in England and Wales in the decades
of this century. They note that the most remarkable increases were in the
decades of the two world
wars with dramatic inTable 1: Longevity Expansion in England
creases in many forms of
and Wales in 20th Century
public support including
Increase in Life Expectancy Decade (years)
public employment, food
Female
Per Male
Decade
rationing and health care”.
4.1
4.0
1901-1911
When, however, we turn
6.6
6.5
1911-1921
to India or other colonised
2.4
1921-1931
2.3
countries, there is complete
1.5
1.2
1931-1940
consensus that not only is
7.0
6.5
1940-1951
over-population the cause
3.2
2.4
1951-1960
of both poverty and disease
Source: Dreze and Sen. 1993
- Malthus resurrected in a
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Figure:
6
(UOI||IUJ
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new avatar as the colonial and continuing drain of resources from these
countries is forgotten - but that the McKeown model is absolutely
irrelevant as solutions are sought in the domain of medical technology
alone. This faith in the magic bullet approach to medical technology or a
germ-cenired health history is not confined to medical professionals
alone.
Kingsley Davis in his classic The Population of India and Pakistan
perhaps set the trend to be taken up by other “dismal scientists”,
demographers. He argues that the gift of “death control technologies”
from the West was responsible for the decline of the death rate in the
country. He was referring of course to the role of DDT in the control oi
malaria. His primary argument was the essential and urgent need for birth
control technologies to control population growth. Perhaps picking up
from Davis, the Cambridge Economic History of India in its chapter on
population assumes that the post-1921 decline of the death rate was due
to measures of public health: while plague somewhat mysteriously
subsided, cholera and small pox were vanquished by public health
intervention. Indeed this understanding even colours the Marxist economic
history of Amiya Kumar Bagchi [Bagchi: 1982] who observes “the fall
in mortality... seems to have been caused by spectacular advances in
medical technology for controlling such bacterial diseases as malaria.
small pox and cholera”.
One major problem with this thesis is that of the onset of the decline
of the death rate in the country. This decline, beginnning in the twenties.
a major proportion of which was due to a decline of deaths from malaria.
preceded by at least three decades the launch of the malaria control
programme in the fifties. Further, over the same period, mortality due to
a range of diseases, for which there were no preventive measures or
specific therapies, also declined.
Zubrigg's (1992) work on hunger and epidccic mortality not only
brings fresh insights challenging received wisdom, but strengthens a
McKeowenite understanding of health history in the country providing
empirical evidence challenging both technological determinism and the
methodological individualism characteristic of the behavioural approach
to public health. While it is no doubt true that under the colonial regime.
per capita availability of food declined, what Zurbrigg's work reveals is
the critical importance of state intervention: the political exigencies
which compelled the British government to reluctantly, haltingly, initiate
steps to control epidemic hunger. While these did not reduce the pre valence
of diseases or indeed remarkably their lethality, what they did do was to
control excess deaths due to humankinds apocalyptic horsemen, hunger
and pestilence.
The specific measures which probably had a critical role to play was
the abandonment of the Malthusain policy of laisscz fa ire in favour ol
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purposive intervenlion through a changed famine code which mandated
public intervention through income support through employment
generation in times of dearth and price rise. While these steps did little to
combat chronic hunger or endemic hunger, they did succeed in leavening
the excess deaths due to acute epidemic hunger and disease that underlay
the periodic subsilence crisis of lhe period. Although ihis is a matter of
continuing conlrovcrsy, Zurbrigg's work offers the most plausible
explanation for the decline of lhe death rate. In epidemiological terms,
what changed was lhe lethality of lhe diseases in response to an altered
configuration of the epidemiological triad [Zurbrigg: 1994].
It is this factor, organised public action, which is most critical in
altering the outlay and impact of the web of factors which determine
health. Chief among these are access to resources, employment, incomes
and thus food. Equally important are other measures to offer a modicum
of security to people’s lives: conditions of work, access to water,
sanitation and health facilities. The task for health, then, is pre-eminently
social, economic and political in nature. This is not to undermine the
importance of public health intervention, but to place it in a perspective.
Among lhe major reasons propelling state intervention in health care
in the twentieth century were the following. First, al the onset of the first
world war, when Britain embrked upon conscription, it was discovered,
to horror, that almost half the potential recruits to the army had to be
rejected on grounds of poor health. It was this factor, above all, which led
to lhe establishment of the Beveridge Committee that was to draw the
blue-print for stale intervention in health care across the globe. The
members of the Beveridge Committee, chief among them lhe remarkable
couple Beatrice and Sidney Webb, were struck by lhe extraordinary
advances in health made by lhe fledgeling Soviet Union. The example of
a backward country taking giant strides towards lhe provision of basic
services to the entire population was heartening to these Fabian socialists
who believed, and believed strongly, that lhe world ought to, and could
be. bettered by purposive stale intervention even in a capitalistic economy.
Secondly, lhe lessons learned from lhe Great Depression, as the western
nations converted by lhe Keynesian revolution attempted to resurrect
their shattered economies through state intervention towards generating
demand in the economy. Among lhe areas it was fell that the stale could
do so. without impinging on the rights to private property and profits, was
in health care. Indeed it was fell that capitalist countries would benefit
both through higher productivity and the muting of working class
struggles by the provision of universal health care by the state. A final
factor was the realisition, even among neo-classical economists, that the
health sector bore certain unique characteristics: one wherein the laws of
lhe market more often led to market failure than otherwise. Health was a
public good wherein demand and supply could not be regulated by the
RJH
(New Series)
Vol 111: 2
1998
85
new avatar as the colonial and continuing drain of resources from these
countries is forgotten - but that the McKeown model is absolutely
irrelevant as solutions are sought in the domain of medical technology
alone. This faith in the magic bullet approach to medical technology or a
germ-centred health history is not confined to medical professionals
alone.
Kingsley Davis in his classic The Population of India and Pakistan
perhaps set the trend to be taken up by other “dismal scientists”.
demographers. He argues that the gift of “death control technologies’
from the West was responsible for the decline of the death rate in the
country. He was referring of course to the role of DDT in the control ol
malaria. His primary argument was the essential and urgent need for birth
control technologies to control population growth. Perhaps picking up
from Davis, the Cambridge Economic History' of India in its chapter on
population assumes that the post-1921 decline of the death rate was due
to measures of public health: while plague somewhat mysteriously
subsided, cholera and small pox were vanquished by public health
intervention. Indeed this understanding even colours the Marxist economic
history of Amiya Kumar Bagchi [Bagchi: 1982) who observes “the fall
in mortality... seems to have been caused by spectacular advances in
medical technology for controlling such bacterial diseases as malaria.
small pox and cholera”.
One major problem with this thesis is that of the onset of the decline
of the death rate in the country. This decline, beginnning in the twenties.
a major proportion of which was due to a decline of deaths from malaria.
preceded by at least three decades the launch of the malaria control
programme in the fifties. Further, over the same period, mortality due to
a range of diseases, for which there were no preventive measures or
specific therapies, also declined.
Zubrigg’s (1992) work on hunger and epidceic mortality not only
brings fresh insights challenging received wisdom, but strengthens a
McKeowenite understanding of health history in the country providing
empirical evidence challenging both technological determinism and the
methodological individualism characteristic of the behavioural approach
to public health. While it is no doubt true that under the colonial regime.
per capita availability of food declined, what Zurbrigg’s work reveals is
the critical importance of slate intervention: the political exigencies
which compelled the British government to reluctantly, haltingly, initiate
steps to control epidemic hunger. While these did not reduce the prevalence
of diseases or indeed remarkably their lethality, what they did do was to
control excess deaths due to humankinds apocalyptic horsemen, hunger
and pestilence.
The specific measures which probably had a critical role to play was
the abandonment of the Malthusain policy of laisscz faire in favour ol
84
RJH
(New Series)
Vol 1U:2
/91a\
purposive intervention through a changed famine code which mandated
public intervention through income support through employment
generation in times of dearth and price rise. While these steps did little to
combat chronic hunger or endemic hunger, they did succeed in leavening
the excess deaths due to acute epidemic hunger and disease that underlay
the periodic subsilence crisis of the period. Although this is a matter of
continuing controversy, Zurbrigg's work offers the most plausible
explanation for the decline of the death rale. In epidemiological terms,
what changed was the lethality of the diseases in response to an altered
configuration of the epidemiological triad [Zurbrigg: 1994).
It is this factor, organised public action, which is most critical in
altering the outlay and impact of the web of factors which determine
health. Chief among these are access to resources, employment, incomes
and thus food. Equally important are other measures to offer a modicum
of security to people’s lives: conditions of work, access to water,
sanitation and health facilities. The task for health, then, is pre-eminently
social, economic and political in nature. This is not to undermine the
importance of public health intervention, but to place it in a perspective.
Among the major reasons propelling state intervention in health care
in the twentieth century were the following. First, at the onset of the first
world war, when Britain embrked upon conscription, it was discovered,
to horror, that almost half the potential recruits to the army had to be
rejected on grounds of poor health. Il was this factor, above all, which led
to the establishment of the Beveridge Committee that was to draw the
blue-print for stale intervention in health care across the globe. The
members of the Beveridge Committee, chief among them the remarkable
couple Beatrice and Sidney Webb, were struck by the extraordinary
advances in health made by the fledgeling Soviet Union. The example of
a backward country taking giant strides towards the provision of basic
services to the entire population was heartening to these Fabian socialists
who believed, and believed strongly, that the world ought to, and could
be. bettered by purposive stale intervention even in a capitalistic economy.
Secondly, the lessons learned from the Great Depression, as the western
nations converted by the Keynesian revolution attempted to resurrect
their shattered economies through state intervention towards generating
demand in the economy. Among the areas it was fell that the state could
do so. without impinging on the rights to private properly and profits, was
in health care. Indeed it was fell that capitalist countries would benefit
both through higher productivity and the muting of working class
struggles by the provision of universal health care by the slate. A final
factor was the realisition, even among neo-classical economists, that the
health sector bore certain unique characteristics: one wherein the laws of
the market more often led to market failure than otherwise. Health was a
public good wherein demand and supply could not be regulated by the
RJH
(New Series)
Vol ill: 2
1998
85
new avatar as the colonial and continuing drain of resources from these
countries is forgotten - but that the McKeown model is absolutely
irrelevant as solutions are sought in the domain of medical technology
alone. This faith in the magic bullet approach to medical technology or a
germ-centred health history' is not confined to medical professionals
alone.
Kingsley Davis in his classic The Population of India and Pakistan
perhaps set the trend to be taken up by other “dismal scientists’’,
demographers. He argues that the gift of “death control technologies”
from the West was responsible for the decline of the death rate in the
country. He was referring of course to the role of DDT in the control of
malaria. His primary argument was the essential and urgent need for birth
control technologies to control population growth. Perhaps picking up
from Davis, the Cambridge Economic History' of India in its chapter on
population assumes that the post-1921 decline of the death rale was due
to measures of public health: while plague somewhat mysteriously
subsided, cholera and small pox were vanquished by public health
intervention. Indeed this understanding even colours the Marxist economic
history of Amiya Kumar Bagchi [Bagchi: 1982] who observes “the fall
in mortality... seems to have been caused by spectacular advances in
medical technology for controlling such bacterial diseases as malaria.
small pox and cholera”.
One major problem with this thesis is that of the onset of the decline
of the death rate in the country. This decline, beginnning in the twenties.
a major proportion of which was due to a decline of deaths from malaria.
preceded by al least three decades the launch of the malaria control
programme in the fifties. Further, over the same period, mortality due io
a range of diseases, for which there were no preventive measures or
specific therapies, also declined.
Zubrigg’s (1992) work on hunger and epidccic mortality not only
brings fresh insights challenging received wisdom, but strengthens a
McKeowenite understanding of health history in the country providing
empirical evidence challenging both technological determinism and the
methodological individualism characteristic of the behavioural approach
to public health. While it is no doubt true that under the colonial regime.
per capita availability of food declined, what Zurbrigg’s work reveals is
the critical importance of state intervention: the political exigencies
which compelled the British government to reluctantly, haltingly, initiate
steps to control epidemic hunger. While these did not reduce the prevalence
of diseases or indeed remarkably their lethality, what they did do was to
control excess deaths due to humankinds apocalyptic horsemen, hunger
and pestilence.
The specific measures which probably had a critical role to play was
the abandonment of the Malthusain policy of laissez faire in favour of
84
RJH
(New Series)
Vol Hl: 2
/9‘aS
purposive intervention through a changed famine code which mandated
public intervention through income support through employment
generation in times of dearth and price rise. While these steps did little to
combat chronic hunger or endemic hunger, they did succeed in leavening
the excess deaths due to acute epidemic hunger and disease that underlay
the periodic subsitcnce crisis of the period. Although this is a matter of
continuing controversy, Zurbrigg’s work offers the most plausible
explanation for the decline of the death rate. In epidemiological terms,
what changed was the lethality of the diseases in response to an altered
configuration of the epidemiological triad [Zurbrigg: 1994],
It is this factor, organised public action, which is most critical in
altering the outlay and impact of the web of factors which determine
health. Chief among these are access to resources, employment, incomes
and thus food. Equally important are other measures to offer a modicum
of security to people’s lives: conditions of work, access to water,
sanitation and health facilities. The task for health, then, is pre-eminently
social, economic and political in nature. This is not to undermine the
importance of public health intervention, but to place it in a perspective.
Among the major reasons propelling state intervention in health care
in the twentieth century were the following. First, at the onset of the first
world war, when Britain embrked upon conscription, it was discovered,
to horror, that almost half the potential recruits to the army had to be
rejected on grounds of poor health. It was this factor, above all, which led
to the establishment of the Beveridge Committee that was to draw the
blue-print for stale intervention in health care across the globe. The
members of the Beveridge Committee, chief among them the remarkable
couple Beatrice and Sidney Webb, were struck by the extraordinary
advances in health made by the fledgeling Soviet Union. The example of
a backward country taking giant strides towards the provision of basic
services to the entire population was heartening to the^e Fabian socialists
who believed, and believed strongly, that the world ought to, and could
be. bettered by purposive state intervention even in a capitalistic economy.
Secondly, the lessons learned from the Great Depression, as the western
nations converted by the Keynesian revolution attempted to resurrect
their shattered economies through state intervention towards generating
demand in the economy. Among the areas it was felt that the state could
do so. without impinging on the rights to private properly and profits, was
in health care. Indeed it was felt that capitalist countries would benefit
both through higher productivity and the muting of working class
struggles by the provision of universal health care by the slate. A Final
factor was the realisilion, even among neo-classical economists, that the
health sector bore certain unique characteristics: one wherein the laws of
the market more often led to market failure than otherwise. Health was a
public good wherein demand and supply could not be regulated by the
RJH
(New Series)
Vo! Ill: 2
1998
85
invisible hand of the market mediating between the anonymous buyer and
seller.
All these lessons were not lost on the post-colonial nations as they
rushed to their trysts with destiny. India’s commitment to health sectoi
development was guided by two over-riding principles: first, the provision
of health care services was the responsibility of the state and second, that
comprehensive health care should be available to the entire population
irrespective of their ability to pay. The model for the development of
health services that was outlined by the Bhore Committee emphasised
preventive services, focusing on rural areas and linking health with
overall development.
Despite a policy commitment to primary health care, India witnessed
the birth of a series of vertical programmes such as those for the control
of small pox, cholera, malaria and what was soon to be seen as a major
disease, population growth. These programmes had certain singular
characteristics: planning these programmes had not always been influenced
by epidemiological considerations. They had often been initiated without
an understanding of the nature of diseases, their distribution, their
underlying causes and interlinkages, their behaviour over time, and
indeed, often even their quantum. Thier launch had been guided not so
much by epidemiological prioirities as by technological determinism.
often inspired by western aid agencies and experts.
It is not surprising therefore that these programmes not only failed to
meet their goals but deprived the development of general health services.
Widespread international disillusionment with vertical programmes, the
recognition of the need to provide sufficient coverage to rural populations
and the faltering integration of preventive and promotive programmes
together contributed to the WHO-UNICEF initiative towards the
declaration of the goal of Health For All through Primaray Health Care
at Alma Ata in 1978 Indeed at this point, the WHO saw a “major crisis
on the point of developing" in both the developed and the developing
world as a result of the “wide and deep sealed error in the way health
services are provided” [Newell: 1978]. This coincided with the growing
awareness among international agencies of the failure of the family
planning apporoach to the problem of poverty even as they accepted
the need for intergrated programmes of public health along with the
satisfaction of the minimum needs of the population in order to meet
demographic goals. Indeed there was such a sense of hope and optimism
accompanying those rallying for HFA that here was talk of a new
international economic order to arrest the continuing drain of resources
from developing countries.
This sense of optimism was however to prove short-lived. For this was
precisely the period when, for a complex number of reasons, the long
boom of the post-war golden age of capitalism ground to a profound
86
RJH
(New Series)
Vol Hl: 2
1998
crisis. This period was also marked by the rise of right-wing monetarist
regimes in the US and UK along with the domination of the belief in the
mantras of what Hobsbawn (1994) describes as “ultra-liberal economic
theologians” whereby “the idological zeal of the old champions of
individualism was now reinforced by the apparent failure of conventional
economic policies’’. As the Keynesian world increasingly came under
attack, that of actually existing socialism turned upside down and burst
asunder.
The rallying cry that echoed across borders was no longer liberty
equality and fraternity but globalisation, marketisation and privatisation.
As the importance of agencies like the WHO shrank in this new global
environment, that of the World Bank came to increasingly set the agenda
for health.
Third world countries, burdened with debt, were prescribed a package
of macro-economic reforms under the rubric of structural adjustment
programmes. These reforms advocating the remorseless “cut-back” of
state intervention in social sectors, along with the rolling back of the state,
led to increasing economic differentials between the developed and
developing countries and within these countries. The health conse
quences of these programmes, described often as a neo-colonial on
slaught, were soon to become apparent in the countries of Africa and
Latin America where the World Bank-IMF inaugurated the programme
of reforms. They saw an alarming reversal in the post-war improvements
in many health indices leading UNICEF to call for for “adjustment with
a human face”.
As the prospects of Health For All through PHC recede, we see again
the dominance of the magic bullet approach to public health technology
accompanying what Renaud (1978) describes as eliminating society
from disease whereby disease occurrence is ascribed to individual
proclivities and failures As we witness increasing privatisation of health
care along with cuts in stale spending on health, we see the reversal to
technologically driven vertical programmes. Accompanying these have
been declines in public employment and food security, among the basic
prerequisites for health. Thus while a holistic vision of public health was
eclipsed, the chicken of technological determinism and methodological
individualism came home to roost with a vengeance.
Il is increasingly becoming clear that morbidity and mortality levels
are determined not by levels of per capita income alone but by economic
equality. As in the stale of Kerala, those countries where wealth is
distributed least inequitably reveal the lowest premature mortality. It is
equally being realised that we live a country of profound economic
inequalities which tell remarkably on health indices. Indeed (here is
evidence that under what has been described as the neo-colonial on
slaught of structural adjustment programmes, inequalities in income
RJH
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1998
87
distribution and in the other determinants of health are increasing.
reversing secular trends in this regard. These signs do not augur well for
the development of health and human potential in all societies.
References
Bagchi, A K (1982): The Political Economy of Underdevelopment, OUP.
Dreze, Jean and Amartya, Sen (1993): Hunger and Public Action, OUP.
Hobsbawm. E J (1994): Age of Extremes, Viking.
McKeown, Thomas (1976): The Modern Rise of Population, Edwin Arnorld.
Newell, K W (1978): ‘Selective Primary Health Care: The Counter Revolution'.
Social Science and Medicine, Vol 26, No 3.
Raynaud, M (1975): ‘On the Structural Constraints to State Intervention in
Health’, International Journal of Health Services, Vol 5, NO 4.
Zurbrigg, Sheila (1992): ‘Hunger and Epidemic Malaria in Punjab, 1869-1940 .
Economic and Political Weekly. Vol XXVII, No 4.
Zurbrigg, Sheila (1994): ‘The Hungry Rarely Write History and Historians are
Rarely Hungry: Reclaiming Hunger in the History of Health’, Department ol
History, Dalhousie University.
Mohan Rao
Chairperson
School of Public Health and
Community Medicine
JNU, New Delhi
NOTICE TO SUBSCRIBERS
Due to certain circumstances, we have not been
able to bring out any issues for 1997. All subscription
for 1997 will however be honoured for 1998. Multiple
year subscriptions will accountfor loss of 1997 issues
and will be extended accordingly.
We sincerely regret the inconvenience caused
and ask you to continue to extend your cooperation.
For further clarificationplease write to the editorial
address.
-Editors
88
RJH
(New Series)
Vol 111:2
1998
Expenditure Trends in Government
Sector in Health, Kerala,
1977-78 to 1992-93
Implications for Health System of State’s
Response to Fiscal Crisis
V Raman Kutty
This paper analyses the expenditure on health by the government
in Kerala state India from 1977-78 to 1992-93 during which time
the state experienced a steady worsening of the fiscal situation.
Kerala has consistently registered better health indicators than other
states in India and most other developing regions of the world
partly as a result ofprevious policies ofhigh levels ofpublic investment
in health and education. Some analysts have suggested that fiscal
position of the government currently is such that if may not be
possible to continue this policy. The article focusses on (i) what
part government spending in health has played in the development
of the current fiscal situation (ii) what are the adjustments made
as a reaction to the difficulties and(Hi) what are the policy implications
from these. Government spending on health as a proportion of the
total government spending, continued to be more or less constant
during the period of growing fiscal deficits in the state budget.
Though total spending in health was unaffected, detailed analysis
shows that revenue expenditure grew at the expense of capital which
suffered cut-backs hi revenue expenditure salaries grew faster than
supplies which showed no growth or declined. The secondary sector
consisting of most rural hospitals was the worst affected by the
cut-back in supplies resulting in poor quality ofservice to the majority
of the population, it has been argued that quality' of services in
the government health system can be upgraded with greater resource
mobilisation coupled with reorganisation ofservices However, contrary'
to current thinking in international health policy circles, user charges
may not be the best option for this, as they may have serious negative
implications in terms of equity. We may have to consider options
that require a more participatory' approach in health.
THE study of health sector expenditure by the government and its trends
over time constitute an important tool in health policy analysis. Analysis
of sources of finance a id the bodies controlling the spending is an
essential element in the planning and implementation of health policy[ 1 ].
RIH
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1998
89
It helps to focus attention on resource flows in the health sector and often
unmasks hidden inequities. It can also bring to light the response of the
health system to external influences which curtail the availability of
funds.
Although Kerala is only one of the smaller stales in India it has right I \
been in the limelight in the matter of health, because of the better health
status of its people in comparison to other third world countries and othci
states in India. Table 1 reviews the major health status indicators in the
state in comparison with the all-India figures. Il is generally agreed that
the health services of the state government have had an important role to
play in this achievement [2]. But of late, the importance of the governmeni
sector in health care in the stale has waned greatly. A very relevant
question is whether inadequate financing of health sector by governmeni
has been al least partly responsible for this trend.
Kerala’s lead in social development through public investment in
education and health has the question has been raised whether the state
can sustain such levels of public spending in the social sector[ 3], thus
challenging the relevance of its development experience. The 1980s have
been difficult times economically for most developing countries, and
India has been no exception. During this time the governmeni of India
accepted the position that government spending needs to be reduced if
budgetary deficits are to be contained. According to one analyst, expen
diture compression’, or cut backs in spending by the central Indian
government, and as part of it, contraction in money transfers to stales,
started some years before the government of India officially proclaimed
a policy of curtailment of governmeni spending [4]. Since part of the
health programmes of the stales are financed by central government
funding, this has affected the states’ expenditure in health. Kerala, as one
of the slates in the Indian union has been subject to this tightening of
expenditure controls by the central government. It is important to see
what effect this fiscal crisis has had on the social sector spending,
including health.
The last two decades have been a lime of increasing fiscal difficulty for
the state in other ways also. These fiscal problems have not arisen
completely independent of the national and international economic
climate. This period coincided with the global economic recession of the
eighties, which affected third world economies very badly. International
agencies dominated by the western industrialised nations have been
actively advocating structural adjustment programmes’ (SAP) as a
remedial measure. In essence these consist of drastic reduction of govern
ment expenditure in all sectors including social sectors and allowing the
market forces a free reign in many of these areas. In health this would
mean introduction of user charges for services. Kerala, as one of the slates
in the Indian union is not directly subject to pressures by international
90
RJH
(New Series)
Vol III: 2' 1998
bodies in policy formulation. Nevertheless, their very strong indirect
influence in the form of control of funding for specific health projects and
lobbying of administrators has resulted in a strong policy environment
favouring structural adjustment. This paper attempts to look at the
government allocations for the health sector during this crucial period of
the stale’s development. Il is to be emphasised here that I have only
examined the slate expenditures in health, this does not give us a true
picture of the health expenditure trends, which would include the house
hold and private spending on health during the period. Nevertheless, since
the government is a leading player in deciding the direction of health
policy, this becomes important.
The specific objectives of this exercise has been, to seek answers to the
following questions.
(1) To what extent and how has the fiscal difficulties of the Kerala slate
government involved the health sector, during the period 1977-78 to
1992-93? (2) What are the adjustment in expenditure in the government
health sector as a reaction to this situation? (3) What are the policy
implications from these?
Every year the government publishes the detailed break-up of the
government budget, which gives (i) the estimated expenditure under
different heads in the coming fiscal year, (ii) revised estimates of
expenditure under various heads in the current year, and (iii) final
statement about expenditure under various heads in the immediate past
fiscal year. The analysis is based on item (iii), or final statements of
government expenditures. The period from I 977-78 to I 992-93 saw an
initial growth in the health sector expenditure followed by a trend towards
cutbacks To smoolhen out the trends over time, the 3-year moving
averages were calculated. The fiscal year in India runs from 1 April to 3
March. Whenever appropriate, the figures in current rupees were deflated
using the Wholesale Price Index (WPI) to retain the comparability over
lime. The WPI was based on the year 1981-82, which meant that all
figures were converted into 1981-82 rupees.
Budget statements in Kerala, like in other Indian states, divide the
expenditure into revenue accounts and capital accounts. Capital accounts
mainly list the expenditure on buildings and structures, which are onetime investments. Expenditure on machinery, though conventionally
considered capital, is not included under the capital accounts. Revenue
accounts include all recurrent expenditures such as salaries, wages.
expenditure on consumable items, maintenance, as well as on machinery
and equipment Revenue expenditure on health was examined (a) category
wise, i.e., the proportions spent on salaries /wages, and supplies, the two
most important categories of spending, and (b) sector-wise, ie, divided
into primary, secondary, and tertiary sectors. Primary health centres.
family welfare, preventive and promotive programmes, and the national
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disease control programmes were considered as constituting the primary
care sector, the teaching institutions and the hospitals affiliated to them
as the tertiary sector, and by default, all institutions of intermediate size
not falling into these two categories as the secondary sector Thus the
secondary sector consisted of the community health centres, taluk (sub
unit of district) hospitals, and district hospitals
Trends of Expenditure
Figure I shows the trend of expenditure on health by the government
in the period under discussion as a proportion of total government
expenditure. Spending on health varies between 4-79 per cent Table 2
shows total expenditure by government under the revenue (recurrent)
account, total revenue receipts, state domestic product, and surplus 01
deficit of receipts over expenditure under the revenue account for various
years covering the period under review. From Table 2 we see that money
received by the government failed to keep pace with the spending, leaving
an ever increasing deficit in the revenue account. The growing revenue
expenditure is constituted by two main components: development expen
diture and non-development expenditure. Development expenditure
traditionally comprises the total of government spending on such items as
health, education, animal husbandry, agriculture development, housing.
and the like. Non-development expenditure comprises of money spent on
repayment of debts, interest payments and such. Table 3, shows the
figures under these various heads from 1985-86 to 1992-93.
Figure 2 shows 3-year moving averages of capital and revenue
expenditure on health by in government after adjustment to 1981-82
rupees. The steady growth of revenue expenditure in health throughout
the 1980s is evident, whereas capital expenditure shows a tendency to
drop after the mid-1980s. Figure 3 shows that salaries display a sharp and
upward trend from the mid-eighties onwards, which has been somewhat
curbed starting the beginning of the nineties. But it does not show any
tendency to drop down as yet, whereas the curve for supplies shows that
Table 1: Crude Birth Rate, Crude Death Rate and Infant Mortality rate
(IMR), India and Kerala, 1993
Indicator
India
Kerala
Crude Birth Rate (per 1000 population)
Crude Death Rate (per 1000 population)
Infant Mortality Rate (per 1000 live births)
28.5
9.2
74
17.3
13
Source: Office of the Registrar General. India (Vital Statistics Division). Ministry
of Home Affairs. New Delhi Sample Registration System- Selected
Demographic Indicators 993 (mimeo).
92
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it has followed a much slower rate of increase in the 1980s, followed by
cut backs beginning the late 1980s. Figure 4 shows the break up of the
expenditure on supplies in the primary, secondary, and tertiary sectors.
Primary sector shows an almost flat curve, registering not much growth
nor contraction Secondary sector, which is by far the largest of the three
and consisting of district and taluk level hospitals shows a steady upward
trend during the eighties followed by a sharp fall from the start of the
nineties. Tertiary sector shows a milder increase all through the eighties,
with a tendency to flatten in the recent years.
The question of the existence and nature of fiscal crisis in this state are
put to detailed analysis in an in-depth study brought out recently[3]. The
Table2: Trend in Overall Position of State Budget(Revenue Account)
(Rs Millions)
Year
Revenue
Receipts
iture
(1)
(2)
1980-81
6403.8
1985-86 13714.7
1986-87 150025.3
1988-89 18970.6
1989-90 20476.4
1990-91 24929.8
Revenue
Expend(S/D)
(-)
(3)
Surplus/
State SID as Percent SID as
Deficit Domestic of Revenue of SDP
Product Received
(SDP)
(4)
(5)
(6)
(7)
6676 1
14443.4
16547.7
20610.0
22680.9
28249.5
-272.3
-741.7
-1522.4
-16394
-2504.5
-4220.2
38227.3
40863.6
39929.7
45841.0
48923.6
52693.7
4.25
5.41
10.43
8.64
12.23
16.93
0.71
1.81
3.81
3.58
5.12
8.01
Source: (i) Government of Kerala. Kerala Budget in Brief 1993-94 (ii) Govern
ment of Kerala. Economic Review 1993.
Table 3: Total Revenue Expenditure, Expenditure under Medical and Public
Health Accounts and Proportions, 1985-86 to 1992-93
1
Year
1985-86
1986-87
1987-88
1988-89
1989-90
1990-91
1991-92
1992-93
Ii
Total
Revenue
Expenditure
(Rs millions)
III
Medical
and Public
Health
(Rs millions)
111 as Per cent
of II
III
as Per Cent of
Development
Expenditure
by the State
14453.4
16547.7
17806.5
20610.0
22930.9
28249.5
32164.6
38512.5
1205.5
1437.5
1665.3
2142.0
2395.6
2785.0
2920.0
3379.8
8.34
8.69
9.35
10.39
10.45
9.86
908
8.78
11.63
12.89
14.32
15.76
16.40
15.45
14.83
13.76
Source: Government of Kerala. Kerala Budget in Brief 1993-94.
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Fiscal Year
Figure I: Percentage Share of Health Sector in T otal Government E xpenditure and Revenue Expenditure by
Government, 1977-78 to 992-93
Percentage share
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Fiscal Year
Figure 2: T otal Government Expenditure on Health under C apital and Revenue, 1977-78 to 1992-93
(Three-year Moving Averages)
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Fiscal Year
Figure 3: Expenditure by Government on Salaries and W ages (Salaries) and Supplies in Health Sector. 1977-78 to 1992-93
(Thrce-year moving averages)
Millions of Rupees
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main points highlighted in this study are (i) though budgetary deficit has
become a common feature for all states in India, the magnitude of (he
deficit in Kerala has been steadily growing and substantively higher than
the all-states average (ii) Unlike in other states, the deficit here has its
genesis in the revenue account. This means that the recurrent expenditure
by the state has been growing at a greater rate than the total spending. The
gap between government receipts of money or revenue, and expenditure
has been steadily widening This mounting and recurring revenue deficit
has been financed by drawing on capital receipts, or funds meant for
capital expansion.
Spending on health as a proportion of total revenue expenditure remained
steady all through this period of expansion, whereas as a proportion of total
development expenditure it actually showed an increase (Table 3). In fact
health forms, after education, the second most important head of revenue
expenditure for the state government. As such, the health sector expense has
been a major component of the mounting revenue spending. Capital
expenditure on health has been cut back probably as an attempt to contain the
growing fiscal deficit, even by the mid eighties (Figure 2). Il is reasonable to
conclude that the adjustment in health expenditure first affected capital and
only rather late, after 1990, was the revenue expenditure affected.. Total
revenue spending on health has continued growing, at least till the beginning
of the 1990’s. This is because of two reasons: (a) Having built up the health
infrastructure, the government found it difficult to close down facilities for
fear of public reprisal. Thus the momentum of spending could not be
contained, (b) There was an increasing demand for more services, which the
government tried to provide within the existing physical infrastructure by
recruiting more personnel.
The curve showing the growth of expenditure on salaries is remarkably
parallel to the curve for total revenue expenditure on health, thus confirming
that rising salary expense has been a main contributor to growth in revenue
spending in health (Figure 3). Increase in salaries comprises of two elemenls(a) increase in value of salaries and wages over the years, and (b) increase in
number of employees. Both these have probably contributed to the observed
trend. The high level of political consciousness in the slate, strong unions, and
precariously balanced governments all create a political environment in
which curtailment of salary expense is not easv. On the other hand, the curve
for supplies shows a much gentler upward slope all throughout the 1980s.
indicating a moderate degree of increase. By the beginning of the nineties.
this curve already shows a tendency to drop down, whereas the curve for
salaries continues to go up and only shows a mild tendency to flatten towards
the end of the period under review. Successive governments, faced with the
necessity of controlling revenue expenditure but denied the choice of even
trying to check the growth of salaries, was left with no option but to reduce
spending on supplies. Figure 4 shows that supplies in the primary sector were
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largely unaffected because a good proportion of these is constituted by
vaccines, oral rehydralion salts and such whose supply is supported by
international agencies and the central government. A good number of
programmes for disease prevention and the Family Welfare Programme.
which are all supported by the central government, also come under the
primary sector, possibly because of this, supplies in the primary sector have
been unaffected by the crisis in the state government’s finances. A similar
picture, where the primary sector was unaffected and in fact continued to
grow at a greater rate than the overall growth of the health sector in the 1980s,
has been reported from Andhra Pradesh[5].
The medical colleges and other large hospitals which form the tertiary
sector have also been comparatively spared from the worst effects of the
adjustment. Possible reasons are the greater amount of public attention
they receive, their urban location, and their perceived strategic importance
in the medical care set-up in the state. The brunt of the adjustment,
therefore, has been borne by the secondary sector. This sector comprises
of the large number of smaller hospitals which cater mostly to the vast
rural population in the state.
Reviewing the whole picture, we see that fiscal adjustment, in the form
of expenditure compression, has affected capita) earlier and in greater
degree than revenue expenditure. Moreover, in revenue expenditure,
supplies have been affected much more than salaries; supplies to the
secondary sector have been affected more acutely than those to the
primary or tertiary sectors. What this means in real terms is that expansion
of facilities and provision of good quality care has suffered; and this
affected selectively the secondary sector to the greatest extent. Since the
secondary sector caters to the curative care needs of a large section of the
population, this has in effect meant erosion of the standards of health care
in the public sector.
Fiscal problems of the government affecting the health sector has been
a recurring theme in developing countries. Lowenson[6] comments on
the adverse health conscquenes of ‘structural adjustment policies’ (SAP)
which have been introduced in sub-Saharan Africa. In the case of Kerala,
though SAP may not be directly responsible for the crisis situation, the
state’s finances have not been unaffected by the national and international
economic trends.
Policy Implica tions
As we have seen, one has to seriously look al option (i), i e, enhancing
health sector’s share of total government spending. Government spending
on health as a share of total government revenue expenditure in Kerala.
al around 8 per cent, can not be said to be loo high. In industrialised
countries, it is often a higher percentage of total government expenditure
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in the US, il was reportedly around 20 per cent of the government
expenditure by the states in 1991 [7) There is a definite case for
increasing the public spending on health in the state, contrary to the
popular notion that the state already spends loo much on health.
At present the lion’s share of spending on health comes from the stale’s
own revenues. There is a case for further flow of funds from the central
government to the state in the health sector. Performance indicators for
most of the centrally sponsored health schemes in Kerala such as the
family welfare programme and universal immunisation are much better
compared to other states. Paradoxically, this often results in proposals for
cutting back on allocations to the state for health programmes, on the
grounds that since the stale is already a high performer in health, il does
not need more central funds. However, actually there is a case for an even
greater share of central resources being allocated to the state for its health
programmes, to sustain its comparatively high level of achievement. To
make maximally effective use of this, the stale should be free to deploy
these in areas where returns would be greatest.
Option (ii), viz, enhancing revenue collection in general, is one which.
however justifiable, is socially and politically unpalatable and will meet
with wide resistance: nevertheless, its feasibility should be explored. For
similar political and social reasons, eliminating redundant posts may als<
not be an acceptable option immediately in a stale where unemployment
runs high. However, the stale has to evolve a long-term human power
policy in health to make sure that available skilled personnel are pul to
greatest use.
Option (iv), ie, raising finances within the health sector, should be
examined in the context of the proposed decentralisation of government,
confering more administrative power and financial resources to the local
bodies. The interim report of the Resources Commission in the slate, a
body appointed by government to look into ways of improving (he
financial position of the government, recommended levying user charges
for outpatient services, and introduction ofdifferential charges depending
upon the income of the patient[ 8]. One can see here the influence of the
policy environment created by the structural adjustment programmes.
Many developing countries have experimented with the introduction of
user charges in the health facilities, even in primary health centres. Not
only has this met with great opposition from the public, this has also
proved to be disastrous in areas like sub-Saharan Africa User charges,
though perhaps simple to operate, have some built in problems in a
developing community, (i) Sick people arc already at a disadvantage
economically because of their sickness. To be obliged to pay for hospital
services to get well puts an additional burden on them, which is contrary
to the principles of equity, (ii) Charging uniformly for similar services
puls differential burden on different classes of people. What may be an
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insignificant amount to the richer households, may be a considerable
c ncumbrance for a poor household. This introduces an additional clement
of inequity: the poor are asked to pay a relatively greater price for getting
well. If to (ide over this problem, wc introduce differential charges, then
ihe additional administrative cost of categorising people may make the
whole exercise counterproductive.
But user charges are not the sole means of Improving the financial
status of the health sector. Other policy options need to be examined with
a view to their suitability in the Kerala context:
a) Community financing: In a well defined community such as a
punchayat, a specific amount per household can be collected as decided
by the panchayat, the poorer households being exempted; this amount can
be set apart specifically for running of the local level health institutions
such as the primary health centre. There are two pre-conditions which
have to be met for the success of this policy: (i) the local level health
institution should be brought under the control of the local administration
such as the panchayat. and (ii) the services which will be available at the
local level have to be clearly spell out. with a good referral system being
instituted The amount collected locally as health tax can be specifically
used for augmenting the facilities of the health centre including its drug
supply, since the government is already paying the salaries of the staff A
considerable amount of improvement in the conditions of care can be
brought about this way, without collecting charges from the users at the
facility. Here the emphasis should be on local control of the facility and
not merely on the collection of taxes. The state Resources Commission
also favours entrusting management of the health facilities in the rural
sector to local level bodies such as panchayats [8]. Recently the state
government and the state planning board look initiatives to set apart
400<0 of the funds for schemes in the Ninth Five Year Plan in the state
starling 1997. for allocation by the panchayats themselves. This amount
can be augmented by such health related household level resource
mobilisation.
In the matter of raising additional revenue for the health facilities,
prepayment is more equitable because those who have the misfortune to
fall ill arc not penalised by the system. Since nobody can discount the
small risk of falling sick, and since every family knows that all families
in the village are paying, there would be very little resentment against
this. As it is a designated tax and it is administered by the panchayat
there can be greater accountability and public participation In fact, the
panchayat can be required to publish the annual revenues and expendi
tures for the local health system, which can be scrutinised by the public.
A system of progressive taxation with families of greater income paying
progressively greater taxes would ensure that no family is excessively
burdened.
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b) Health insurance: Health insurance is another potential resource
base which is much favoured in the international health policy circles
currently. However, for health insurance to be successful, total coverage
is a must. The problems of copying the western model of private
insurance for health in developing countries have been documented: it
leads to inadequate coverage inappropriate use, and exclusion of the
most needy sections from the health network! 10). If insurance is to be
effective and equitable, coverage must be total and risks pooled.
There arc certain realities which may make the conventional type of
health insurance not the ideal option for a country like India: (i) Only a
small proportion of the working age population is employed formally the
others who make up the large informal sector have a very unpredictable
income and as such, can not be expected to contribute insurance premiums
regularly. Moreover, in the informal sector the logistics of collecting the
premium is itself formidable (ii) there is also a large section of the people
unemployed or under-employed, who are too poor to pay even the
insurance premiums however low. A just and equitable policy should
take care of their health needs also.
One way out of this situation is to make the village councils,
panchayats responsible for payment of premiums for the whole
village. The panchayats can decide locally which are the households
who arc too poor to pay. and find some mechanism for payment on
their behalf. The local body can decide how they are going to raise this
collective premium: probably this would include a certain amount of
subsidising of the poor families. Thus each pwichayat pays to the
insurance agency an annual sum depending on the population in the
village it represents. This would amount to a kind of community
rating. Each government health institution can make claims to the
company for reimbursement of charges on the number of people they
have treated. Il is also desirable to create a single insurance agency
which will cover the whole population of the slate which will provide
adequate pooling of risks and total coverage.
Both pre-payment at the panchayat level and group health insurance
as outlined above have certain features in common: they envisage (i) a
more active role for the local governments such as panchayats. and
(ii) greater resource mobilisation at the local level. The difference is that
local level financing of health institutions leads to more direct control foi
the local governments on the health centres.
c) Cost containment: Another important policy option geared towarcK
better performance of the health sector is to see if costs can be contained.
without affecting the level of services The savings thus generated could
obviously contribute to expanding services in quality and/ or quantity
Currently most of the energy of the administrative machinery in the
health services is taken up by transfers, postings and such non-productive
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activity, which are all done centrally By delegating this authority to the
local administrative bodies, a lot of efficiency could be introduced into
the functioning of the health services. In this area also, decentralisation
of administration would be an obvious step towards smoother running of
the system.
Thus we find that all options for strengthening the financial position
of the health care system in government point towards the need for a less
hierarchical model. Decentralisation of overall government is a national
commitment ever since India’s independence and reiterated periodically.
Dismantling the hierarchical structure of the health care network, which
is a legacy of the colonial and feudal past in the state, and replacing it with
a more democratic and participatory alternative is a pre-requisite for
health care reform which would ultimately lead to realisation of the full
potential of the Kerala model.
Conclusion
Kerala presents a unique model among developing countries where a
commitment to investment in social sectors such as health and education
has reaped great benefits in the improvement of the health status of its
people. Growing fiscal problems of the state administration pose a serious
threat to the survival of this model. Policy prescriptions now in vogue all
propose a conscious orientation towards less of public spending and more
privatisation in health Our analysis shows that (i) the proposition that
there can not be expansion in public spending in health is not necessarily
correct, (ii) some remedies that are planned, such as user charges, will
undermine the very foundation of the health care network in Kerala,
which is based on a premise of universal access, and (iii) there are
alternative policy instruments which can lead to greater resource
mobilisation as well as efficiency in resource use in health. All these
presuppose a more participatory model of administration.
Policy making in health demonstrates the need for in-depth
understanding of the health situation. Improving health finances is not a
simple question of collecting more money. Each option carries its own
implications forequily and efficiency. Unless there is a deep understanding
of the local health system, we are likely to end up with more problems
than we started with.
[The author wishes to record his appreciation of the fruitful collaboration he had
with P C K Panikar which made the analysis more complete. He is also grateful
to Abraham Babu for help in compilation and computer entry of the data. The
work would not have been possible without the active support of the Directorate
of Health Services Kerala Secretary for Health Kerala and UNICEF Madras
who funded the study. Thanks are due to all of them.)
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Reverences
[ ] ] World Health Organisation (1978): Financing of Health Services. Report ol
a WHO Study Group Geneva,WHO. 1978-9.
[ 2) Panikar PG K and C R Soman (1984): Health Status of Kerala: Paradox of
Economic Backwardness and Health Development. Centre for Development
Studies, Trivandrum, pp 90-97.
[ 3 ] George K K (1993): Limits to the Kerala Model ofDevelopment, Centre for
Development Studies, Trivandrum .
[4] Tulasidhar, V B (1993): ‘Expenditure Compression and Health Sector
Outlays'. Economic and Political Weekly. 2473-2477.
[5] Mahapatra P and P Berman( 1991): Allocation of Government Health
Services Expenditure in Andhra Pradesh, India, During the 1980s.
Demography India: 20: 297-310.
[6] Loewenson R (1993): Structural Adjustment and Health Policy in Africa’.
International Journal of Health Services. 4: 717-730.
[7] Calkins D; R J Femandopulle. B S Marino (1995): Health Care Policy.
Blackwell Science, Cambridge.
[8] Government of Kerala ( 1993): Report of the Resources Commission.
[9] Moses S, F Manji. J E. Bradley. N J D Nagelkerke. M A, Malisa and F A
Plummer (1992): ‘Impact of User Fees on Attendance al a Referral Centre
for Sexually Transmitted Diseases in Kenya. The Lancet. 340: 463-6
110] Mills A (1983): ’Economic Aspects of Health Insurance’ in Lee K and
AMills (eds): The Economics of Health in Developing Countries, Oxford
University Press, Oxford pp64-88.
V Raman Kutty
Health Action by People
Krishnalaya,
Opp Mutharamman Kovil.
Petlah, Trivandrum 695024
Note to Contributors
We invite contributions to the RJH. Original research articles,
perspectives, field experiences, critiques of policies and pro
grammes in health care, medicine and allied areas are
welcome. Please send manuscripts preferably typed in
doublespace. If the material is on a word processor, please send
us a hard copy along with the matter on a diskette preferably in
WS4. Address all communications to the editor al the address
on the inside front cover.
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National Health Insurance and Financing
Review of International Scene
K Balasubramaniam
A critical review and analysis of health insurance systems in
the developed countries shows that in general they have not only
improved access to health care, but have played an important role
in nation building and in bringing about community solidarity. Private
health insurance is not a viable option and market mechanisms
have not been able to provide universal coverage, nor have health
care costs been held in check.
THE health care systems in the developed or Organisation for Economic
Cooperation and Development (OECD) countries can be classified into
two groups depending on their financing mechanisms. One group fi
nances its health care from general taxation. The UK is an example. The
second uses compulsory social insurance. Several European countries
including France and Germany are examples of this group. The US is an
exception. Free choice and market competition are the features of the
American system.
In addition to general taxation and compulsory social insurance, direct
payment by patients (user-fees or fee-for-service) and private health
insurance are two other mechanisms for financing health care. Malaysia
and other countries in the British Commonwealth use these two
methods together with general taxation. The health care systems in all
countries are pluralistic with respect of financing; this means that each
country uses more than one mechanism but one particular method
predominates.
This paper provides: (i) A description of the different models of health
care services; (ii) Relevant details of how a selected number of developed
countries have organised their health care services in regard to: financing.
ownership and organisation of the delivery services and payment of
health care providers. These details will enable participants to compare
systems of alternative methods of financing payment, ownership and
organisation of services, (iii) A comparative assessment of the perfor
mance of the alternative systems in a number of selected countries. This
assessment is based on the following six criteria that represent common
goals expected of a health care system: universal coverage, equal access,
control of expenditures, efficient use of resources, equity in financing and
consumer choice.
Based on a critical analysis of empirical data presented, this paper
arrives at the following conclusions: (i) The public insurance system in
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the OECD countries has not only improved access to health care, it has
also played an important part in ‘nation building' and community solidar
ity as it emphasises a fndamental equality among citizens. Greater wealth
and/or position can buy many things, but they do nul buy more or better
health; in this respect all citizens are equal, (ii) The public insurance
system, either through general taxation or compulsory social insurance.
premiums, is a very efficient mechanism to redistribute income from the
healthy or high income groups to the unhealthy or low income groups.
The economic burden of the health care system is collectively shared
according to the ability of the citizens. No one in countries with a public
insurance system lives in fear of economic ruin following in-patient
treatment for a catastrophic illness and more importantly no one needs to
depend on charity, (iii) Private health insurance is not a viable option for
financing health care, (iv) The most important function of the state is
regulation. Formulation and implementation of statutory legislation re
lated to financing methods, organisation and functioning of the financing
organisations, payment of providers and a global budget have been the
central features of a successful health care system, (v) Ownership and
provision of services is not a critical issue, whether the financing is
through general taxation or compulsory health insurance. Canada fi
nances through general taxation but has a mixture of private and public
hospitals and its physicians practice as independent entrepreneurs. Most
countries with compulsory health insurance have a mixture of public and
private providers. The private providers include not-for-profit and forprofit hospitals, (vi) Controlling health expenditures while providing
universal coverage and equal access to health care has not been achieved
through market mechanisms in the more affluent countries.
I
Introduction
The health care services systems in the advanced industrialised coun
tries can be classified into two groups depending on their financing
mechanisms. (1) The Bismarckian model introduced in Germany in the
1880s. (2) The Beveridge plan described by Sir William Beveridge in
1942. Tables 1 and 2 describe the main characteristics of these two
systems.
The major objectives of a health care service include: (i) An equitable
distribution of health care to all citizens, (ii) Clinical and economic
freedom for providers, (iii) Budgetary and cost control.
But these arc three competing objectives. A health system can simul
taneously attain only two of the objectives in their purity. Therefore a
compromise, among these three objectives is always necessary since one
of them always conflicts with the other two (Table 3).
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Before policy analysts are asked to devise options for health care
reforms, they should be given clearly articulated guidelines on the
relative priorities to be attached to the three objectives in Table 3 and to
others lurking behind these three.
II
Health Financing
There are only four basic alternative methods of financing health care:
(1) Direct payment by users; (2) Private health insurance; (3) Compulsory/social/state insurance; (4) Direct general taxation.
All health systems are pluralistic with respect to financing and
organisation with tendencies to one method rather than another, for
example, the Bismarckian model uses compulsory insurance and the
Beveridge plan general taxation. Tables 4 and 5 give the sources of
health financing in selected OECD countries for 1975 and 1990. The
Bismarckian and the Beveridge models together with US system are
included in these tables. The US system depends on free choice and
market competition.
Table 6 gives details of the public and private sector health budgets in
16 OECD countries in 1992. The infant mortality rates and the total health
expenditure expressed as a percentage of the GDP are alsogiven. This
table shows the following: (a) The public sector contributions in OECD
countries except the US vary from 63.5 to 87.7 percent of the total health
budget, (b) Out of pocket expenditure by households vary from 11.1 to
Table I: Bismarckian Model - Social/Health Insurance System Models
Financed by compulsory contributions paid by employers and employees
Funds go to non-governmental statutory finance management bodies - ‘funds’
Funds contract hospitals, family doctors, etc, to provide service - through
‘budget’ - based contracts ol lee-for-service work
Austria
Belgium
France
Germany
Netherlands
Many Latin American countries
Korea
China
Philippines
Thailand
Ghana
Nigeria
Zimbabwe
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24.5 per cent of the total health budget. The World Health Organisation
(WHO) estimates for out of pocket expenditure by houeholds in develop
ing countries vary' from 70-90 per cent of the total, (c) Infant mortality rate
is one of the most sensitive indices of the health status of a country. US
spending is 13.3 percent of its GDP on healthcare; It is very much higher
than others but has the highest infant mortality rate. Japan, Spain and UK,
spending about 6.5 per cent or half of the amount spent by US, have
much belter health outcomes.
Table 7 shows how public funds finance the three components of
health care sen ices in six OECD countries. Except US, in all the other
five countries, 85-100 per cent of in-patient care is paid for from public
funds; outpatient care 60-90 per cent and pharmaceuticals 50-90 per cent.
In-patient care is the most expensive of the three. In countries where there
is no public health insurance, in-patient care for major illnesses often
cause financial ruin for those who have no private health insurance.
Ill
Systems of Financing Health Care in Selected
OECD Countries
Compulsory social insurance, direct government financing and pri
vate user charges are three common options used in almost all countries.
both developed and developing. There is now considerable information
about each of these options to enable policy analysts to develop appro
priate systems of health financing, (i) How to mobilise sufficient funds to
Table 2: Beveridge Plan - National Health Service Type
Financed by taxation, free access for all citizens,
government-controlled, state-managed, high profile
state budgets, physicians paid salary' or capitation lee
some private sector, some co-payment,
Canada
Denmark
Finland
Greece
Ireland
Italy
Norway
Portugal
Spain
Sweden
United Kingdom
Commonwealth countries
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finance health care? (ii) How to allocate the resources to get the best value
for money; to provide universal and equal access to reasonable health
care? In other words how to ensure effective use of resources? (iii) Who
determines where and how health care resources will be directed and
used? Figure 1 describes three models of financing and organising health
care.
Model 1A relies on a free choice and bilateral exchange between
consumers and providers. Control over what services to buy at what price
is exercised by consumers (as for any other consumer goods). Market
forces come into play; competition for the consumer’s dollar is expected
to constrain provider behaviour. In this model control is exercised at the
demand side. The traditional private sector in most developing countries
including Malaysia follows this model.
Models IB and C have introduced a formal financing organisation to
pool the financial risks. Since health is not a marketable commodity,
serious market failures will occur with model 1 A. Therefore, a public or
quasi-public agency is given the power to use payment system, technol
ogy assessment and capital planning to constrain provider behaviour. In
these models control is exercised at the supply side.
Model 1 B is a prototype of the Beveridge plan. The state collects its
revenue from taxes. A portion of this is allocated for health care. All
health care providers are paid from public funds. Consumers get free
services from providers. However, consumers do pay some user fees.
Two other varieties of this model as in Canada and Sweden will be
described later. The health care systems in developing countries includ
ing Malaysia are a combination of Models 1A and B.
Model 1C introduces a fourth player in addition to the consu
mer. provider and the state - the financing organisation, which has to
Table 3: Competing Objectives in Health Care
Equity
Remarks
Objectives
Clinical and Budgetary
Economic
and Cost
Freedom
Control
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
No
Yes
Yes
An impossibility
A dream world of providers no country
can afford
National health insurance. All OECD
countries except the US. Most
developing countries.
Price competitive market system - US
Source'. Adapted from Reinhardt UE (1985) - ‘Hard Choices in Health Care: A
Matter of Ethics’ in Health Care: How to Improve h and Pay for It.
Washington. DC, Center for National Policy.
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mobilise funds and pay providers. Funds are obtained from insurance
premiums and government subsidies from general taxation. The
financing organisations are popularly known as plans. The procedure
adopted by the plan determines: (i) Who will bear the cost; (ii) Who
will benefit; (iii) What services will be covered; and (iv) Methods of
payment.
The institutional context in which the plan operates and the method it
uses to maintain fiscal balance will determine whether the system can
contain costs. The methods of payment to hospitals include: - prospective
budget; - fee-for-service; and - charge per day/per admission/pcr diag
nosis-related group. Physicians may receive their payment by: -salary; ca[itation; or - fee-for-service.
Each of these methods has its advantages and disadvantages. Negotia
tions between the plans and providers should result in the most appropri
ate method of payment. The major function of the Stale in this model is
to enact and implement appropriate legislation to regulate the plans and
providers. The models in Fig 1 show two strategies to determine the
supply of facilities and health personnel as well as the total expenses on
health. One strategy depends totally on the free market principle. In the
second strategy, governments establish a health policy and a global
budget with regional arrangements to oversee facilities and equipment,
technological assessment and manpower policy.
Other than the US all other OECD countries have compulsory univer
sal health insurance either through general taxation or social insurance
scheme. Several developing countries have also introduced compulsory
national health insurance schemes. These include several countries in
Latin America, China, Republic of Korea, Philippines and Thailand. Il
was once thought that countries in Africa were economically not strong
enough to introduce compulsory social insurance. However. Ghana.
Nigeria and Zimbabwe are also introducing compulsory national health
insurance.
Table 4: Sources of Finance (1975): Selected International Comparisons
Country
UK
Sweden
Switzerland
USA
Germany
France
General
Taxation
Social
Insurance
Direct
Payments
Private
Insurance
87.3
78.5
41.7
31.1
14.6
7.0
5.0
13.1
24.8
11.7
62.5
69.0
5.8
8.4
33.5
27.1
12.5
19.6
1.2
—
—
25.6
5.3
3.0
Source: Maxwell R J (1981) Health and Wealth: An International Study ofHealth
Care Spending, Lexington. MA.
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OECD countries have already established systems of financing, p»ivment and delivery of health care. The central health care concern in (hoc
countries is how best to integrate these three components to achieve
societies’ goals of equity, universal access, efficiency and controlling
costs. Table 8 shows the kinds of financing ownership, payment and
delivery organisation in 10 OECD countries. They have three main
categories, defined by the source of financing: general taxation, social
insurance and pluralistic provisions.
IV
General Tax Financing
Three types of general tax financing have been employed.
(i) Central Government Financing with Direct Pubic or Private
Provision of Services
Many countries finance health care through general taxtion. The
government collets its revenue through general taxation. A portion of the
annual budget is allocated for health care. Each year health budget
competes directly for funds with social and economic sectors. Best
examples are UK, the countries of the Commonwealth and Scandinavian
countries. The government owns, manages and operates hospital and
medical services. Physicians may be salaried employees or independent
practitioners. Very often the specialists are salaried employees of hospi
tals. In this model the financing, payment and organisation of delivery are
integrated to the fullest extent possible. A serious disadvantage with
general tax financing is that health has to compete with several other
sectors for its share of the government budget. Almost all countries using
this system are facing severe constraints to meet the spiralling costs of
healthcare.
To control the escalating costs in health care the British National
Helath Service (NHS) has embarked on a massive programme of change
Table 5: Sources of Funds of for Health Services: International
Comparisons, 1990
(in percentages)
Source of Funds
Norway,
Sweden, UK
Federal
Republic of
Germany
Belgium,
France
United
States
Taxes
Social insurance
Private insurance
Patients payment
85
—
5
10
15
60
10
15
10
60
10
20
35
—
30
35
Source: OECD database, 1990.
in (he way ii provides health care. The financing of the health service is
at the heart of this change. Health care in the UK has been switched on to
a new course. But the changes are not perhaps as radical as some had
predicted. A brief summary of these changes are given in Annexure 1. Not
all these changes have a bearing on the issue of health care financing, but
many do either directly or indirectly. The NHS has not been privatised:
it is still funded largely from taxation: the private health care sector has
not been privatised: it is still funded largely from taxation: the private
health care sector has not been encouraged to any significant degree via
subsidy or other means to ‘take over’ NHS.
(ii) Regional and Central Government Financing with Direct or
Indirect Provision of Services as in Canada.
Table 6: Percentage Share of Total Health Budget Between Public and
Private Sectors in 16 OECD Countries 1992, Infant Mortality Rate (1993)
and Total Health Expenditure Expressed as a Percentage of GDP (1993)
Country
Sweden
Denmark
Spain
Luxcmberg
Germany
UK
Austria
Belgium
Ireland
Netherlands
Italy
France
Canada
Japan
Switzerland
US
Developing
Countries
Social Central Total
Security Govt
(Fr Tax)
11.0
0.0
32.7
52 1
67.7
7.0
54.3
44.0
5.7
72 1
36.4
66.2
1 0
49.4
31.3
1.9
76.7
86 1
47.0
27.3
11.3
71 8
24.0
34.1
72.0
49
39.0
6.2
70.1
21.3
32.2
37.5
87.7
86.1
79.7
79.4
79.0
78.8
78.3
78.1
77 7
77.0
75.4
72.4
71.1
70 7
63.5
39.4
Out of Private Miscel- Total Infant
Total
Pocket Insu Ineous
Monalit y Health
rance
Rate Exp as a
1993 Percentage
of GDP.
1993
11.1
12 1
15.5
17.7
12.0
15.8
13.9
166
13 7
8.1
20.2
17 8
23.8
24.2
24.5
21 1
l0-*0
1.2
1.8
48
2.8
7.9
5.4
76
53
84
14.9
2.3
9.0
5.1
2.4
9.5
36.1
12 3
13.9
20.3
20.5
210
21.2
21.5
219
22.4
23.0
24.6
27.7
28.9
29.4
36.4
60.7
0.0
0.0
0.0
0.0
1 1
0.0
0.0
0.0
0.3
0.0
2.1
0.9
0.0
2.8
2.4
3.5
5
7
7
na
6
7
7
6
7
7
8
7
7
4
6
9
88
7.7
6.5
na
9.1
6.6
8.5
8.1
8.8
8.7
8.3
9.1
9.9
6.6
8.0
13.3
70-90
Source: (i) Infant mortality rale and health expenditure - World Development
Report, 1995. World Bank
(ii) Health Budget. Gesundhcitssystemc in internationalen Vergleich,
Ausgabc 1994. Germany
(in) Developing countries - Estimates by WHO 1996.
1 12
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The federal government provides a fixed sum, indexed to the GNP to
each province for health care. The provincial government uses its own tax
revenue by the provincial government contracts with public and private
providers for services. Canada has a mixture of public and private
hospitals. The physicians practice as independent enierpreneurs and
Table 7: Percentage Expenditure Financed by Public Funds (Tax Plus
Compulsory Insurance 1990) in Six OECD Countries
Country
In-patient Care
Expenditure on
Outpatient Care
Pharmaceuticals
100
98
90
95
85
55
90
95
60
90
92
55
90
50
60
90
80
25
Sweden
Germany
France
UK
Japan
USA
Table 8. Methods of Financing, Payment and Delivery Organisation in 10
OECD Countries
Country
Financing
(hvnership
Canade
General taxation, central
or regional government
Mandated social insurance
(multiple public and
private plans)
same
same
same
Mixed public
and private
Mixed public
and private
Global budget and not integrated
single channel
Global budget and not integrated
single channel
same
same
same
not integrated
integrated
not integrated
Pluralistic, universal
provision by public
hospitals, with private
insurance, ‘opt-out’
Social insurance, govt plan
General taxation, local
government
General taxation, central
government
Pluralistic, free choice and
competition
same
same
same
Not limit on
exopcndilU'es
No limit on
expenditures
Public
Public
Global budget
Global budget
integrated
integrated
Public
Global budget
integrated
Mixed public
and private
no limit on
expenditure
not integrated
France
Germany
Japan
Korea
Singapore
Spain
Sweden
UK
US
Payment
(Drganisation
of Services
not integrated
Source: Hsia, W C, ‘A Framework for Assessing Health Financing Strategies and
the Role of Health Insurance’ in An International Assessment of Health
Care Financing. (Ed) Dunlop D W and Marlins Jo M World Bank, 1995.
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Table 9: Membership and National Coverage of Insurance Plans in Selected
Asian Countries, 1985-1986
Country and
Insurance
Plan
NonCoverage Coverage
Primary
Total Popula- Labour
Force Agricultural of Non- Population
Members Coverage lion
Labour (Per Cent)
COOOs) COOOs) COOOs) COOOs) Labour
(Per Cent) (Per Cent)
China
GEIS
22530 22530
Labour insurance
- State enterprise
10500 165000
- Town and village
enterprise
79400 123900
Private
8000 12480
Collective
310000
Total medical
214930 633910 1069000 630000
India
Total medical
8190 31240 793000 299144
Indonesia
Total medical
3305 13066 169735 65007
Korea
4304
Industrial
12389
1074
KMIC
3459
Occupational
271
1131
Regional
608
608
Medical Aid
0
4386
Total medical
6257 23743
17164
42031
Malaysia
SOCSO
2600
2600
EPF
4500
4500
Private
45
250
Total Medical
45
250
16560
6357
Myanmar
Total Medical
347
347
38410
17023
Papua New Guinea
10
3494
1721
Public Service Assoc
10
Philippines
4700
GSIS
1200
SSS
3300 15600
58279 20395
Total Medical
4500 20300
Sri Lanka
6009
90
16362
Total
90
Thailand
Workmen’s
compensation
1108
1108
2
8
Private
1600
Rural
0
1800
Government
450
262
Public enterprise
66
Free care
0 10750
14420
53535 27232
Total Medical
518
39
87.5
59.3
30
9.1
3.9
43
11.8
7.7
64
570
56.5
58
1 2
1.5
47
43
0.9
24
24
0.3
48
46
34.8
47
3.2
0.6
29
6.6
269
Source: Charles C Griffin (1992): Health Care in Asia: A Comparative Study oj
Cost and Financing, World Bank, Washington DC.
114
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receive payment on a fee-for-service basis. Patients have the freedom to
choose any hospital or physician. Canada uses the supply side to control
resources allocation and the rising costs of health care. The provincial
governments make all the decision. Standardised payments for all physi
cians’ services go through a single channel which also monitors the
volume of services and their appropriateness. Several provinces have
established a single budget for the services under their jurisdiction
through negotiations between the government (payers) and providers.
This is also referred to as a global budget, but in this case it applies to a
province and not to the country.
Canada’s health care systems are under considerable stress from four
related areas, (i) Fiscal pressures on governments; (ii) Lack of knowledge
Table 10: Assessment of Alternative Methods of Financing, Payment and
Delivery Organisation in Affluent Nations
Method of
Financing
__
Equity
LUniversal Equal
Equity in
Coverage Access
General Tax
Central government,
direct provisions
Yes
(eg United Kingdom)
Regional government,
indirect provision
Yes
(eg Canada)
Local government.
direct provision
Yes
(eg Sweden)
Social Insurance
Government, direct
Yes
provision (eg Spain)
Mandated insurance
with global budget
Yes
(eg Germany, Japan)
Mandated insurance
without global budget Yes
(eg Republic of Korea)
Pluralistic
Universal provision by
public hospitals with
Yes
private insurance ‘output’’
(eg Australia. Singapore)
Free choice and market No
competition (eg US)
Cost
Control
Financing
Efficient Consumer
Use of
Choice
Resources
High
Progressive
Strong
(supply)
Moderate
Low
High
Progressive
Strong
(supply)
High
Low
Moderate Progressive
Strong
(supply)
High
Moderate
Strong
Mildly
regressive (supply)
Moderate
Low
Moderate/ regressive Strong
High
(supply)
Moderate
High
Moderate regressive Weak
High
(demand)
Low
High
Moderate
Mildly
Weak
(demand)
Low
High
Low
regressive
Weak
(demand)
Low
High
High
Source: Hisiao W C. op cit. •
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about the links between health care and health; (iii) Complex ethical
dilemmas involved in rationing health care services; and (iv) The contra
dictory incentives built into the rules and regulations governing health
care deliver)'. To understand these issue and take .suitable remedial
actions, there is a need for information that shows how health care affects
health and how much it costs to achieve this health. The lack of informa
lion gave rise to the project on ‘Cost effectiveness of the Canadian Health
Care System’.
The project developed a resource allocation framework so that a few
scenarios could be tested for their feasibility anbd their impact on health
outcomes. In general, these scenarios reflect the direction of change in
provincial health policy in recent years. They are: reducing aculc-care
bedsand length of stay in hospitals; substituting continuing care for acute
care; reducing the rate of unnecessary surgery and subslituing same-da)
for in-patient surgery; and reducing institutionalisation of the elderly by
substituting home and continuing care for ionstitulional care The project
also identified successful modes of delivery in some provinces that could
be used as benchmarks for ‘better practice’ to generate savings in other
jurisidictions.
Table 11: Population per Docior and Number or Hospital Beds (Both Pubi h
and Private Sectors) per Million Population by State, Malaysia, 1993, Tut
Ranking Orders oe the Two Statistics arl also Given
State
Kuala Lumpur
Penang
Malacca
Negri
Sembilan Selangor
Perak
Johor
Kelantan
Perlis
Pahang
Kedah
Trengganu
Sarawak
Sabah
Malaysia
Population
Per Doctor
573
1689
2230
2357
2376
2455
2891
3047
3463
3715
3742
4303
4327
5449
2320
Ranking No of Hospital Ranking Order
Order
Beds Per
No of Hospital
Beds Per Million
Population
Million
Per Doctor
Population
Population
1
2
3
4
5
6
7
8
9
10
11
12
13
14
3400
2807
1900
1920
904
2150
1337
1049
2046
1325
1498
1330
1604
1447
1662
1
2
6
5
14
3
10
13
4
12
8
11
7
9
Source: Social Statistics Bulletin, Malaysia 1993. Department of Statistics. Gov
ernment of Malaysia.
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The overall reduction in the cost of the Canadian health care system is
estimated (conservatively) to be about 15 per cent of public health care
costs, after taking into account the necessary investments in new. less
costly, facilities and services, based on 1990 health care expenditures
data, this translates into savings of about $ 7 billion.
The overriding goal of doing the appropriate things to the appropriate
people al the Appropriate lime can be achieved. However, in reducing
overall costs and becoming more efficient, there are notable implications
to consider:
- First, significant cost savings are feasible, but they do require a major
reconfiguration of health care facilities - replacing high-cost acute care
treatment with continuing care. As long as appropriate continuing care
services are available and working well, these alternatives are viable over
a wide range of problems.
- Second, as hospital capacity is reduced, the need for effective continu
ing care in the community will increase. Policy will have to focus on
developing cost-effective continuing care as well as support services for
families, friends and other informal caregivers who represent important
elements of such care.
- Third, part of the savings to be realised by this reconfiguration will
have to be set aside to cover the real human costs of such transitions.
Table 12: Public’s View of their Health Care Systems (Expressed as a
Percentage of Responses)
Per Capita
Health
expenditure
USS
Country
Canada
Netherlands
Germany
France
Australia
Sweden
Japan
UK
Italy
USA
The system These are some Our health system
works well. good things. But
has so much
fundamental
wrong with it
Only minor
changes changes arc needetJ that we need
necessary to to make it work
to completely
belter
rebuild it
make it
work better
1.483
1.041
1.093
1,105
939
1,233
915
758
841
2.051
38
46
35
42
43
58
47
52
46
60
56
47
41
41
34
32
29
27
12
10
■
05
05
13
10
17
06
06
17
40
29
Source: Blendon Robert J. Robert Leitman, Ian Morrison and Karen Douchan
1990. Satisfaction with the Health System inTen Nations' HealtliAffairs,
(Summer): 185-92.
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through strategies like training programmes and worker assistance
programmes, outplacement programmes and, where unaviodable. sever
ance packages.
- Finally, as provinces regionalise their health care system, they must
retain the strong central control of health care financing and overall helath
care costs. Al the same time, regional authorities must be given authority
to reconfigure health services to meet the needs of the population. To do
this, new kinds of information will be required on health needs, on the
costs of alternative treatments, and on the outcomes flowing from those
interventions.
Ill
County Government Financing with Direct Public Provision
of Services
Sweden uses the general tax approach but the responsibility is decentra
lised. The county governments provide the funds and also the services to
their residents. This is referred to as ‘direct democracy’, local taxes are
linked to highly visible local health care services. Hospitals are owned,
managed and operated by county governments. Most physicians are paid
a salary by hospitals but some practice as independent enterpreneurs paid
on a fee-for-service basis. One disadvantage is that not all the counties can
collect sufficient tax revenue losupport an optimum level of helath care
service. This central government provides subsidies to these counties.
China has adopted a similar system. Under its collective agricultural
system, China relies on the local community to finance and deliver basic
health care to most of the rural population (Table 9).[ 1 ]
Social Insurance
There are two types of social insurance programmes to provide
universal health insurance:
(i) Government plan with standardised benefit structure and contribu
tion rates. This plan is financed through a combination of pay-roll and
general taxes.
(ii) Varied plans, both public and private. These offer consumers a
choice. However, insurance is mandatory. The government specifies a
standard benefit structure and the actuarial standards with which the
private plans must comply.
(i) Government plan
A government run social plan mobilises funds from three sources:
payroll taxes from employers, payroll taxes from employees and a
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contribution from general taxes. Decision-making is centralised and rests
with the administrators of the public insurance plan. The contribution
rates are legislated to fully finance the anticipated outlays over the next
several decades. Health care service may be provided directly or indi
rectly. Several countries own and operate hospitals, clinics and hclath
centres. Spain and portugal are two countries which have a government
plan with direct provision of services. The financing, ownership, payment
and delivery are well integrated.
(ii) Mandated Private and Public Plans
France, Germany, Japan and the Republic of Korea are examples of
countries which have mandated private and public plans. The government
mandates that every citizen must purchase helath insurance but the public
is free to choose one from several public or private plans. The private
plans are mostly offered by non-profit organisations. Governments use
general tax to subsidise the premiums of the elederly and low inome
people.
In most cases services are provided indirectly. The plans differ
primarily in whether the country has established a global budget to limt
the total health expenditures. For example, France and Germany have set
a global prospective budget and all insurance plans pay their claims
through a single channel which sets a standaridised method and rate for
medical services. There is evidence that these countries using the single
channel paying system linked to a global budget have been able to control
their health care costs [2]. On the other hand, the Republic of Korea which
does not set a global budget has experienced rapid rise in its health care
costs [3].
The organisation of health care delivery varies under different social
insurance plans. In Japan most of the specialist physicians are salaried
hospital employees; physicians and hospital services are therefore well
integrated. On the other hand in France and Germany the plans treat
physicinas and hospitals as separate entities. As a result the services are
less integrated when patients are hospitalised and consts are more
difficult to control because there is less coordination between hospitals
and physicians.
China, Philippines and Thailand are developing countries in Asia that
have set up compulsory social insurance programmes (Table 9).
Pluralistic System
Pluralistic systems provide helath coverage in one of two ways:
(i) Univeral provision by public hospitals and an independent and parallel
private sector, (ii) Free choice and market competition.
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Universal Provision by Public and Private Sectors
Almost all countries in the Commonwealth have this system. How
ever, in most of them including Malaysia, citizens do not buy a private
insurance. They pay out-of-pocket for al I their health expenditure (Fig I i
In the pluralistic system patients have a wide choice of services. Thest
arc: - public hospitals funded by general taxation; private hospitals; and
private practising physicians (also called general practitioners or family
physicians). In these countries people who buy private insurance still
have to pay the taxes that fund public insurance.
The pluralistic system decentralises decision making and gives greater
discretion to the higher income people who can and want to pay higher
prices to have wider choices. They often demand high technology. expensive
ci ••’alive medical service and dominate resource allocation causing esca
lation of the total health budget. Several Asian countries with pluralistic
systems, for example. Bangladesh. India, Indonesia and Sri Lankam permit
the salaried physicians in public hospitals to engage in private practice
It has been reported that many senior physicians limit the hours they
will treat public patients so that they can devote more of their lime to
private patients whom they can charge higher fees. Over lime public
hospitals deteriorate because of the lack of universal support. Eventually
health care becomes a two-tired system burdened by rising costs because
of inadequate market constraints on the private sector [4|.
A serious shortcoming in this pluralistic system is that people who opt
out of the public sector health services and go to the private sector, do not
buy private health insurance. Available empirical data from both developed
and developing countries clearly indicate that private health insurance is
not a viable option for helath care financing (Tables 6 and 9). Data for
Malaysia indicate that in the mid-1980s, 45,000 people purchased private
health insurance from 65 insurance companies; a total of 250.000 people
were covered; this represented only 1.5 per cent ol the populalion[5].
A recent publication of the WHO had concluded that “There are no
private health insurance markets at all. When they do exist they are guilty
of ‘cream skimming"’. The insurer excludes the very people most in need
of protection - the poor and the unhealthy|6|. Insurance companies arc
unique. Health insurance is the only business enterprise which encour
ages its most active clients to go to other insurance companies, preferably
to its competitors.
Free Choice and Market Competition
The underlying principle of free choice and market competition is that
market forces can best produce efficient health care and control its costs.
The US is the only developed country which has used this approach
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Employees who choose health insurance through their place of employ
ment are given a lax incentive. A public insurance programme, Medicare,
introduced in 1966 covers the elderly. About half of low-income people
are covered through an income-tested programme, Medicaid.
In the US have 38 million people no health insurance. An additional
60 million arc estimated to be under-insured. These 98 million or about
40 per cent of the Americans are not the unemployed, the poor and the
aged; these people arc covered by Medicare and Medicaid The 98 million
who have no insurance or are under-insured are all employed but with low
income or employees of small companies and do not have the money to
buy insurance. Only about 35 per cent of the Americans have adequate
health insurance!?].
Under free choice and market competition approach, the focus of
decision making remains with the consumer. According to its advocates,
the market will ensure that private insurance plans have to compete for the
consumer’s dollar and therefore, will seek the financing and delivery
arrangements that best meet consumers’ preferences. Consumer demand
will force insurance plans and health management organisations to
compete on price. The insurance plans will, in turn, pressure providers
into delivering the highest quality of health care at minimum cost [ 8 ]. This
theory has not been borne out by experience. Though the US has
physicians with unsurpassed training and probably among the very best
in the world, yet the health care deliveries in the US has been described
as the most expensive, least efficient and least equitable in the world[9].
IV
An Assessment
The performance of the different systems described in section HI arc
assessed in Tabic 10. The assessment is based on six criteria: Universal
coverage, equal access, control of expenditure, efficient use ol resources.
equity in financing and consumer choice.
(i) Universal Coverage
The experience of US clearly illustrates that universal coverage cannot
be achieved through a free market alone. Il is clear from the experiences
of other OECD countries that universal coverage can be attained only
through some type of compulsory programme.
Three options are viable: Government can use a general lax (UK.
Canada, Sweden); Government run social insurance to cover everyone
(Spain. Portugal); Government can mandate that all citizens should enrol
in a public or private insurance plan and provide subsidies for the poor
(Germany, France, Japan).
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(ii)
Equal At <■(w
Equal access can only be achieved through a fairly even distribution
of health professionals and health facilities across regions. Market
competition draws tesourccs to those who can pay more. Since income is
not evenly distributed across regions, supply is uneven. In countries with
pluralistic financing the number of physicians and hospital beds per
1.00,000 people can differ as much as four or five. Table 1 i gives the
number of people per doctor and number of hospital beds per million
people by states in Malaysia. The difference in population per doctor
between Kuala Lumpur and Sabah is almost 10-fold. On the other hand,
general lax and social insurance financing places decision making in the
hands of a government agency (Fig I. Model IB and 1C). The political
process usually produces a more even distribution across regions.
(iii)
Controlling Health Expenditures
Countries have been successful in controlling the rate of increase in
health expenditure by constraining the supply side. UK. Sweden and
Canada which use general lax have constrained increases through the
governmental budget process. Where the services are provided indirectly
as in Germany and Japan, the supply side approach is to allow the payment
system to control the escalation. Global budgets and payment through a
single channel gives the financing organisation full control over price and
volume. Higher payment rales for primary care services encourages
physicians to provide primary preventive care.
The US. Korea. Australia and Singapore employ a demand side
strategy to control cost escalation. Korea established a very high rate of
cost-sharing by patients [3J. The US established a more competitive
strategy known as managed competition. Under this scheme consumers
can compete for insurance plans and health maintenance organisations
(HMOs). At the same lime cost sharing for the consumer is increased.
Several recent evaluations of the managed competition in the US have
revealed the perverse impact of HMOs on the health care service in the
US. [10, 11, 12, 13, 14]
The strategy chosen by Singapore is to have employees contribute
to an individual savings fund for each employee. This savings fund
know as Medisave Plan can only be used to pay for medical services.
Any unused balance can be bequeathed to the individual’s survivors.
At the time of obtaining a health service, the consumer pays 10 percent
of the costs by draw ing on his or her Medisave fund It has been reported
that the evidence to date suggests that the demand-side strategies do not
seem to have been effective in constraining the increases in health
expendiiure[4J.
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(iv)
Efficient Use of Resources
The three factors which determine the efficient use of resources are:
resource allocation, technology diffusion and administrative efficiency.
The effectiveness of prevention and primary care as measured by cost
benefit ratios has long been demonstrated. It is also well-known that
consumers are reluctant to pay for prevention and primary care in
comparison with curative medicine. The resource problem caused by
many new technologies is that they are adopted before they are clearly
demonstrated. Private for-profit hospitals rush to install them to attract
consumers, who through lack of objective information on new technolo
gies, choose, the provider that offers the latest and dazzling technology.
Unless capital outlays are carefully planned, equipment and facilities may
proliferate in a country leading to wasteful duplication and escalation of
health care costs.
Pluralistic and free-choice method of financing incurs higher admin
istrative costs than other financing strategies in the area of administrative
efficiency. At the same time pluralistic or free-choice method of financ
ing cannot exert sufficient market pressure to ensure that private hospitals
and clinics are managed efficiently. A financing system that provides
services and control al the supply side through a global budget and a single
payment channel would be est capable of imposing fiscal discipline and
efficient use of resources.
(v)
Equity in Financing
The fundamental principle in equity in health financing is based on
solidarity and social responsibility. This can be done when healthy people
people and high income earners subsidise the costs of health care of the
sick and low income earners. This can only be done either by general lax
financing or public social insurance plans. These pool the risks of all the
people in a country - the healthy, the rich, the unhealthy, the poor, the
young and the aged. In pluralistic systems and free-choice methods of
financing, there is no equity.
(vi)
Consumer Choice
Consumers make choices regarding three kinds of providers: primary
Care physicians, medical specialists and hospitals. Countries that provide
services directly allow consumers to freely choose the primary care
physician bin restrict choice on hospitals and specialists (Figure 2). This
practice is of critical importance in controlling health care costs. General
practitioners or family physicians should be the gale-keepers to ensure
cost-containment, whatever be the mechanism of financing. This is the
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case in UK and Sweden. Financing plans that provide services indirect h
usually give consumers greater choice in selecting their hospitals anj
specialists.
V
Some Lessons from Developed Countries
(i) The public insurance system in OECD countries has not only ini
proved access to health care, it has also played an important role in ‘nation
building’ and community solidarity, as it emphasises a fundamental equa
lity among citizens. Greater wealth and/or position can buy many things.
but it does not buy more or better health; in that all citizens are equal.
(ii) The public insurance system, either through general taxation or
compulsory social insurance premiums, is a very efficient mechanism to
redistribute income from the healthy or high income groups to the
unhealthy or low income groups. No one in countries with a public
insurance system lives in fear of economic ruin following in-patient
treatment for a catastrophic illness and more importantly no one needs to
depend on charity.
(iii) Private health insurance is not a viable option for financing health
care.
The
(iv)
most important function of the slate is regulation. Formulation
and implementation of statutory legislation related to financing methods.
organisation and functioning of the Financing organisations, payment of
providers and a global budget have been the central feature of a successful
health care system.
(v) Ownership and provision of services is not a critical issue, whether
the Financing is through general taxation or compulsory health insurance
Canada finances through general taxation but has a mixture of private and
public hospitals and ns physicians practice as independent entrepreneur^
Most countries with compulsory health insurance have a mixture ol
public and private providers. The private providers include not-for-profit
and for-profit hospitals
(vi) Developing countries can learn that controlling health expendi
tures while providing universal coverage and equal access to health care
has not been achieved through market mechanisms in the more affluent
countries |4].
References
11J Hsiao, W C (1984): ‘Transformation of Health Care in China’, New Engl I
Med. 310:932-36.
|2J Reinhardt, Uwe, E (1989): ‘Respondent to Bengt Johnsson: What can
Americans learn from Europeans?' Health Care Financing Review. Suppl:
97-104
124
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1998
(3 J De Gey nt, W (1991). Managing Health Expenditure under National Health
Insurance - The Case of Korea, World Bank, Technical Paper 156. Asia
Technical Department Series, Washington, DC.
|4] Hsiao, W C (1995): ‘A Framework for Assessing Health Financing Strat
egies and the Role of Health Insurance’ in Au International Assessment of
Health Care Financing: Lessons for Developing Countries, The World
Bank, Washington, DC.
15 ] Griffin, C G (1992): Health Care in Asia: A Comparative Study of Cost and
Financing, World Bank. Washington, DC (Tables 5.4 and A16).
[6| WHO (1993). Evaluation of Recent Changes in Financing of Health
Sei vices: Report of a WHO Study Group, World Health Organisation,
Geneva, 1993, p 26
[7| Jones. M G (1992). ‘Consumer Access to Health Care: Basic Rights,
21st Century Challenge’, Journal of Consumer Affairs, Vol 26. No 2,
pp 221-241.
|8] Enthoven A and R Kronic (1989): ‘A Consumer - Choice Health Plan for
the 1990s: Universal Health Insurance System Designed to Promote
Quality and Economy’, New Engl J Med, 320 (I and 2).
[9| Anon (1990): ‘Can for Radical Surgery’, Time, May 7. p 31.
| 10] Ana (1995): ‘HMDs: A Threat to Life?’ Corporate Crime Reporter, USA,
September.
Ill) Levinsks N G (1996): ‘Social, Institutional and Economic Barriers to the
Exercise of Patients Rights’, New Engl J Med, 334, pp 532-534.
112| Woolhandler. S and D U Hinimelstein (1995). ‘Extreme Risk - The
Neu Corporate Proposition for Physicians’, New Engl J Med, 333:25,
pp 1706-07.
[13] Guyat. G (1996): ‘Managed Care or Managed Revenue’, Medical Reform.
Vol I 5:4, March, p 13.
[ 14] Kilburn, P J (1996) ‘New York Times, quoted in the New Straits Times.
Malaysia, June 23, p 3 and 7.
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Communications
Focus Group Discussions
A Methodological Note
Alex George
Focus group discussions can generate the kind of data which
would be inaccessible using the questionnaire-based survey method.
While the method is now being used increasingly in field studies,
the data that they gathered through this method needs to be analysed
and used with care.
FOCUS group discussions are being increasingly used in social research
now. Even hardcore empiricists agree on its ability to unearth the
subterranean social attitudes in the synergy and anonymity of the group,
which would otherwise not surface in a mere questionnaire based survey.
I he method itself is now being used to make the survey method more
sensitive and its users more self questioning of the data which they
generate and subject to statistical analysis to make inferences. Thus focus
groups can be complementary to and supportive of the survey method.
But if conducted simultaneously with a survey, in sufficiently large
numbers and in a well distributed manner they can also throw up data to
countercheck the survey findings. One such exercise to assess the ‘De
mand and Satisfaction of the Health Delivery System’ was conducted in
Mauritius by the author [Murray el al 1996 and George 19951. This paper
brings out the theoretical bearings of the method of focus group discus
sions which was adopted for that study along with a detailed discussion
on the implementation of the method.
Krippcndorf distinguishes between two types of data: ‘emic’ and
‘etic’. Emic data are data which arise in natural or indigenous form, and
are only minimally imposed by the researcher’s view of the setting.
Elie data on the other hand represent the researcher’s imposed view of
the situation. However, little research which is being carried out can be
called completely etic or emic. Focus groups along with a few other
techniques such as unstructured individual depth interviews provide
data that are closer to the emic side of the continuum because they allow
individuals to respond in their own words, using their own categorisa
tion and perceived associations. They are not completely without
structure however, because the researcher does raise certain questions
for discussion. Survey research (with structured questionnaires
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particularly) and experimentation, tends to produce data that arc closer
to the elic side of the continuum, because the response categories used
by respondents have been generally prescribed by the research
[Krippcndorf 1990].
Focus group discussion is not a way to measure precisely the amount
of some behaviour in a population. But it is excellent for gelling an
indication of how pervasive an idea, value or behaviour is likely to be in
a population, and for understanding how deeply feelings run about
products, issues or public figures [Russel 1988]. Groups are not just
a convenient way to accumulate the individual knowledge of their
members. They give rise synergistically to insights and solutions that
would not come about without them. Focus group interview was
developed in recognition that many of the consumer decisions that
people make are ma’de in a social context, often growing out of dis
cussions with other people. Thus market researchers used focus group
interviews in 1950s as a way of simulating the consumer group process
of decision making in order to gather more accurate information about
consumer preferences .The participants are typically a relatively
homogeneous group of people who are asked to reflect on questions
asked by interviewers. Participants hear each others responses and
make additional comments beyond their original responses as they hear
what others have to say. It is not necessary for the group to reach a
consensus - nor to disagree. The object is to gel high quality data in a
social context where people can consider their own views in the context
of others [Patton 1987].
Among the more common uses of the focus groups are the following:
(1) Obtaining general background information about a topic of interest.
(2) Generating hypotheses that can be tested with quantitative meth
ods.(3) Stimulating new ideas and concepts. (4) Diagnosing the potential
for problems with a new programme, service or product (5) Generating
impressionsol products, programmes, services, institutesor other objects
of interest. (6) Learning how respondents talk about the phenomenon ol
interest, so as to facilitate the design of questionnaires and other survey
instrument for qualitative research (Stewart and Shamdasani 1990]. (7)
Interpreting previously obtained quantitative results.
Focus groups have the following advantages: (1) Provide data from a
group of people much more quickly and at less cost, compared to
interviewing individuals separately. (2) Allow researchers to interact
directly with respondents, provide opportunity for clarification of
responses, for follow up questions and probing of responses. Il also
allows respondents to qualify their responses and give contingent
answers to questions. (3) Provide large and rich amounts of data.
Researcher obtains deeper levels ol meaning, make important con
nections and identify subtle nuances. (4) Allow respondents to react
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and build upon responses of other members. (5) Useful for gening
infotmaiion from children or illiterate or less educated people (Stewart
and Shamdasani I99<)|.
In addition Patton (1987) also points out that focus groups provide
some quality control on data collection in that paiticipants tend to provide
checks and balances on each other which weed out false or extreme
views.The group dynamics typically contribute to focusing on the most
important topics and issues in a set of issues and it is fail ly easy to assess
the extent to which there is a relatively consistent, shared view of a group
of issues among participants.
The following are the limitations ol focus groups: (I) The small
number of respondents and the convenience nature of most focus group
recruiting practices limn generalisation. (2) The responses from members
are not independent of one another. Results may be biased by dominant
or opinionated members. (1) Ihc live and immediate nature ol the
interaction may lead a tesearcher or decision maker to place greater faith
in the findings than warranted. (4) The moderator may bias results
knowingly or unknowingly (Stewart and Shamdasani 1990|.
It needs however to be added that focus group sampling is not always
convenience sampling as the following section on sampling will show.
The need to control the group from being led by dominant or opinionated
members has been taken note of by users of this method and in order to
prevent this generally persons of authority are not included in groups. In
addition the facilitators who conduct the discussions should be briefed to
encourage the silent or less talking members to express themselves and
then build up on those views by asking more and more members to talk
about that. They are also to be told not to express their own view's or
encourage only those views which they support. A note on conducting the
discussion should be given to all facilitators and recorders for this
purpose after properexplanalion. One such note is given elsewhere in this
paper. In addition the facilitators and recorders should be given in-house
and on the field training before starling the discussions By adopting these
measures most of the shortcomings of focus groups discussions can be
controlled if not got over completely.
Sampi ing in Focus Groups
In quantitative research, one’s sample should be representative of
some larger population for which one hopes to generalise the research
findings. In qualitative inquiry, of which locus groups are part, sampling
is driven by the desire Io illuminate the questions under study and to
increase the scope or range of data exposed to uncover multiple realities.
Quantitative sampling concerns itself with representativeness anil quali
tative sampling with information richness (Kuzel 1992], Che two
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methods differ also, in that quantitative inquiry usually starts with theory
that is closed and needs to be proven or disproved while qualitative
inquiry generally begins with theory' or understanding that is to be
modified and confirmed in the context of the study [Kuzel 19921. Nonprobabilislic nature of the sampling underscores the distinction made
earlier between the goals and the resulting sampling strategies of quali
tative vis a vis quantitative inquiry.
The sampling strategy we had adopted combined aspects of maximum
variation sampling and snowball sampling. Both are part of Patton's
typology on sampling in qualitative methods [Patton 1990 and Kuzel
1992].
Maximum variation sampling occurs when one seeks to obtain the
broadest range of information and perspectives on the subject of study. By
looking for this broad range of perspectives, the investigator is challeng
ing purposefully his or her own preconceived (developing) understand
ing. of the phenomenon .This perspective also mitigates against the
tendency to make the ‘messiness’ of reality appear unduly ‘neat and tidy’.
This is in contrast to studying a homogenous group and seeking to
understand a particular group of individuals particularly well, with some
appreciation of course on the unarticulated diversity yet to be explored.
Patton (1990) points out that maximum variation sampling “documents
unique or diverse variations that have emerged in adapting to different
conditions”, and also “identifies important common patterns that cut
across variations” [Ibid A 39]. Maximum variation sampling allows us
and makes us sensitive to represent all the possible variables in the sample
groups. Al the same time if in-depth information of say women on
intimately private aspects as gynaecological problems or family planning
behaviour are required, there can be separate homogenous groups of
women for that purpose.
In snowball sampling, one identifies in whatever way one can. a few
members of the phenomenal group one wishes to study. They are used to
identify others, and they in turn others. Unless the group is very large, one
soon comes to a point al which efforts to net additional members cannot
be justified in terms of the additional outlay of energy and resources; this
may be thought of as a point of redundancy. Snowballing is also used to
constitute groups of information rich cases, wherein one such case
suggests other similar cases [Patton 1990].
We had to sometimes break the prescribed upper limit of 12 members
for a group suggested by Scrimshaw and Hurtado (1987) because of the
enthusiasm of people to participate. Scrimshaw’s own position is not
very rigid on the size of groups. She says that in the Indian and African
sellings people from the neighbourhood may also join in and that they
need not be turned away; instead it be treated as a natural group.
Regarding the number of focus groups; although rules are not hard and
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fast, experience has shown that 6-8 data sources or sampling units will
often suffice for a homogenous sample, while 12-20 are needed com
monly when looking for disconfirming evidences or trying to achieve
maximum variation, Marshall and Rossman 1989, Me Cracken 1988,
Patton I990|. When the search for disconfirming evidence also add up to
redundancy it can be reasonably presumed that the sample strength is
adequate.
The selection of villages and towns and subsequently the settlement
groups in villages and the wards/lanes in the urban areas should be done
keeping in view the representativeness of the groups which are to formed.
After selecting the location from where groups are to be constituted, we
can solicit participation from different clusters of houses al different
points on the same lane or on nearby lanes/settlements. In these groups
also care should be taken for sufficient representation of all relevant
variables. Contact could be established through youth clubs,
neighbourhood women groups, mahila mandals, and different caste and
community groupings and other occupational groups to ensure participa
tion. By using the snow balling technique, one household whom we
contact could be utilised to put us in touch with other co-operating
households and they themselves may even organise a suitable venue. The
members of this focus group would again put us in touch with other
houses in the locality who formed the next group provided this fit in with
the sampling frame for locations.
Special care should be taken to ensure that the venue was not the house
of persons of authority or (hose in the Government, to enable people to
speak out. Discussions should not be conducted in the local offices of any
Government department which come within the purview of the study
concerned. Focus group discussions can also be conducted for grass root
level opinion leaders, such as the village panchayat members or village
school teachers to bring out certain points which the household group may
not express or are not aware of.
The facilitators of focus group discussions should be capable of
generating a discussion by posing questions related to the various issues
on which information is to be collected. For this purpose a Discussion
Guide should be prepared which lists the issues to studied along with a
string of questions some of them hypothetical also which would be aimed
to spark off a discussion. These questions should not be posed to collect
the individual responses as in the case of a questionnaire used in a survey,
but to generate a discussion by commenting one person’s view, support
ing another contradicting yet another and finally arriving at some consen
sus if possible.
A note prepared on conducting focus groups is given here. The
Facilitators and recorders started carrying out the discussions only after
conducting pilot discussions.
A Manual for l<uilitaoi \ and Reeorders
[Bused on Scrimshaw and Hutardo I987|
- it should he an open conversation in which each participant
speaks, asks questions to other participants and responds to questions
- Facililaloi will only guide the discussion so that all subjects gel
covered.
--The first discussions lake a long time.
- Location of focus group discussion should be neutral visa vis the
topic of study.
• Invitations to focus groups should be made ahead of time.
The discussion facilitator
-• Should be thorough with the objectives of the study.
-- Uses the discussions guide which has open ended questions, to
keep the session focused.
- Facilitator should not convey the impression of an expert.
- Formulate appropriate questions on the basis of the discussion
guide to encourage a discussion. Take care to react neutrally to the
different views that are expressed by participants.
- Emphasize that there are no right or wrong answers.
- Gestures and non-verbal communication should not suggest
agreemcnl/disagreement with participants.
- Facilitator should avoid expression of personal opinion.
- Observe participants and be aware of the extent of their involve
ment and reactions.
- Encourage all to participate, do not allow a few to monopolise the
discussion.
- Keep track of the points to be covered.
- Guide the meeting away from Question Answer. InterviewerInterviewee session to a group discussion where all participate.
- Take a sincere interest in the participants and in learning about
them.
— Be flexible and open to suggestions / interruptions.
- Subtly control the lime allotted for each question.
- Conversation should move quickly over issues expressed by
other groups and move on to views received afresh.
- Observe the participant’s non-verbal communication.
The discussion recorder
- Is present primarily as observer and documentor.
Recoid the discussion along with group dynamics.
- Document the interest level, anxiety, boredom expressed by
the group
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Document the interruptions and distractions that occur during
meeting.
- Note what makes them laugh, what seems to make them reluctant
to answer, how the discussion ends.
- Record what is the majority vicwVThe other views. Record points
in their own words.
Intel vening on points missed by facilitator.
Intervening to collect a participant's view not expressed / heard
properly.
The focus group session
-Facilitator/recorder should come to the place of discussion before
the time of the discussion. Al this lime learn names of participants.
- Sil in a circle, everyone face to face.
To open a meeting
- Make introduction. Explain the study and the roles of facilitator
and recorder.
- Ask their names.
-- Say that the meeting is not an educational lecture but to get views
of participants lo improve lhe health system.
- Say that the views of all are important. All should participate and
feel free lo express themselves.
- Only rule being that lhe speaker should address the subject of lhe
locus group discussion and lhai one person will speak al a lime.
- Ask a question to each participant not related lo lhe topic so that
all start talking.
Some focus group meeting techniques:
Specialists, experts, people ol authority should not be there in the
group.
•• More eye contact should be used to open oul lhe reluctant
participant.
- Less eye contact with dominant participant to prevent him from
monopolising the discussion.
End a discussion by
- Explaining that lhe meeting is about lo end Ask if anyone has
anything more to add.
- The relevant comments among these can be explored further.
- If there arc no more fresh comments thank lhe participants and
real linn that their ideas will he used in lhe study and conveyed lo the
policy makers.
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i:
Content Analysis of Discussions
Organising and simplifying the complexity of qualitative data into
some meaningful and manageable themes or categories is the basic
purpose of content analysis |Patton 1987]. The most common uses of
content analysis is to know the frequency and the intensity with which
certain items, symbols or themes appear in a document | Willamson, Karp
and Dalphin 1977]. The content analyst also looks into the context in
which a concept appears in the text [Fetterman 1989). In this case the
discussion notes of focus groups will take the place of texts/documents.
The computer packages for content analysis have considerably re
duced the manual process involved particularly in organising the data.
But the sheer sophisticated nature of qualitative data demands human
involvement particularly for interpretative analysis to bring out the
subtleties and the interconnections between the data. The framework for
content analysis is based on the construction of categories into which the
data can be grouped. These categories should reflect the theoretical
concepts on which the study is based and bear close relation to the
research problem. We have used the concept of key words in context
(KWIC) [Stewart and Shamdasani 1990] in developing categories. This
concept takes into account the meaning of the key word in the context in
which it is occurring.
The discussion notes could be entered in a precoded manner following
the same numbers of the aspects / issues which were provided in the
discussion guide. In order to group the data as per the several aspects I
issues we experimented with Anthropac but later found that it was more
convenient to do this under the Window-based word processing functions
of Amipro. Several discussion notes which were entered as separate files
were opened simultaneously and the relevant section of the discussion
note as per the precoded numbers of issues / aspects in the discussion
guide were grouped into separate files. Later print outs of these grouped
files were taken out and manually analysed for the various key words. The
frequency of occurrence of various observations can be calculated and
their percentages can also be presented in the total number of group
discussions conducted. However these percentages are only meant to be
a measuring rod for the extent and depth of a certain perception or attitude
among the groups and as there are multiple responses which are not
mutually exclusive the total numbers of these responses will not add up
to the total number of groups nor will the percentages total up to 100. Care
has to be taken to present the various shades of perceptions and attitudes
in the people’s own words with the minimum of editing for the sake of
clarity. Verbatim quotations can be used to enliven the text. The depth of
emotions reflected in gestures must be taken note of in the analysis and
distinctly mentioned. All groups may not express themselves on every
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aspect and sub aspect. These will be reflected in the frequcncy distribu
tions and percentages also. Therefore we have to be cautious in using
these percentages as absolute values, since they will be affected by the
response level. Always they should be weighed against the overall
response level for each aspect. It would not be wise to subject the
responses of focus group discussions to a sophisticated statistical
analysis, mainly because the sample would be usually rather small and
also because consensus making in groups would be affected by group
dynamics.
Conclusion
Focus group discussions can generate the kind of data which would
otherwise not be available through the individual-to-individual question
ing of the survey method. It can be used to add depth and richness to the
data collected through other quantitative or qualitative’ methods. If in
some cases the survey data gives rather routinised, or irrational patterns
which does not fit in with the over all understanding of the phenomenon,
the focus groups data should be relied upon and highlighted. The re
sponses of focus group discussions should be used for critically triangu
lating the information collected by other quantitative or qualitative
methods and an input for more sensitive quantitative approaches at a later
stage.
|The author acknowledges the Institute of Health Systems, Hyderabad and the
Harvard Center for Population and Development Studies, for the association with
the study, The Health Sector in Mauritius.]
References
Fetterman, David M (1989): Ethnography Step By Step, Sage Publications,
Newbury Park, pp 96-97.
George, Alex (1995): Study of Demand and Satisfaction of the Mauritius Health
System, Institute of Health Systems, Harvard Centre for Population and
Development Studies, Cambridge, Massachussets.
Kuzcl, Anton J (1992): ‘Sampling in Qualitative Enquiry’ in Crabtree Benjamin
F and Miller William E (ed), Doing Qualitative Research, Sage Publications,
Newbury Park, p33, pp 37-41.
Murray, C J L ct al (1996): The Health Sector in Mauritius, Harvard Centre for
Population and Development Studies, Cambridge, Massadhussets, pp 101102, pp 375-415.
Patton, Michael Quinn (1987): How to Use Qualitative Methods in Evaluation,
Sage Publications, Newbury Park, p 135.
- (1990): Qualitative Evaluation and Research Methods, Sage Publications,
Newbury Park, p 17, p 39, pp 169-186.
Russel, Bernard H (1988): Research Methods in Cultural Anthropology, Sage
Publications, Newbury Park, p 267.
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135
Scrimshaw. Susan C M and Elena Hurtado Elena (1987): Rapid Assessment
Procedures for Nutrition and Primary Health Care, I '('LA Latin American
Centre Publications. UC. Losangeles. California, pp 15-19.
Stewart. David and Prein Shamdasini N (1990): Focus Groups Theory and
Practice, Sage Publications, Newbury Park, pp 13 17. pp 114-1 I 5.
Williamson. B John. David Karp A and John Dalphin R (1977): The Research
Craft: An Introduction to Social Science Methods. Little Brown & Co.
Boston, p 289.
Alex George
Institute of Health Systems
5-9-22/27. Adarshnagar,
Hyderabad - 500 063
Medico Friend Circle
Publications
In Search of Diagnosis edited by Ashwin Patel, pp 175,1977
(reprinted 1985), Rs 12. (Currently out of stock)
Health Care: Which Way to Go? Examination of Issues
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4
To The Red Flad
For him who only knows your colour,
red flag,
you must really exist, so that he can exist:
he who was covered with scabs is covered
with wounds,
the labourer becomes a beggar,
the Neopolitan a Calabrese, the Calabrese
an African,
the illiterate a buffalo or dog.
He who hardly knows your colour, red flag,
won’t know you much longer, not even
with his senses:
you who already boast so many bourgeois
working class glories,
you become a rag again, and the poorest
wave you.
-Pier Paolo Pasolini, Roman Poems
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