Development of a Medium Term Health Sector Strategy and Expenditure Framework
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Development of a Medium Term Health Sector Strategy and
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DRAFT
Development of a Medium Term Health Sector Strategy and
Expenditure Framework
for Andhra Pradesh
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Report of Phase 1
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International Health Systems Group
Harvard School of Public Health
May 29, 2002
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Table of Contents
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Executive Summary
Summary Report
Annex 1: Report of Social Development Team
Annex 2: Government Health Care Delivery
Annex 3: Governance Aspects of the Health Systems in Andhra Pradesh
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Annex 4: Report of Decentralization Team
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Annex 5: Private Health Care Provision in Andhra Pradesh
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Annex 6: The State of Health and Burden of Disease in Andhra Pradesh, about 2000
A.D.
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Annex 7: Financing Health in Andhra Pradesh
Annex 8: Reading Materials and Background Papers
Annex 9: Terms of Reference/Scope of Work
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Annex 10: Schedule of Persons Met (forthcoming)
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6. A.P. has made exciting advances in broader social development activities, including
the mobilization of community and women’s groups for social and economic
development. There are also successful, though relatively small scale, efforts to link
social development with health programs and goals. The team identified this as a key area
for further development as part of the MTSEF. We feel that achieving the ambitious
health goals of Vision 2020 will require movement beyond the formal governmental
health care delivery system.
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7. Another key area is strengthening the role of district and local governments in health,
through well-designed decentralization of funds, authorities, and accountability and
involvement of civil society institutions. This will also require significant new
investments in capacity-building, monitoring, and evaluation.
8. A.P. has a large, widely dispersed, and diverse private health care provision sector
which is barely being tapped for its potential to enhance coverage and impact with
priority health interventions. The DoHMFW could initiate some immediate actions to
strengthen the contribution of private providers in improving health outcomes.
Tables 5 and 6 in the Summary Report list some of the key recommendations for shortand medium-term action emerging from the team’s work. These can provide the basis for
specific planning for Phase 2.
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Proposal for Phase 2
The team proposes that the GoAP steering committee and DflD staff review this report to
decide on whether to proceed with Phase 2. A timetable for Phase 2 is proposed in the
main report. Phase 2 should be planned for 12-18 months. It could begin at the end of
July 2002 with a launch workshop to which this Phase 1 report and its recommendations
for short- and medium-term actions would be a major input.
Phase 2 would assist the GoAP to produce the MTSEF reports it needs by October 2002
and March/April 2003. Phase 2 would also develop some of the background analysis
needed to plan and cost priority reform innovations as recommended by the team. It
could include initial investments in field experiments that could be continued under a
possible Phase 3. GoAP should consider that a serious program of sectoral reform should
be planned for at least a 3-5 year period, with continuous technical support inputs.
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DRAFT
Development of a Medium Term Health Sector Strategy and
Expenditure Framework
for Andhra Pradesh
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Summary Report
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Peter Berman and Team Members
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Development of a Medium Term Health Sector Strategy and
Expenditure Framework
for Andhra Pradesh
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Summary Report
1. Background, Description of Task, and Situation Analysis
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1.1 On behalf of the Department of Health, Medical, and Family Welfare (DoHMFW),
Government of Andhra Pradesh (GoAP), the United Kingdom’s Department for
International Development (DUD) contracted the International Health System s
Group (IHSG) at Harvard School of Public Health to provide technical support to a
first phase (Phase 1) of the development of a Medium-Term Strategy and
Expenditure Framework (MTSEF) for the state. The DoHMFW appointed a steering
committee to oversee this work. An IHSG team of seven advisors worked with
government counterparts and other stakeholders during April 20-May 10, 2002. This
report presents the results of the Phase 1 work and proposes further work under
Phase 2, as per the Terms of Reference of the task. Annexes to this report provide
the individual advisor reports produced under Phase 1.
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1.2 The IHSG team included the following people and main areas of focus:
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Prof. Peter Berman: Team Leader and Private Sector Health Care Delivery
Dr. Ajay Mahal: Team Coordinator and Health Sector Financing
Dr. Thomas Bossert: Organization and Governance
Mr. Shiv Kumar: Organization and Governance
Dr. Marc Mitchell: Government Health Care Delivery
Dr. Vimla Ramachandran: Social Development
Dr. Hilary Standing: Social Development
Dr. Prasanta Mahapatra: Burden of Disease and Health Priorities
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The team was supported by Ms. Terri Saint-Amour, Ms. Seedang Simonin, and Ms.
Naomi Bums at IHSG.
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13 The IHSG team entered into a process of strategic planning for health in A.P. in which
there had already been a substantial amount of work since 1999, as indicated in the
reading list in Annex
Some of the highlights of that previous work include:
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Vision 2020 - a major policy statement on government goals from A.P.’s dynamic
Chief Minister, Mr. Chandrababu Naidu, which includes a prominent chapter on
health and one on governance. Vision 2020 sets forth ambitious goals for health
status improvements and good governance and lays out a set of priority strategies
for achieving them.
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GoAP internal efforts to “operationalize” Vision 2020 and momtor progress in
achieving its goals. The DoHMFW and major divisions within it have produced
operational goals and targets for achieving Vision 2020 results and periodic
reports on achievement of quantified targets. It is expected that budget allocations
to departments and divisions will be based in part on progress in these measurable
indicators.
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Strategic planning exercises involving the DoHMFW, DflD, the World Bank, and the
European Commission. To date these have included:
DoHMFW strategy documents including a Health and Family Welfare
“Approach Paper”, “Health Policy”, and “Health Sector Strategy”.
ii.
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DflD consultants and advisors who have explored the potential for sectoral
assistance strategies, reviewed health financing and health policy issues
generally, and reviewed specific health programs such as Reproductive
and Child Health and Tuberculosis Control.
iii.
EC consultants reviewing specific health program and governance issues.
iv.
Several strategic planning workshops in the state, involving state stakeholders,
government counterparts, and international organizations and producing
reports on health sector strategy and specific proposals.
v.
Ongoing World Bank review of prionty health problems and programs.
J Recent development of a major sectoral assistance instrument (USS350M loan and
credit) for budgetary support to GoAP, including agreement that these funds
would provide support to health and education and that the GoAP would double
its own sectoral allocation to “primary health care” over five years. GoAP has /
agreed to produce a strategy and expenditure framework reflecting these plans. J
1*4 Thus, the IHSG team entered onto the scene receiving a very large and impressive body
of previous work in goal-setting, analysis, and strategy development. After
reviewing this work, we found ourselves asking several questions: What was
perceived to be missing or still needed in terms of a MTSEF? Who held these views
and was there a concensus among key stakeholders? What, if anything could we
contribute to this process which would be useful in improving health system
performance and outcomes for A.P.?
1.5 DflD also clarified our relationship with our clients. The IHSG was clearly asked to work
with the DoHMFW under the leadership of Ms. Rachel Chatterjee and a steering
committee to assist that department and the GoAP more broadly in formulating its
strategy and expenditure framework.
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To clarify the situation to which we are trying to respond, let us pose, and answer, several
key questions.
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a.
Who wants what from a MTSEF for A.P.?
1.6 All stakeholders share the same basic goal for developing a MTSEF for A.P.: a feasible
planning framework which will guide investment and implementation to unprove
health system performance in the state. Vision 2020 provides the basic statement of
health outcome objectives - a key element of health system performance. Vision
2020 also lays out a view of governance improvements needed to achieve these
outcome gains.
1.7 But there are some differences between stakeholders in their specific expectations for a
MTSEF. We have identified two key dimensions across which these differences lie:
the contrast between “systemic” and “programmatic” strategies for improving health
system performance; and the contrast between shorter-term strategies and medium
and longer term strategies.
1.8 The “systemic” view seeks to Jdentify strategies which will change some of the
underlying determinants of health system performance, Tuch as the overall level of
financing, the incentives which drive the perfbrmanceUf administrators and health
care personnel, and the organization of institutions. The J*programmatic” view
focuses on the operationalconstraints- to improving existing programs, for example'"
the need for moresupplies^ndttansport, better training, filling staff vacancies, etc.
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Let’s examine some examples of these different views.
1.9 Vision 2020’s health goals are very ambitious. The DoHMFW is profoundly challenged
by these goals. The government’s health care delivery system faces many problems.
The causes of these problems are diverse, but include some very fundamental
conditions, such as years of low investment and expenditure on health in the state, a
complex administrative structure, and many bureaucratic constraints to better
performance.
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1.10 One natural reaction to this possible mismatch between high expectations and low
capacities can be seen in some of the DoHMFW’s initial strategy documents, which
/propose major new public investments to renovate facilities, build up staff
//(including a new program of community health workers), and other expansions of
7 the existing primary care delivery system. These “programmatic” strategy proposals
/ were not well received by the aid agencies. They were perceived as being requests
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for simply “more of the same”, without a clear strategy for how this would improve
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performance.
1.11 One the aid agency side, there is a clear bias towards thinking about systemic changes
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which is expressed through their comments at state-level strategy meetings and the
reports of their consultants. They are thinking about new strategies for assistance,
such as sectoral aid and financing changes tied to the new sectoral assistance
instrument. They are promoting broader linkages with other social development and
poverty alleviation initiatives, strategies which build on underlying governance
changes such as panchayati raj and janmabhoomi, and more effort to link
government health strategies with the private sector and major reforms in health care
financing.
1.13 A third dimension is introduced by the urgent pressures on the DoHMFW and its key
units and officers (Directorate of Health, Commissioner of Family Welfare,
APWP) to develop and monitor specific operational and performance indicators on
a regular basis. The Chief Minister shows strong personal interest in this process and
future budget allocations have been tied to reported performance achievements. This
performance monitoring activity increases the pressure on the DoHMFW to look for
short-term strategies to improve performance indicators. Conversely, medium- and
longer-term strategies which may require some research and analysis, or about which
there is significant uncertainty, become relatively less attractive as priorities. This
message came through very clearly from our meetings with Mrs. Rachel Chatteqee.
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1.14 Yet another dimension concerns the views of stakeholders outside the DoHMFW and
interested aid agencies. This includes government departments with broader poverty
and social development focus, NGOs, panchayati raj institutions, and other elements
of civil society. This dimension was exammed by the members of our team dealing
with social development and governance, although this was limited by the time
available. It is clear from our investigations, however, that a xMTSEF for health
cannot be limited only to those institutions that make up the formal government
health care service delivery institutions. The development of a MTSEF must be
done with significant input from a wide range of stakeholders.
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How can the MTSEF process address these concerns?
1.15 Our response to these concerns is to propose a balanced strategy with both short and
longer-term elements and both systemic and programmatic elements, We feel that
stakeholders in the GoAP cannot (and should not) focus solely on the systemic
issues, nor should they focus solely on the urgent programmatic issues.
1.16 We also propose a process through which institutions in A.P. can work together to
consider these options and develop specific implementation plans.
1.
Overview of Health and Health Sector Situation in Andhra Pradesh
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1.16 Recent national and state-level analyses of health and the health sector have provided a
reasonably current and consistant picture of the overall situation in Andhra Pradesh. It is
not the intention of this report to restate this information or provide another substantial
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analysis of these issues. But review of a few key points are important to set the stage for
development of a MTSEF.
a.
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Health statusJjuA.P. is about average in All-India comparisons but
lags behind the performance of other southern states.
1.18 As shown in Table 1, for these key child and women’s health indicators, A.P. ‘s
performance is somewhat behind the achievements of the other southern states it views as
appropriate comparators. It is this lagging position that provides one of the key stimuli to
emphasis given by the Chief Minister to health goals in Vision 2020.
Table 1: Comparative Health Outcome Indicators (1996-8)
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Infant
Mortality
Rate
67.6
65.8
51.5
16.3
48.2
All India Average
Andhra Pradesh
Karnataka______
Kerala_________
Tamil Nadu
Child
Mortality
Rate
94.9
85.5
69.8
18.8
63.3
% of Children % of Women
with Anaemia with Anaemia
(6-35 months) (15-49 years)
51.8
74.3
49.8
72.3
42.4
70.6
22.7
43.9
56.5
69.0
Total
Fertility
Rate
2.9
2.3
2.1
2.0
2.2
Source NFHS II, as reported in Pearson, et al “Impact and Expenditure Review, Part 1.”, Draft, DfID, 2002.
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1.19
1.19 Table 2 provides a comparison of some key health service output indicators. Interestingly,
on many of these A.P. performance well above the all-India average and sometimes above
the levels of neighboring southern states.
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Table 2: Comparative Health Service Indicators
% Children
Receiving All
Vaccinations
% of
% % of Births
%
% Mamed Stenlisat % of Pregnant % of Pregnant
Pregnant Instit Attended by Children
Women
Women
ion
Women
Receiving
Health
Receiving at Receiving at Women Deliver
Using any
Professional at least 1
Recaving ies
least 2
least 1 Ante
Contracepnve
Vitamin A
Folic
Tetanus
Natal Check
Method
Acid
65.4
9X7
Toxoid
Injections
66.8
8L5
57.6
8L2
33.6
49.8
42.3
65.2
Suppiemen
t
29.7
241
86.3
9^8
98T
74.9
867
957
78.0
952
932
51.1
910
793
59.1
94.0
83.8
48.4
43.6
16.2
Up
All India
Andhra
42.0
587
48.2
36.0
597
sTo
60.0
58.3
617
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52.1
Pradesh
2
Karnataka
Kerala
Tamil Nadu
79.7
88.8
51.0
46.0
Source: NFHS 2, 1999, as reported in Pearson, et al “Impact and Expenditure Review, Part 1.”, Draft,
DfID, 2002.
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Government health expenditure in A.P .is relatively low
1.20 In terms of overall health expenditure, A.P. also shows a below average level of public
spending, lagging behind other southern states in both absolute (Rs. Per capita) and
relative (Percent of SDP) terms. Figure 1 presents of these figures.
1.21 In terms of private spending, A.P. is somewhat above the all-India average, as shown in
Figure 2. This may reflect the relatively lower level of public spending and an above
average propensity to consume health care. It also probably represents an above average
out-of-pocket financial burden, which survey data suggests significantly affects the poor.
Figure 1: Public Spending on Health in States, 1995-96
K e ra la
la
1 32R I ,/$4
| 1 23 R • J$ 3.7
P u nja b
TN
□
□
1 02 R » ./$ 3
Q SR s /S 3 I
□
a
a
S3 R ■ ./$ 2 .8
88R » /$ 2 . 7
8 5R ■ ./.$ 2.5
0 ri s s a
uP
1 8R * ./$ 2.3
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72R4./S2.2
68RI./S2
M P
B iha r
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1 04 R s ./$ 3 1
G u |a ra t
Andhra Pradesh
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1 02 R » ./$ 3
M aharashtra
W B
w
1 08 R i /$ 3 1
Assam
H a rya na
0
12ORI /53 6
R a |a s th a n
Karnataka
p
□
0
s 7R • ./s t .7
2 5
50
75
El C entral P er capita
1 00
1 5 0
1 2 5
■ S late P er capita
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Source: World Bank, 2001 “Raising the Sights”, New Delhi, citing Selvaraju 2000.
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Figure 2: Private Spending on Health in States: 1995-96 (Rs.)
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RAJASTHAN
I
B IH AR
KARNATAKA
O R IS S A
NORTH EAST
GUJARAT
TAM IL NADU
MADHYA PRADESH
I
W EST BENGAL
1
ALL IN O IA
ANDHRA PRADESH
MAHARASHTRA
UTTAR
PRADESH
HARYANA
PUNJAB
KERALA
0
1 00
■ Out of Pocket to Pub lie Fac ititie s
2 00
3 00
4 00
500
■ Out of Pocket to Private Facilities
Source: World Bank, 2001 “Raising the Sights’’, New Delhi.
C.
Government Health Care Delivery Faces Significant Systemic
Constraints
1.22 In terms of health system capacity, A.P. has an overall structure of governmental health
facilities similar to that found in other Indian states. It has benefitted in recent years from
significant new investments in government hospitals at the “first referral” level, using a
loan from the World Bank.
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1.23 The private health care sector is discussed in some detail in Annex . Recent studies
suggest that private health care is much larger than regular government data suggest, but
it is not clear whether this indicates that A.P. has a large private sector relative to most
Indian states or simply has compiled more complete data.
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1.24 One key issue in public health care delivery is shown in Table 3 - the issue of vacant
posts. A.P. has a significant number of vacant positions in government health facilities,
both physicians and paramedical staff. The latter is particularly important in terms of
ability to deliver services through the major communicable disease control programs.
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-/Table 3: Cadre Strength - Department of Health
Doctors__________
Paramedical______
Gazetted Officers
Ministerial & Others
Sanctioned
2478
16,862
710
7157
Working
1996
14,640
563
6545
Vacancies
' 482
' 2,222
147
' 612
Source: Pearson, et al “Impact and Expenditure Review, Part 1.”, Draft, DflD, 2002.
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Health System and Governance Innovations in Andhra Pradesh
1.25 As stated above, we believe a MTSEF for A.P. must balance “systemic” and
programmatic reforms in a strategy that mcludes both actions that can be earned out
quickly to improve health system performance as well as actions that may require more
information, analysis, and testing. Systemic reforms need to be considered for two
important reasons. First, we believe that simply increasing government funding of
existing health programs, institutions, and strategies is a necessary, but is not a sufficient
approach to improving performance - there are important underlying constraints to better
performance that cannot be addressed in this way. Systemic changes in governance and
management of the public health system are needed to be able to implement many of the
operational improvements which can lead to performance gams. And second, there are
significant systemic changes taking place outside the health system - for example,
panchayati raj, the expanding private health care sector, and major programs of social
mobilization such as janmabhoomi, which offer potentially greater opportunities for
performance gains than those available within the government health system alone.
1.26 Fortunately, the GoAP and the DoHMFW are quite receptive to ideas of systemic reform
and innovation. Indeed, A.P. has been a leader among states in India in developing certam
health system innovations. Some recent examples of these include:
The APWP, a para-statal commissionerate which manages all government
district and first-level referral hospitals in the State, with some
independence from government rules and regulations — a type of
“hospital autonomy” strategy.
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Development of other para-statal entities to manage procurement of drugs and
supplies and physical facilities and capital investment programs
(APHMHIDC) and traditional and Indian systems of medicine facilities
(APYP).
iii.
Introduction of option for contracting of medical and paramedical staff to fill
vacancies in government posts.
iv.
Development of user fees in public hospitals and other facilities
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New law on regulation on private health care providers, with specific rules and
procedures currently being developed.
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Development of financial incentives in the family welfare program for poor
households: sukhibava, to encourage institutional deliveries by poor
mothers; and arrogyaraksha, a type of financial health insurance
coverage for families with two children who accept to have sterilization.
vii.
As in other states in India, increased use state and district-level “societies to
manage specific disease control activities such as TB, HIV/AIDS, etc.
viii.
vm. The strong commitment to performance monitoring developed for Vision
2020 itself is an indication of the interest of the GoAP in refomung the
governance and management of the public sector.
1.27
1.27 These and other initiatives indicate that the GoAP is not averse to implementing
institutional reforms and innovations. The more relevant question is whether these
reforms have been designed and selected based on an analysis ot their likely impact on
the health system performance outcomes which have been given pnority in A.P. In our
view, while A.P. has had significant reform initiatives, it has not had a coherent program
of systemic reform designed to address pnonty health and other goals.
A Diagnostic Framework for a Medium Term Health Sector Strategy
3.
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1.28 There have been several efforts to put forward a strategy for the health sector in A.P. We
can identify the following:
1.
DoHMFW has been instructed to develop specific plans for “operationalizing”
Vision 2020 and for monitoring performance towards achievement of the
Vision 2020 goals. Much of this operationalization and performance
monitoring relates to increasing coverage with existing service delivery and
public health programs. One important new initiative proposed under Vision
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Vision 2020 identifies the following health goals: IMR to 10, CMR to 20, life
expectancy of 68.1 and 70.6 years for men and women respectively,
TFR of 1.5 and population growth rate of .8 percent per year. To achieve
these goals a seven-pomt set of “key priorities” is proposed: providing
universal access to primary health care; encouraging private investment
in tertiary health care; focusing on specific programs to promote family
welfare, particularly the health of women and children, and family
planning; focusing on improving health levels in disadvantaged groups
and backward regions; ensuring a strong prevention focus; enhancing
the performance of the public health system; and formulating a State
EEC program, which includes leveraging the electronic media
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2020 is expanding the development of Village Health Workers in Tribal
Areas.
ii.
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Two recent DoHMFW documents propose health sector strategies: “Strategy
Paper on Health and Family Welfare” (January 2001) and “Strategy
Document on Health Policy” (no date). Two reports are also available
from strategy development meetings: “Health Strategy Meeting with
DflD, March 13, 2001” and “Proceedings of the Strategy Development
Workshop for Health Sector in Andhra Pradesh, April 24-25, 2001.”
Our review of these documents suggests that much of what they contain
are proposals tor increasing public expenditure on existing institutions
and service delivery programs with a focus on more inputs and
expanding the numbers of areas covered by different activities.
Although it preceded at least one of these meetings, the report by Pearson et al
“Impact and Expenditure Review: Health Sector, Part 2 Policy
Analysis while commenting positively on the development of
quantified health goals and inclusion of some innovative strategies,
offered a sharp critique of these efforts. The critique included comments
that the specific strategic proposals were unrealistic, not clearly linked
with the goals of Vision 2020, lacked an analysis of constraints in the
health system, were not well prioritized, lacked a financing and
monitoring plan, and didn’t specify a process for further development
and implementation. DflD response to these efforts also indicated
dissatisfaction with the types of strategies proposed.
1.29 These previous benchmarks represent a not-inconsiderable effort of human and other
resources to develop a health sector strategy for A.P. This effort did not result in
development of a satisfactory strategy. These activities were followed by the current
contract to IHSG. How can we encourage progress beyond the current state of discussion,
learning from previous experience?
1.30 Developing a MTSEF requires devising a technically and politically feasible strategy that,
based on available evidence, has the potential to improve the performance of the health
system of A.P. in terms of a set of socially desirable outcomes. This strategy must also be
financially feasible in an environment of very limited resources and where the amount of
discretionary resources is likely to be only a modest share of the total. In A.P. one must
also consider: the high profile goal statement of the Chief Minister in Vision 2020 and the
associated efforts to have the DoHMFW operationalize and monitor efforts to achieve
those goals; and the potential to mobilize significant new resources committed in the
state’s five-year financial plan.
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The MTSEF should be based on1:
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Identification of health system performance problems in terms of ultimate
outcomes and intermediate outcomes
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A diagnosis of the causes of these problems, based on evidence and an explicit
logical framework
•
Linkage of the diagnosis (the causes of problems) to specific areas of health
system policy, policy change, and intervention strategies to improve
performance - the control knobs of the health system. This would be the
technical basis for the MTSEF.
•
Development of a plan for implementing change and the costing of that plan,
with reference to the available resources. This would be specific content of the
MTSEF.
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To be effective, these steps should be earned out m collaboration with colleagues in A.P.
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and accepted by them as viable and useful basis for action. This is not a small exercise in
a place as large and complex as an Indian state, especially if one wants to develop a
substantive causal analysis and identify appropnate interventions based on evidence.
Phase 1 of this exercise can make some progress on steps 1-3 above and offer some
recommendations on step 4. But a further process of consultation with counterparts in
A.P. and more detailed planning and analysis will certainly be needed to develop a full
MTSEF.
Figures 3 and Table 4 outline the key elements of the diagnostic approach that we began
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to develop in A.P. as part of the Phase 1 work. Figure 3 provides an overview of the
diagnostic approach. It begins, properly, with the ultimate outcomes of health system
performance that A.P. seeks to achieve with its health strategy.
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133 It is important that the strategy be based on a frank and serious assessment of goals. At
this time, the main basis for this is the Vision 2020 document, which emphasizes major
health outcomes such as IMR, CMR, MMR, and overall life expectancy. Vision 2020
also highlights the importance of improving these outcomes among the poor and
disadvantaged populations of the state.
1.34 The goals outlined in Vision 2020 are very ambitious. It is certainly impossible to achieve
these goals without having a major impact on the health conditions of the poor. It was
also noted by several members of our team that the health status gains highlighted in
Vision 2020 depend significantly on factors which the health care system can affect only
1 This framework is based on Roberts, Hsiao, Berman, and Reich (jetting Health Reform Right
forthcoming 2002.
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to a limited extent, such as nutritional status, age at mamage, and women’s
status.
1.36 Vision 2020 diso
also includes oojectives
objectives and strategies related to increasing access and
improving quality of hospital-based services through government efforts, as well as
increasing private participation in the development of ternary services. These strategies
would likely have only a limited direct affect on the pnonty health outcomes at
population level.
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1.36 Figure 1 adds to the Vision 2020 outcomes another dimension of health system
performance - financial protection for the poor from the high costs of illness and health
care. This is typically one of the implicit goals of free public service delivery, especially
free or highly subsidized inpatient treatment, which has been a high pnonty in A.P.
through the first referral hospital project.
1.37 Figure 1 links these ultimate outcomes to intermediate outcomes, which are typically the
more observable characteristics of the health care system. These are related’ to a
diagnostic and causal analysis and then back to strategies for change. Change strategies
are developed by drawing on the evidence and technical content of different dimensions
of reform, which we conceptualize as the five health system “control knobs” shown in the
nght-hand panel.
1.38 The Strategies for Change panel (second from right) represents one of the key
conceptual results of our Phase 1 work. Development of the MTSEF must find a balance
across several important dimensions of potential strategy development. It must be
substantive enough to make a difference, yet not so complex or comprehensive that it is
not feasible to plan or implement. It must address health care system factors, but also
broader social development factors. It must provide guidance on actions that can be
undertaken immediately or in the short-term, but also address longer-term strategies. It
must consider both “systemic” and “programmatic” changes.
1.39 Under Strategies for Change” we have listed 4 major headings:
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13
•
Improving the functioning of governmental health care services and programs.
(Focus more on programmatic and short-term changes, with some attention to
systemic and longer-term changes).
•
Strengthening broader poverty and social development programs,
decentralization and governance reforms and their linkages with health
outcomes and health programs. (Focus more on social development and non
health-system determinants of outcomes and performance, improving
management skills, strengthen ment motivations, developing local accountability
and responding to local health status needs. Both shorter and longer-term
changes).
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•
Development of new policies and strategies to enhance the contribution of
private providers. (Mainly systemic changes but some programmatic changes.
changes,
with both shorter and longer-term actions).
•
Development of new financing strategies to mobilize resources and improve the
use of resources. (Mainly systemic changes but some programmatic changes,
with both short and longer-term actions).
Page
We believe these provide a substantive yet feasible agenda for MTSEF development.
1.40 Table 4 expands the central panel of Figure 3, the diagnostic and causal analysis of
factors determining health system performance. In Table 4 we have listed some of the
main factors identified by team members in their reports. Much greater detail and
discussion of these and other factors are contained in the individual reports, which are
annexes to this summary report.
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Figure 3:
Broad Diagnostic Fraemework for A.P. MTSEF
Intermediate
Ultimate
Outcomes
Outcomes
Health Status
Goals (as per
Vision 2020
and other
priorities)
1MR
CMR
MMR
Improving the
functioning of
governmental
health care
services and
programs
Technical and
Perceived
Quality of
Health Care
Services
LE
Fertility
With particular
focus on poor
and
disadvantaged
populations
Financial
Protection for
poor
populations
from high cost
of illness and
health care.
Control
Knobs
Strategies
for Change
Diagnostic and
Causal Analysis
Access to health
care services
◄
i
See
Table 4
Efficiency of
resource
allocation and
resource use in
producing health
care services
◄
Strengthening
broader poverty
and social
development
programs and
governance
reforms and their
linkages with
health outcomes
and health
programs
Development of
new policies and
strategies to
enhance the
contribution of
private providers
Financial burden
of out-of-pocket
and other costs
for health care
on the poor
Development of
new financing
strategies to
mobilize
resources and
improve the use of
resources.
15
Finance
Payment and
incentives
◄
Organization
Regulation
Behavior
3
Table 4
Some Causal Factors in Poor Performance Highlighted in Team Member Reports
Government Service Delivery
Limited ability to deliver services in communities: e.g.
I
Weak support for ANMs, community-based workers
Overemphasis on facility-based approach
Poorly designed target focus in programs
Weak management skills and systems
Inadequate information systems
Low motivation of health staff at all levels
Unfilled staff positions
Lack of essential supplies and other inputs
Lack of financial and other incentives for peripheral workers
I
Weak linkage with broader social development and poverty alleviation programs
fl
I
Some priority outcomes closely linked to broader social conditions such as age at
marriage, literacy and education, nutrition.
_
_
Private Sector Service Delivery
.1
Widespread access to unregulated , less-than-fully-qualified providers, especially for
lower income groups
High rates of utilization of unqualified providers for health needs given high priority
i
for achieving targeted outcomes
Limited participation for qualified and less-than-fully-qualified providers in
information and outreach activities to address priority health outcomes
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Lack of information on numbers, types, and roles of private providers and weak
regulation of private health care providers
_
_
Governance, Organization, and Decentralization
Lack of significant deconcentration of authority and responsibility to
district levels limiting management flexibility by health staff to promote
efficiency and responsiveness
Lack of significant devolution of authority and responsibility to PRI and
health advisory committees limiting local responsiveness, accountability and
participation and discouraging mobilization of local resources
16
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Table 4
Some Causal Factors in Poor Performance Highlighted in Team Member Reports
Government Service Delivery
Limited ability to deliver services in communities: e.g.
Weak support for ANMs, community-based workers
Overemphasis on facility-based approach
Poorly designed target focus in programs
Weak management skills and systems
Inadequate information systems
Low motivation of health staff at all levels
Unfilled staff positions
Lack of essential supplies and other inputs
Lack of financial and other incentives for peripheral workers
Weak linkage with broader social development and poverty alleviation programs
Some pnority outcomes closely linked to broader social conditions such as age at
mamage, literacy and education, nutntion.
Private Sector Service Delivery
Widespread access to unregulated , less-than-fully-qualified providers, especially for
lower income groups
I
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High rates of utilization of unqualified providers for health needs given high pnority
for achieving targeted outcomes
Limited participation for qualified and less-than-fully-qualified providers in
information and outreach activities to address pnority health outcomes
I
1
Lack of information on numbers, types, and roles of private providers and weak
regulation of private health care providers
r
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a
Governance, Organization, and Decentralization
Lack of significant deconcentration of authority and responsibility to
district levels limiting management flexibility by health staff to promote
efficiency and responsiveness
II
Lack of significant devolution of authority and responsibility to PRI and
health advisory committees limiting local responsiveness, accountability and
participation and discouraging mobilization of local resources
Complex and (likely to be) inequitable allocation of resources from state to
districts ending up exaggerating existing inequities in resources and income
among districts
3
Civil Service rules of recruitment, promotion and incentives that discourage
initiatives, good performance, efficiency and responsiveness to patients
Lack of sufficient training and lack of consistent training capacity
especially in management and financial control at all levels
Poor worker motivation, lack of appropnate organizational culture, and
avenues of corruption in staffing selection and promotion and procurement.
Lack of staff in essential positions in state and district administrations .Lack of
essential skills and training in some state, district, and lower level institutions.
Complex organizational structure of line departments, commissionerates, societies
with unclear lines of responsibility and accountability in relation to service delivery
activities.
_____________
Broader Social Development Linkages
Insufficient coordination and linkage between health priorities and interventions and
community-based social mobilization programs, especially women’s empowerment
initiatives
Insufficient targeting of resources to poverty groups and disadvantaged populations.
Inadequate attention to role of gender and socio-economic factors as causal factors in
poor outcomes that need to be addressed to improve outcomes.
|
ii
!
!
Models exist for more successful collaboration, but their implementation is limited
Lack of effective forum for NGO involvement in health program strategy and
development____________________________ _ ___________________________
18
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Health Financing
Low level of government health spending overall in comparison with other Indian
states.
Imbalance between plan and investment spending and ability to support ongoing
recurrent costs of existing facilities and programs, especially personnel and
consumable supplies and drugs. This is exacerbated by mandated wage increases for
government employees.
Lack of adequate information on total health financing and non-govemment flows to
health sector
Inadequate efforts to develop new resource mobilization strategies, such as locallycontrolled health funds
Weak resource mobilization through user charges and insufficient attention to issues of
| equity and access effects of charges impacting on poor
5.
J
Preliminary List of Short- and Medium-Term Actions
1.41 Team member reports (Annexes 1-7) contain sections listing short-term and medium
term actions recommended for inclusion in the medium-term strategy. As shown in
Figure 3, these recommendations have been bundled under four broad areas of strategy.
1.42 Short-term actions are those which our team feels can be initiated quickly and require
little new information, analysis, or experimentation. However, they will require that
choices be made on priorities. They also require detailed planning and budgeting, a key
task for Phase 2. These short-term actions can be expected to provide some improvements
in terms of the intermediate outcomes which should offer some benefits in terms of better
performance on the ultimate outcomes. They emphasize more the programmatic changes.
1.43 The medium-term actions are those which require more information, analysis, planning,
and experimentation. These actions emphasize more the systemic changes, addressing
more complex underlying causes of poor performance, broader social development
linkages, and changes which may be more difficult to design and implement. Again,
choices need to be made on priorities and detailed planning and budgeting is needed once
specific action strategies are determined.
1.44 We are very concerned to preface these recommendations with a strong caveat. The
suggestions in Tables 5 and 6 were formulated based a short field visit and the
information that was available prior to and during that visit. They should not be viewed as
a comprehensive strategy, but rather as an initial set of ideas towards the development of
such a strategy. They can provide the basis for discussion and decision-making by the
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Table 5
Recommendations for Short-Term Actions as Part of Health Sector Strategy
Government Service
Delivery
Broader Social Development and Governance
Linkages
Links to poverty,
gender, broader social
development and civil
society__________
Pilot greater authority to Create forum for review,
Expand community
discussion, debate about
institutions in
district
based distribution
between social
running priority health
channels for essential
development
programs.
commodities
stakeholders and health
Develop matching grants program stakeholders.
Community-based
program to encourage
disinfection of water
Assure that health sector
district and local level
supplies
has representation on
financing and
government task
innovations.
Targetted community
forces/working groups
based disease control
on
poverty and social
Revise formula for
activities focussed on
development.
resource transfers to
specific problems in
districts
to
focus
more
specific areas
Increase information,
on areas with higher
education, and treatment
Public awards and notice health needs in relation
activities through
to priority outcomes.
for communities with
community groups,
successful health
health melas
Increase
representation
mobilization
of civil society on
Expand coverage to
district-level health
Closer links of
Private Sector Service
Delivery
Health Financing
Create senior state-level
post with responsibility
and budget for
developing government
private provider
collaborations to address
priority health problems.
Develop state and
district health accounts
for planning on ongoing
basis. Includes training
and capacity building for
health accounting and
computerizing accounts.
Create state-level
committee to review
current govt-private
collaborations and
propose strategy. Should
involve key
stakeholders.
Define and cost
appropriate benefit
package for different
financing scenarios.
Decentralization and
Governance Strategies
Assess current user
charges implementation
in terms of resource
mobilization,
Assess Sukhibhava
contribution to health
program for cost and
effectiveness. Implement care quality and
efficiency, and impact
recommendations.
on poor. _________
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supervision and
cooperation between
ANMs and PRIs
Narrow and focus work
assignments of ANMs
New ANM training and
better supply of
commodities
New models for ANM
residence either by
improving housing in
village or providing
transport for them to live
in nearby towns.
Restructuring efforts to
address maternal
mortality, for example,
developing emergency
transfer services for high
risk deliveries with
community involvement
j
committees.
Monitor performance of
PRI institutions related
to health programs.
Strengthen performance
monitoring system.
Strengthen role of
advisory boards .
Make contract
employment are reality
through higher payments
and incentives for
remote areas.
Review experience with
user fees to reform for
significant contribution
to health facilities.
scale with positively
evaluated community
programs like urban link
volunteers.
Link health with efforts
to reduce child labor.
Develop more
disaggregated health and
monitoring data
capturing socio
economic and gender
aspects, not only
geographical
differences.
Develop database on
NGO activities in health
and use this to increase
involvement of NGOs in
priority programs.
Assess current efforts to
integrate private
providers in all disease
control programs. Fill
gaps and inaction caused
by lack of staff,
operational resources,
attention.
Require all disease
control programs to
develop action plans for
govt-private
collaboration.
Focus new finances on
non-salary inputs to
PHCs.
Increase advocacy to
raise government
allocation to health.
Enforce rules on care for
poor in public hospitals
Launch new DoHMFW
initiative to provide
information and health
promotion materials on
priority problems to
private providers.
Develop training
programs for private
providers on disease
control priorities and
strategies.
Increasing the
reproductive health
elements of the family
welfare service package
21
A
-
Shift from focus on
output targets to better
performance measures.
Major push to introduce
reproductive health
approach throughout
family welfare program,
with new training,
activities, etc.
Restructuring of
provision and financing
of drugs and supplies to
assure adequate inputs at
primary level with more
co-financing at
secondary and tertiary
levels.
Develop initiative to
strengthen skills and
capacities of ANMs,
moving towards a
“women’s health
service”.
Review and develop
strategies to deal with
underlying issues like
age at marriage and
chronic undemutrition.
mandal panchayat
oversight of PHC.
Develop accreditation
and quality assurance
scheme for private
providers and diagnostic
facilities.
Experiment with new
finance and organization
strategies for private
providers, e.g. family
doctor model with new
financing approach in
rural areas.
Develop state database
on private and NGO
providers, including
fixed practice LTFQ
providers.
Major replanning of role
of institutional deliveries
in reducing MMR.
Develop and test
strategies to involve
LTFQ providers in
priority health programs.
More focus on effective
treatment of
communicable diseases.
Monitor and evaluate
new initiatives.____
23
mu m
6.
Some Thoughts on Priorities
1.45 Sending a team of seven experts to think about strategy in a large Indian state with a
wide range of potentials and problems is a sure recipe for a long list of ideas and
proposals. Predictably, our team offers many ideas on things that ought to be done and
could be done.
1.46 Collectively though, we are concerned that launching too many initiatives across
too broad a front could lead to a lot of activity but not much progress. We have proposed
four broad areas for strategy development and action to introduce some focus. But this is
not sufficient. We strongly that the subsequent steps of consultation and planning identify
a manageable set of priorities to move forward. The following are some thoughts on areas
that could be given high consideration.
•
Assuring adequate financing for health interventions. Annex
on Health Care
Financing argues convincingly for both short and medium-term action to assure that
funds are channeled to priority health needs. There are clear contradictions in the
GoAP’s current strategies - proposed increased financing for primary care, but real
constraints to increasing the government’s overall health expenditure envelope. The
DoHMFW needs to move aggressively in the short-term to assess what it needs and
put forward claims for additional resources, rather than waiting for others to define
the constraints. For the medium-term, new strategies of finance, payment, and
organization must be developed and tested to move beyond the limited potential of a
bureaucratically-organized public delivery system.
•
Focusing reforms on priority needs and populations. Improving the operational
performance of government health services, strengthening capacities and roles of
local governments, and effective linkages with broader social development and
poverty alleviation programs can all contribute to better outcomes, both in the shortand medium-term. Would it not make sense to link these different strategies together
with a focus on several priority health needs and populations (specific communicable
diseases, or children’s infections of the poor, for example), rather than view them
“top-down” as broad strategies. The recent work by the World Bank to identify the
pathways resulting in poor outcomes may be helpful in this focus. The critique of this
approach - that it leads to wasted efforts through excessive “vertical” strategies, also
needs to be considered.
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A serious commitment to making decentralization work for health. One of the
constraints to comprehensive action is the limited capacity of the DoHMFW at state
level to manage widespread innovation will still running an immense vertical delivery
system. Even APVVP, one of the state’s major reforms, does not go that far in
reducing centralized management and control, although it does move this somewhat
out of the direct bureaucratic line. One strategy for increasing the potential for
innovation and change is to give greater authority to district and mandal panchayat
institutions. However, as Annex
on decentralization highlights, this requires
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substantial commitment to proper design and strengthening capacities at lower levels
of government and in civil society.
•
Learning how to build on the existing capacities of private health care_providers. One
of the most striking facts emerging from recent health systems analyses in India is the
high level of access to ambulatory care treatments in both rural and urban areas. Even
highly disadvantaged populations do obtain care for many priority problems. But they
do so mainly from non-govemment providers. This “access” to care often means poor
quality and a high out-of-pocket cost burden. But shall this private provision capacity,
which far exceeds that of government services, be ignored? This is a major task for
medium-term development which may offer great potential for improved outcomes.
7.
Proposed Work Plan for Fuller Development of a Medium-Term Strategy
and Expenditure Framework
3
147 The situation analysis, strategic and diagnostic framework, action
recommendations, and individual team member reports contained in this Phase 1 report
provide the basis for a more subsUntial process of developing a MTSEF, in collaboration
with colleagues in A.P. This section of our report proposes how Phase 2 of this process
could proceed.
■w
1.48 The DoHMFW in A.P. is working with several deadlines which must be considered
iii nlanning Phase 2. A draft (at least preliminary) strategy and expenditure framework is
expected to be prepared by September 30, 2002, as part of the state’s obligations under
the structural adjustment loan/credit. A more fully developed work plan may be needed
by end December. A complete MTSEF is expected by late March/early April 2003.
1.49 Another key step is for colleagues at DfID and GoAP to review this report and
decide to proceed with Phase 2. In practical terms, moving ahead with Phase 2 also needs
DfID to put in place additional funds and a new contract or contract extension with
IHSG.
-4
1.50 We propose that Phase 2 be planned; as a 12-18 month exercise, beginning on July
The following work plan is
29,2002 .----’ put forward for discussion:
■ y jk vy
wv
— ——— — ~
A
,
May 30
Receipt of draft Phase 1 report by DfID and GoAP
May 31-June 20
Review and discussion of report, comments back to IHSG. Final
report submitted. Decision to proceed with Phase 2.
June 20- July 20
IHSG proposes core team and consultant list for Phase 2, along
with specific TOR and budget. Negotiations with DfID and GoAP.
Final agreement and approval of Phase 2 contract.
25
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Week of July 29
Launch workshop for Phase 2 in A.P. Working groups address four
main strategy areas, develop work plans and working teams for
developing MTSEF
August/S eptember
IHSG team and GoAP counterparts initiate work on specific areas
of MTSEF. Preliminary strategy and expenditure framework draft
completed by September 30, 2002. This based on significant work
to define resource envelope for financing strategy and indicative
costs for main areas. Some stakeholder consultations organized
during this period.
October, 2002 March, 2003
April, 2003July, 2003
J
August, 2003January, 2004
a.
IHSG core team, consultants, GoAP counterparts continue work on
specific areas of strategy development and costing. More extensive
stakeholder consultations organized during this period. Draft
MTSEF prepared by end March.
IHSG core team, consultants, GoAP counterparts continue work on
strategy, with focus on medium-term activities, design of pilots
and experiments, and monitoring/evaluation activities. Develop
and cost proposals for pilots and experiments for review by DfID,
World Bank, others. Draft MTSEF revised and completed based
on final consultations with stakeholders and GoAP counterparts.
Further investigations, field set up of pilots and experiments,
secure funding for development of medium-term strategies,
including implementation, monitoring and evaluation. Lead into
Phase 3.
F
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1
Staffing the Plan
1.51 In order to implement this plan, human resources must be allocated to these tasks by
the IHSG team and the GoAP. We propose that the GoAP steering committee could be
the nodal point for collaboration, under the direction of the Principal Secretary, Health,
Mrs. Rachel Chatterjee. We request that Mrs. Chatterjee appoint a senior officer as
liaison with the IHSG team.
1.52 If IHSG involvement is requested. Prof. Peter Berman could serve as the Team
Leader/Principal Investigator and Dr. Ajay Mahal as the Team Manager. IHSG will
propose a core team of 4-6 advisors, including both external and Indian members. Dr.
Prasanta Mahapatra would also be part of this core team. The core team will make a
significant commitment of time to Phase 2. The Institute of Health Systems could provide
a Hyderabad-based counterpart organization, as it did during Phase 1 and we would
involve other leading Hyderabad-based experts.
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1.53 In addition to the core team, a larger team of short-term consultants and advisors
will be identified, including both external and Indian consultants. This e
Present a broader range of skills and specialties, as needed to develop diffenmt
components of the strategy. For example, this team might include experts in specific
areas of disease control (such as TB) or reproductive health, in health financing,
private sector regulation, or in training. DflD, IHSG, and GoAP woul
appropriate mechanisms for identifying and hiring consultants to work on specific tasks.
1 54 Taking a longer view, A.P. should envisage at least a 3-5 program of sectoral
Vestments and reform, which would likely require ongoing technical support and
significant budget allocation.
4
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References
Annexes 1-7, Individual Team Member reports.
Pearson. M. Impact and Expenditure Review, Part I, Financing and Part II, Policy Issues,
Draft, DfID, New Delhi, 2002.
World Bank, 2001, Raising the Sights for India’s Health System, Washington, World
Bank, Report No. 22304.
If®
1
ll.
28
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Annex 1
Support for Development of a Medium Term
Health Strategy for Andhra Pradesh:
Report of Social Development Team
3
Hilary Standing and Vimala Ramachandran
=s
i.
Annex 1
Support for Development of a Medium Term
Health Strategy for Andhra Pradesh:
I
Report of Social Development Team
Vimala Ramachandran and Dr. Hilary Standing
Al 1
i
d
d
Andhra Pradesh has made significant progress on a number of s0^^el°^
Z to people. Innovative approaches and bold administrative measures have borne
being state-specific guidelines for
fruit on several fronts - noteworthy among them
'3Rs
)
and
more recently (2001) the
extending credit to women’s groups (self-help groups)
to cross-check system generated statistics through
decision of the state government t_ ----,
,
household surveys to not only estimate the number of chddren w'j> are out of school
(never,h= hardest to reach and
level L.egtes with
to l_ —
report reviews social development
-e wealth
can indeed l^ea.
S forge meaningfill convergence at tb. r>~ Xfong’pJo^e's nTS^has
needs of the disadvantaged / vulnerabie through an
outcomes focused rather than a target focused approach
1.
Current situation/underlying concepts /approaches:
a.
Andhra Pradesh - poverty and social profile
ov^r th^-^X^T^rtht S'ani11 iS"
i
rate halved - from 123 to 63.
1 This section draws upon un
2
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1 ■; .*!! ...
In terms of its poverty profile, AP nevertheless represents a mixed picture, with areas and
sectors of strong economic growth and areas of relative stagnation and associated high
levels of deprivation. Approximately 30% of the population is considered to be in
poverty. This is particularly acute in rural areas. Although there are different estimates of
the numbers of rural poor in AP, the GoAP uses a head count ratio of 27%. According to
recent analyses, this is due to lack of creation of off farm employment in rural areas
particularly in the last decade. This in turn has meant that rural wages have stagnated.
This has serious implications in a context where there are high levels of landlessness and
near landlessness.
Al.3 Poverty is prevalent both geographically, in particular districts and in particular
segments of the population, notably scheduled castes/tribes and among women and
children. The GoAP recognises that poverty is multi-dimensional and includes nonincome indicators like literacy, health status, maternal and infant mortality, lack of voice
etc.
Table 1: Social and Economic Development Indicators for Southern States
Indicators_____
Andhra Pradesh Karnataka
Kerala
Tamil Nadu
Literacy
1981
34.1
43.9
78.9
52.6
1991
44.1
56.0
88.9
62.3
1997
54.0
58.0
93.0
70.0
Rank for 1997
11
8
1
4
Female Literacy
1981
23.3
31.7
73.4
39.4
1991
32.7
44.3
86.2
51.3
1997
43.0
50.0
90.0
60.0
Rank for 1997
8
7
1
4
Infant Mortality
1981
86
69
37
91
1991
71
73
17
58
1997
63
53
12
53
Rank for 1997
7
4
1
4
Per capita income
1980
1544
1687
1694
1680
1990
1995
2298
2109
2513
1997
2450
2936
2725
3249
Rank for 1997_____________
9
__7___
8
5
Note: The ranks given in the table arebased on ranking for 14 states, ^
uauaulc from Economic
Abstracted
Survey l999-200(), Ministry of Human Resource Development (l"7-98), World Bank (2000)
see footnote
lontnntp 1 fnr
'■
J
for source of data
i
Al.4 These figures are indicative of the mixed picture in AP. While it compares
^vourably with some northern states, it lags behind its southern neighbours. Education
w zr 63 * m 1^ators are particularly poor for the level of economic development.
edian years of schooling attained by 50% of the population, is only 2.3 years (MIS,
(joA5 and Umcef. 2001). Drop out rates from primary education have been going down
steadily but the number of children dropping out of the system is still quite high. Out of
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every hundred children enrolled in Class-I, only 60 complete Class-V and 42 go on to
complete Class-VII. The drop out rate is higher for girls. Drop out rates among SCs. &
STs. are coming down but only 32% of SC children and 18% of ST children complete
Class VII.
1
Al.5 Literacy levels are low in AP in comparison to its economic status, and
particularly low for women. There is an estimated 180 lakh illiterates in the age group of
15-50 years and 109 lakh adult illiterates in the 15-35 years age group. Within the state,
overall and female literacy rates are relatively high in the Coastal Andhra region and
particularly low in the Telangana region. Only 16% of SC females and 7% of the tribal
female population in rural areas were literate in 1991.
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Al.6 Infant mortality rates in the rural areas remain high. Urban rural differentials in
IMR persist and decline in fertility indicators in rural Andhra Pradesh continues to be
slow. IMR in the rural areas declined marginally from 73 to 70 in the 1990s. IMR is
particularly high among tribal populations - at almost double the state average. The most
recent NFHS survey (1998-99) indicates that fertility rates are also declining in both
urban and rural areas. However, the decline is slower in rural areas. While fertility in
urban areas has already reached replacement level (TFR: 2.07), in rural areas it is about
10% above the replacement level (TFR: 2. 32).
Al.7 Nutritional status in AP compares poorly with other southern states and this has
particularly worrying consequences for the health of the poor. Table 2 shows that there
has been a steady decline in cereal and milk consumption in AP. Table 3 gives frends in
malnutrition in AP for under fives. While severe malnutrition has decreased by 10
percentage points in the last 20 years, aggregate levels of moderate malnutrition have
remained more or less constant.
Table 2: Trends in average consumption of foodstuffs and nutrients (gr./CU/day)
1975-79
1988-90
1996-97
RDA
568
534
496
460
3£
28
30
40
98
82
76
150
59.8
55.7
51.6
60
Source: National Nutrition Monitoring Bureau (NNMB) (see footnote 1)
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2447
2340
2161
2425
Table 3: Trends in nutritional (weight for age) status of 1-5 year old (% of total cohort)
iNutritiorid^es^^^g’^W1""
Boys 1975-79
Boys 1988-90
Boys 1996-97
Girls 1975-79
Girls 1988-90
'Girls 1996-97
Normal & mild
134.1 _________
’48.2_________
43.6_________
143.2 _________
48.1_________
|47.2
Moderate
49.1________
44.9________
49.6 ________
42.7 ________
43.7 ________
45.3
Severe
T6?8
~~
6.9
6,8_______________
14.1
’8.2
i7.5
Source: National Nutrition Monitoring Bureau (NNMB) (see footnote 1)
Al.8 Rates of child labour are very high in AP, especially among SCs and STs. The
Multiple Indicator Survey found that 16% of children aged 5-14 are engaged in
economically productive labour. Rates for SC children are 20.8% and for ST children are
23.7%. They are in turn markedly higher for girls (22.7 and 31.5% respectively). The
bulk of this is in the agriculture and livestock sector, but there are also significant
numbers of children working in manufacturing and domestic service. A Participatory
Poverty Assessment of five towns in AP found that boys work particularly in hotels,
factories and fishing, while girls work in domestic labour and agriculture (DFID 2001)
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Al.9 The same study noted the limited options for the working poor, especially women,
in AP, with a concentration in health harming occupations such as beedi rolling,
construction and in some specific communities - commercial sex work. They are also
vulnerable to higher levels of crime and personal insecurity, indebtedness and inability to
access key entitlements such as ration cards and credit.
Al. 10 Looking beneath the aggregate figures for the state, AP is characterised by
considerable inequalities at district level, as table 4 shows. However, while social and
economic indicators at district level show some broad convergence, it is by no means
exact, particularly for female literacy. This almost certainly suggests the importance of
other factors, such as the social profile of the population and the different performance of
districts in terms of their health and education sectors.
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Table 4: Poverty and Human Development Indicators at the District Level
in Andhra Pradesh
Hurals :
D,StriCtS
Karimnagar
Cuddapah
Nizamabad
East Godavari
West Godavari
Medak
Nellore
Chittor
Khammam
Prakasam
Ranga Reddy
Krishna
Nalgonda
Visakhapatnam
Warangal
Adilabad
Kumool
Guntur
Srikakulam
Ananthapur
Mahbubnagar
Vizayanagaram
^Poverty
1993/94
13.5
16.2
16.2
18.8
21.1
22.2
22.8
23.1
23.8
24.2
24.6
24.6
28.9
30.0
31.4
32.5
35.3
36.9
38.5
39.1
39.7
40.8
Mortality
1991
35
44
41
54
65
52
46
60
47
46
56
30
58
73
59
51
68
38
77
70
77
99
Andhra Pradesh
27.4
73
Literacy
1991
23.4
32.4
21.4
42.3
47.0
19.3
37.0
36.4
30.5
27.1
36.9
45.5
24.9
34.6
26.1
20.6
26.0
35.9
23.5
27.6
18.0
22.5
;Rank Rural . Rank
Fpnvertv
Infant
^Poverty
Mortality
2
i
5
2
4
3
11
4
16
5
10
6
8
7
15
8
7
9
6
10
12
11
1
12
13
13
19
14
14
15
9
16
17
17
3
18
20
19
18
20
21
21
22
22
Literacy
17
9
19
3
1
21
4
8
10
12
5
2
15
7
13
20
14
6
16
11
22
18
32.7
; estimated from Central and State sample of NSS round 1993-94. The
Note: Poverty ratios are
rural poverty line for Andhra Pradesh is Rs. 187.39. Source: see footnote 1
b.
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Health and poverty linkages
status of people and the utilisation of health services is influenced by the extent ot
poverty, social and gender inequality, good governance and geograp ic ocation.
Al.12 Known and documented links between health and poverty: There is now clear
agreement on the ways in which poverty and poor health status interact and reinforce
each other. These hold irrespective of context. These links are noted below:
.
Poor people are more likely to suffer ill-health as a consequence of their greater
exposure to environmental risks - lack of sanitation, clean water, safe waste disposal,
appropriate housing, greater occupational hazards
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Ill health is also a major cause of poverty. If the working poor lose their productive
capacity, household income is severely compromised. Household health expenditure
on serious illness has emerged as a major cause of impoverishment among the rural
poor where there are no safety nets or social protection measures to absorb the shock.
•
The poor pay proportionately more of their income for health care than the better off,
experience poorer quality services and are more likely to live in areas where facilities
and qualified, competent personnel are fewer.
•
Gender inequalities reinforce poverty and health links, particularly in reproducing
inequalities in access to household and community resources for managing health
care.
•
Many communicable diseases are “diseases of the poor.” For instance in AP, much
of the malaria burden is in the predominantly forested, tribal areas. TB rates are
particularly high among tribal men (Prasad et.al.), reinforced by poor living
conditions. HIV/AIDS is more prevalent among migrant labourers. Diarrhoea and
respiratory diseases remain major causes of infant mortality and morbidity among the
poor.
•
Poor nutrition has complex and wide ranging effects on health status throughout the
life cycle of human reproduction.
•
Poor people have less social and political voice. They are less likely to know their
entitlements and to make demands on government and on agencies that provide
services.
c.
Other social and health indicators in AP
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Al.14 Patterns of marriage and childbearing in AP both reflect and reinforce the poverty
profile and lead to poorer health outcomes. Age at marriage is very low and compares
unfavourably with other southern states. In the age group 15-19, 54% of women are ever
married. The Multiple Indicators Survey (MIS) puts the mean age at marriage as 15.3
(14.7 in rural areas and 16.7 in urban areas). Mean age at marriage of illiterate women
and for scheduled caste and scheduled tribe women is about 14, while for high school
graduates and above, it is 19.2, testifying to the critical importance of completed years of
education in raising the age of marriage.
Al. 15 Early marriage also means early childbearing, with the first pregnancy typically
following one year to 18 months after. 62.8% of women married before the age of 20
have experienced pregnancy. This is the major contributing factor to the very high rates
of pregnancy wastage in first pregnancies (17%). As many as 23% of pregnancies to
women aged 15-19 did not end in a live birth (MIS). This pattern of very early marriage
and childbearing combines with a high use of terminal methods of contraception after
two or three closely spaced live births. Of the 60% of couples reporting use of any
method of contraception, 58% are using sterilisation.
IF
7
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Al. 16 According to the MIS survey, rates of institutional delivery inl rural areas are still
low. A notable finding is the insignificance of PHCs / sub centres in <deliveries. Even in
rural areas, significant numbers of women are opting to deliver in private hospitals.
While in urban areas, half of all deliveries are taking place in private facilities.
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Table 5: Place of delivery, women aged 14-59 who delivered in the year preceding survey
Urban______________
32.7___________ __
49.0
~
00.0__________ __
15.0___________ _____
3.3
________ __
Rural
Place of delivery
13.8
Government hospital
33.4
Private facility
00.0
PHC/sub centre
51.3
Home____________
1.6
Missing___________
Source: MIS, GoAP and Unicef, 2001
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A1.16 Immunisation coverage is a cause for concern. Coverage for some individual
vaccines is high, but only 46% of children aged between 12-23 months are fully
immunised (53% urban, 46% rural). Only 32% of SC/ST children are fully immunised,
compared to 49% for the rest of the population. No significant gender differentials were
found (MIS).
Al 17 Sanitation facilities are severely lacking in rural areas in particular. Only 17/o of
households use any type of toilet facility. More than 50% of all households dispose of a
child’s faeces in the house yard. In urban areas, 13% of households reported that
children defecate in open drains (MIS).
n
Al.18 Overall, in terms of utilisation of health facilities, numerous studies have noted
the desertion of public sector facilities by both the poor and the better off m favour ot
both self-treatment (or no treatment), and increasing use of the private sector, particularly
the commercial sector. The withdrawal of the poor from the public sector is a matter ot
serious concern. They are least able to afford private alternatives and most in need ot
good quality, accessible and affordable services.
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Al 19 AP’s poverty profile therefore presents both paradoxes and challenges,
particularly for improving health status. As the government has clearly recognised, just
as poverty is multi-dimensional, so is health status. Actions to improve health status in
AP are thus intrinsically linked to actions for reducing poverty and require co
ordination across a wide range of agencies. Many of these measures require broader
social transformation, such as reducing gender inequalities m access to social an
economic resources, and will take time to bear fruit. But shorter-term actions can a so e
taken to increase the responsiveness of the health and other social sectors to the needs ot
the poor and vulnerable, which could have a significant impact on health outcomes.
Table 6 gives one example of the way in which, in the context of the prevailing poverty
situation, a specific health problem links to both immediate and broader determinants and
actions. The same exercise can be done on other common health problems.
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2.
Poverty alleviation, income generation and health2
Al.19 It is commonly believed that increased income would lead to improvement in
health status and that effective poverty alleviation programmes is a necessary
precondition for overall progress on the social development front. While increased
income is essential for overall improvement in nutritional levels, as seen in the preceding
sections, social and gender relations exert powerful influence on access to and utilisation
of health services. Andhra Pradesh has initiated a wide range of anti-poverty programmes
and has been one of the pioneers in women’s mobilisation. In the last few years state
government initiatives to bring development administration closer to the people through
the Janmabhoomi programme have attracted considerable national and international
attention. This section gives a broad overview of significant poverty alleviation initiatives
in the state and assesses the potential opportunities for synergy with the health sector.
i
A1.20 There are 21,943 Village Gram Panchayats, 1095 Mandal Panchayat and 22 Zilla
Parishads (District Panchayat Office). The administrative arrangements are made in such
a way that 300-400 Panchayats come under ??and 82 Divisional Panchayat Office in the
state. Each District Panchayat Office difference between district and divisional? has 900
to 1000 Gram Panchayat in its jurisdiction. The government has recently (January 2002)
appointed one full-time Panchayat Secretary (combining the revenue and panchayat
functions) to function as an assistant to the political functionary in the Gram Panchayat.
Rs 364 crores per annum is routed through Panchayat Raj Institutions (PRIs). A number
of rural employment programmes are implemented through them. For example the
Jawahar Gram Samruddhi Yojana (creation of durable community asset and through
employment), a joint GOI-GoAP programme implemented in a 80:20 sharing basis is
implemented through PRIs. Similarly the Employment Assurance Scheme and
Sampooma Gram Swarajya Yojana (also a wage employment schemes) are routed
through Panchayats. However, recent reports indicate that - apart from wage employment
schemes, most other poverty alleviation programmes have their own implementation
structure, and they are not necessarily routed through PRIs.
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Al .21 A wide range of poverty alleviation programmes are underway in AP - Central
Sector Schemes as well as State Government Schemes / Programmes. An indicative (not
exhaustive) list of programmes is as follows:
a.
Women’s Self-help Groups
A1.22 In 1991 Government of India launched a Total Literacy Campaign in many
districts across the country - including Nellore District of Andhra Pradesh. The literacy
movement essentially involved those who have been denied education and literacy for
generations - and interestingly, for the first time in Independent India we had a
programme that was only meant for the poorest of the poor - those who were bypassed by
educational process. Women participated in very large numbers. The anti-liquor
This section draws upon Note On Rural Development Activities In AP - Presentation Prepared For The
Ttative Committee’ panchayat Raj and Rural Development Department, GoAP, April
2002, AP-DPIP documents.
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movement (1992) spread like fire the rest isr
leaders of
arrack in Apnl 1993 (which was ^uendyrevoked
how llteracy,
Nellore and Anantapur D’Jrwte of
in hand Here was a group of
empowering organization budding “d cr^ g
and then moved on to an anti
women who started their journey with a
y
of 15 t0 20 to start a
alcohol (anti-arrack) movement and then go g
of us in India a valuable
savings movement (Podupulakshmi). eir j
activities or to credit would be
lesson - people's access to funds for income ,gcmeratmg
leader declared:
meaningless without awareness and self-confidence. One chansm
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"Literacy campaign made us aware,
Anti-arrack movement gave us confidence, an
Podupulakshmi empowered us. ”
members, Atmakur Mandal, Nellore Distnct, India August 1995)
(Saving group
A1.23 During recent interactions with rural
^owSn^do^s not
P
Samatha Programme of Andhra Pradesh
y
"happen" automatically. Credit, ProducXm
of the poor unless they are aware, con
landlords, moneylenders, unscrupulous mid
be used tQ the benefit
aS a C°lleCtiVe *
and even development functionaries!
^d consciOusness in the absence of
a po*"of
Each aspect of development is inextricably linked
A1.24 poot wom.»'s access ,o
trips the greater the
have access, transaction costs ^clud / s^bribes,
aller’therepeated
?Oan amount,
documentation, collateral etc.) is h gh
unviable for poor households and
transaction costs - thus ma ng m
eOpie’s interaction with banks and other
women who seek sma 1 loans
d-PemDOwering - and grassroots workers remind us
financial institutions is known o be disempowering
women) away
that even an apprehension of loss of dignity
led t0 developing a strategy
rX”ce “eouX'
“S £
“S'XcZiXtoXdit wZut tatfcy will become victa. of m.ddtaeo.
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In the last ten years govenments and donors
self telp groups in
A1.25
credit as the magic formula - leading to a
which has seen an unprecedented'
India. Andhra Pradesh is the leader in this m0^ ’ L t0 the existence of 4.21 lakh
spurt of Women’s Self Help Group Recent ^miates pomt.!for almost 50o/o of
groups covering 55.80 lakh women (GoAP, p
• d under different programmes
all existing groups in the country! While they ar
g
main focus ig on formation of
and schemes - both government and non-g
email loans for both emergency
thrift and credit groups with a view to access small loans
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consumption needs as well as production. Government estimates indicate that the groups
have mobilised 1300.58 Crores as corpus and in the year 2000-01 the Government of
India has contributed Rs 4 Crores towards revolving fund, GoAP has invested Rs 44
Crores (which have been channelled to 44,000 groups) and the groups have been able to
access up to Rs 500 Crores from Banks and Financial Institutions.
A1.26 This has been a remarkable achievement for the state. Review of studies and
documents reveal that this movement got a tremendous boost from a number of social
movements:
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The Cooperative Development Federation (earlier known as Samakhya) was a
trailblazer in this area and worked in several districts to establish credit and thrift
groups of women in the 1980s and 1990s.
•
The Total Literacy Campaign of the early 1990s led to the establishment of
Podupulakshmi groups in several districts.
DWCRA - a GOI programme helped support a very large number of groups in the
state. This scheme was adapted to the specific needs of AP and implemented with a
great deal of flexibility right through the 1990s. This scheme has since been merged
with Swarna Jayanti Swarojgar Yojana (SGSY) in April 1999. Between 1999 and
2002 this programme alone accounted for a disbursement of Rs 221.5 Crores (Source
GoAP, April 2002).
Al.27 WTiile no independent estimates are available, government sources point out that
over 50% of the groups are active and women members have been able to enhance their
income by Rs 2000/- per month. While there has been no comprehensive sample study /
survey on the impact of the SHG movement on health and education, analysis of loans
taken by women indicate significant expenditure on health and hospitalisation.
b.
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Swarna Jay anti Swarojgar Yojana (SGSY)
Al.28 This programme provides the umbrella for the integration of existing poverty
alleviation programmes and encompasses a wide range of employment and resource
management programmes. The total allocation in the FY 2001-02 (GOI + GoAP) was Rs
52.65 Crores. It is noteworthy that additional allocations (over and above budgetary
allocations) of Rs 4.16 Crores pushed up expenditure to Rs 61.33 Crores. It is estimated
that 146997 beneficiaries were reached in 2001-02 (Source: GoAP). Among the
individual schemes / programmes that are now subsumed under SGSY are:
1.
I
Technology and Training development Centres (GOI Programme) in 22 rural
Districts, with an outlay of Ts 15 Crores at the ratio of GOLGoAP of 75:25.
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ii.
Permanent Marketing Centres, also a GOI programme with a centre-state ratio
of 75:25 involving an investment of Rs 12.3 Crores. DWCRA Bazaars and
other rural marketing fairs are organised under this programme.
iii.
Economic generation through coir production through Women SHGs
involving an investment of Rs 14.5 Crores, shared by centre and the state
government at the ratio of 75:25.
iv.
Poverty alleviation through improved agriculture technology in Chittoor
District, a 100% GOI funded project.
V.
Technologically Qualified Global Workers (apparel production), another GOI
programme is underway in the districts of Medak, Ranga Reddy, Nalgonda
and Warangal. The investment in this programme is to the tune of Rs 3.2
Crores.
vi.
Indira Awas Yojana — a rural housing programme for BPL families has been
brought under the ambit of SGSY.
c.
Rural Poverty Reduction Projects
Al.29 A number of rural poverty eradication programmes have been initiated over the
years. In 1996 the UNDP assisted South Asia Poverty Alleviation Project (SAPAP)
covered 20 Mandals in 3 districts - this project demonstrated that the poor both have the
ability to help themselves and they can play a positive interventionist role in their
development. Positive results in this project (which formally concluded in 2000) led to
the design of World Bank assisted DPIP / APRPRP in August 2000 - this project is
known as Velugu in AP.
A1.30 The overall objective of Velegu is to enable the ‘poorest of the poor’ to articulate
their needs; access and influence the quality of service; and create their own opportunities
to improve their livelihoods in a sustainable manner. The strategy adopted in this
programme is as follows:
•
Focus on the ‘poorest of the poor’ across the State in selected Mandals,
•
Address the livelihood issues of the poorest of the poor with a focus on land and
water management of degraded areas,
•
Support greater convergence of health, education, nutrition and natural resource
management,
•
Anti-poverty programs to be responsive to the needs of the poor using a bottom up
and contextualised approach, and
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LIBRARY
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DOCUMENTATION
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Evolve institutional arrangements to include other stakeholders such as local
Government and civil society.
Al.31 This programme is currently underway in 141 Mandals, reaching out to 3779
habitations, 10,000 women’s self-help groups have been formed and they are federated as
Samakhyas in 29 Mandals. This programme has adopted a community-based approach
and works through Community Investment Fund, where decision making on usage is
devolved to community based groups. Eradication of child labour by getting children
back to school through intermediate bridge courses has been integrated into this
programme.
Drought Prone Area Programme (since 1975, GOI: GoAP 50:50
share) and Integrated Wasteland Development Programme (IWDP)
1
Al.32 Since 1991 has attempted to mobilise stakeholders in land and water related
issues. These programmes were reviewed and revised by GoAP in 1995-96 on the basis
on the recommendations of Hanumantha Rao Committee. A significant change is that
Watershed is seen as a concept that integrates conservation, management, budgeting of
rainwater, using a holistic framework to link food security and soil / water conservation.
The government involved NGOs in a big way to develop and manage the community
based Watershed Development Fund. These groups have been linked to NABARD to
enable farmers to access agricultural credit.
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Rural Water Supply and Sanitation Programmes
Al.33 This programme is reported to have covered 44,120 rural habitations (fully) and
17,619 (partially). Government reports point out that 7,993 rural habitations still do not
have any safe source of water.
f.
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Mahila Samantha (a part of Government of India Mahila Samakhya Education for Women’s Equality Programme
Al.34 While this programme does not strictly fall within rural development and is
located in the education sector — the main objective of this programme is to enhance the
capabilities of women to negotiate their world and the system from a position of strength.
This Central Sector Scheme is implemented in 7 districts of AP and covered 1200
villages through formation of women’s groups at the village level and Mandal level /
District level federations of women groups. In the last three years this programme has
tried to forge linkages with food security, agricultural development and health, essentially
empowering rural women’s groups to play a positive interventionist role in community
development initiatives and weaving in gender and equity concerns in mainstreaming
programmes. Managed by an autonomous (government created) society, this programme
has the potential to work across sectors and departmental boundaries.
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Linkages between poverty alleviation programmes and health
4.
A1.35 Notwithstanding significant achievements of poverty alleviation
*e state, recent evidence points that they have not made the desired .ng^on hea h
outcomes. As noted in the sections above in the absence of reliable public health
services in rural areas, the poor are increasing accessing private healthcare provide
According to NFHS-II (1998) 68.7% of poor household who recently visited any hea th
acuity went to private hospitals / elmics anti”'^Xhe|ming
“d 7
Over 62% of below poverty line families financed hospitalisation tn the private: by
borrowing money or selling assets (World Bank 2001). NSSO data 52 round, 1»pom
out that 24% (rural) and 21% (urban) respondents cited financial problem as a reason fo
untreated ailments.
A1.36 A recent qualitative study conducted under the aegis of Velugu (DrRanga Rao,
2002) lists the reasons cited by respondents for delay in seeking healthcare, ey a
nd
(I I
•
Denial of sick role for reasons of explicit symptoms
•
Denial of sick role till the social and economic role performance is effected
•
Delay in view of work demands and social responsibilities, particularly in
women
•
Delay due to lack of assistance in case of women, children and aged
•
Lack of knowledge of appropriate facility
•
Lack of financial resources
•
Problems of physical access
.
Preference to seek treatment from local providers
practitioners in view of prevailing concepts of supernatural causation for diseas
case of
Al 37 It is more than apparent that poverty alleviation is a necessary but not suffic^
condfrion foT improvement of health status of the poor. There is compelling evidence
showing that there is an urgent need to forge formal linkages betweeni exis^i g°p rty
alleviation programmes and the health delivery system. Velegu has taken this on
.
and has recently initiated action to integrate healthcare accessi issue; metheir
programmes. The qualitative study cited above was commissioned to &«tote need
based planning for closer linkages between health care and poverty alleviation
programmes of the government.
14
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A1.38 Rural poverty reduction programmes in AP acknowledge that each aspect of
development is inextricably linked to the other and with growing awareness and control
over earnings women will reach out to health care facilities. Poor women have little
access to institutional health services; as a result many of them seek out private doctors where unethical practices for profit subject them to unnecessary medication and
operations. Support systems built for savings, credit and institutional finance have not
been able to respond to the health needs and the health delivery system has almost no
links with the SHG movement in Andhra Pradesh. Building workable and ground level
linkages between the two programmes could indeed make a difference in the lives of the
poor - especially poor women for whom health of their families and their own health are
indeed important issues. The Society for Elimination of Rural Poverty - the management
system created for the implementation of Velugu has started planning for community
based health insurance programmes for the poor. These initiatives are at a very
preliminary stage - therefore this is an opportune time to forge closer inter-sectoral
linkages.
5.
Community Based Convergence in the Health Sector
k
Al.39 Andhra Pradesh has, in the last fifteen years, acknowledged the value of
community-based convergence. While the savings and credit movement is well known,
smaller initiatives in the health sector are yet to receive national attention. Three
important initiatives undertaken by the government are noteworthy:
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a.
IPP VIII - Community-NGO-Government Partnership for Health
1.
b.
Under the aegis of the IPP VIII programme funded through a
World Bank loan, an effort was made to enhance the utilisation of
urban health care services by building a bridge between poor
women and urban health posts. The focus of this programme was
to improve the utilisation of government healthcare delivery
services by making it more accessible to the urban poor. To this
end, the Municipal Corporation of Hyderabad worked with 19
local NGOs to identify and train link volunteers - one for 20
households. These voluntary workers were trained and supported
to interface between the community and service providers.
Simultaneously, the government made efforts to enhance the
basket of services and make urban health posts functional. This
model has now been extended to 72 municipalities under IPP VIII
Extension Project (World Bank funded). This programme has been
documented as “best practice” and has recently generated a great
deal of interest among health policy / planning community.
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Community Health Worker Scheme under the Tribal Health Plan:
2.
Acknowledging that the primary healthcare delivery system has
been unable to percolate into all tribal villages, a village based
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Community Health Worker was appointed to respond to the health
needs of tribal groups. The focus was on training CHWs to manage
routine maternal and child health problems, including minor
ailments. Like the urban link volunteers, the CHWs are also
expected to work as a liaison between community and health
delivery system. They are also expected to support the ANM /
PNC on MCH tasks (distribution / awareness) and TB (Dots awareness and observe consumption of drugs). The scheme
provided for one worker for 1000 population. Recent evaluation of
the programme has been mixed — while the programme seems to
bring the health delivery system closer to the people, the persistent
absence of doctors from tribal areas has affected the credibility of
the programme. Given the educational status of tribal groups, 54
CHW are illiterate and most of them are in the 15-35 age group.
Sample survey conducted in the area reveals that 68.8% of the
respondents are illiterate, (40.2% female) and only 22.8% of
respondents went up to primary, 3.3 % up to middle and 5% up to
high school level. The silver lining is that this trend seems to be
receding and in the 6-14 age group 8.1% girls and 2.6% boys were
illiterate.
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A1.40 Only 18.5% households surveyed had access to safe drinking water from a hand
pump, 0.5% to covered well, 28.3% to uncovered well and 52.7% to surface water. What
is indeed distressing is that 99.3% do not have access to any sanitation facilities and
65.9% dispose wastewater in the open. Among total deaths occurred in the last one year
22% were due to Malaria. The evaluation report points out that the community is fairly
positive about this programme, however irregular payment of honorarium, poor training
and irregular supply of drugs continue to pose serious challenges. Given that majority o
the CHWs are illiterate, records are not maintained. The sample study showed that pre
puberty marriage had come down and that there has been modest improvement in ANC
check up (94% availed of 3 ANC check ups as different from 67% in control area), 69/o
took IFA tablets, 62% TT injections and better nutrition during pregnancy etc. 96
deliveries at home and 30% attended by ANM, 10% by CHW, 24% observed the 5
cleans. However, there has not been much change in matters related to delivery care,
newborn care and breast-feeding. (Source Evaluation of the scheme, sample survey
conducted in 2001)
c.
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Women and Health Training for Women Leaders in the
Community
A1.41 The MOHFW, GOI (Department of Health) supported a training programme on
women and health issues for women leaders in the community. A committee comprising
of women’s health practitioners developed a module and World Health Organisation
funded the training programmes. This programme is yet to be evaluated and the impact
assessed. What was interesting in this initiative was that it involved the Mahila Samantha
16
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programme of AP and led to closer linkages between the health department and a
women’s empowerment programme.
d.
•
The non-profit sector, popularly known as the NGOs encompasses a wide range
of organisations and can be broadly categorised as follows:
•
Development oriented organisations working among the poor with the objective
of enabling women and men to participate in development processes and those
involved in mobilising people to demand services and information; implementing
specific projects and programmes through grants from the government or donor
agencies. Andhra Pradesh has a large number of such broad based development
groups.
•
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NGO - government collaboration in the health sector.
•
Social action groups that emerged as part of the different people's movement with
a focus on advocacy and mobilisation, organising and networking for impacting
and changing laws, policies and development programmes. Given the interesting
political history of AP, there are a significant number of advocacy groups
focusing on human rights and social justice issues. The women’s movement in the
state is considered a forerunner in the country.
Resource groups, training organisations, and research / development planning
organisations that generate and disseminate information and research, build
national and global networks and provide professional consulting services in the
development sector.
Al.42 For almost fifteen years now the health sector has worked with a number of
established organisations which function as Mother Units to channel government funds to
smaller organisations. This concept was introduced under IPP IX and has since 1996 been
adopted as an integral part of GOI’s strategy to involve NGOs in health and family
welfare. While a comprehensive list of NGOs supported under this programme is not yet
available, it is reported that a wide range of service delivery organisations, charitable
hospitals, medical practitioners have received grants from the government.
A1.43 Since the introduction of the RCH programme in 1997, NGOs have been involved
in advocacy, counselling, raising community demand for RCH services and improving
service delivery through innovative approaches that are complementary to government
services.3 Across the country, Government of India supports 650 field NGOs through 57
Mother NGOs (330 districts across 22 states) - 7 of these Mother NGOs are from Andhra
Pradesh. The state government does not actively participate in either selection or
monitoring the work of NGOs supported by GOI. There is little evidence on the impact of
these programmes and therefore we are not in a position to assess effectiveness of this
strategy. However a recent review of the programme recommended that NGOs could
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3 Aide Memoire: World Bank Mid-Term Review Mission of the RCH Programme, November 2000
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play a crucial role in ‘medium and low-performance states’ in augmenting the pool of
trained paramedical workers — given that availability and accessibility of skilled
midwives continues to be the most important barrier to safe motherhood. Based on this
feedback the Government of India (MOHFW) in collaboration with UNICEF and Sida
are piloting a midwife training and capacity building programme in Medak District of AP
and Bidar District of Karnataka. This pilot project is being designed in collaboration with
a local NGO - Academy of Nursing Studies, Hyderabad.
Al.44 In the last three decades there has been an appreciable growth in the NGO sector
partly because national and international foundations and bilateral donors have come
forward with financial support and grants. Many of them have done path-breaking work
in the area of public health, women’s health and community based programmes. While
the government has acknowledged the importance of community participation in the
health sector and has even supported NGOs and community-based groups - the public
health system is yet to work in collaboration with community based groups.
A1.45 In addition to the 7 Mother Units and 100 field NGOs supported by GOI, a large
number of NGOs are today working with the government in the health sector. For
example over 100 NGOs are involved with the HIV/AIDS programme, 192 with the
Urban Slum Project (IPP VIII extension), 43 in Mahboobnagar District health project, 19
in the Hyderabad City IPP VIII programme and 7 in Ranga Reddy District urban slums
project of the government.
A1.46 Discussions with NGO leaders in the state reveal that there is no forum for
structured interaction between the government and NGOs in the health sector. Over the
last two decades, the Government has recognised the importance of exploring the potential
of organisations and institutions that work directly with the people with a view to bring
social sector programmes closer to their needs. This is an important issue among
development practitioners. Since the Seventh Five Year Plan, Government of India has
publicly acknowledged the potential of voluntary organisations and lamented over the
inherent constraints of development administration. In reality, however, the voluntary sector
has been seen as an effective agent for delivery of services. Government's perception of the
sector as spelt out in the Seventh and Eighth Five Year Plan documents was summarised as
follows:
"Volags4 can introduce innovative approaches in
programmes for rural development, poverty alleviation, relief
and rehabilitation, education, health, family planning, social
welfare, women’s development, release of bonded labour,
non-conventional energy and water conservation as well as
water use.
Volags can deliver services at relatively low costs by using
local resources and mobilising funds as well as labour from
the community.
4 Acronym for Voluntary Agencies
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Volags can provide communication lines between
government and people, pass on government funds to village
based groups and provide feed-back on development
programmes and emerging issues. People can be energised
by Volags to demand quality services from government
programmes."5
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Al.47 While the importance of involving Volags to reach out to people has been
recognised, the limitations of non-governmental organisations to reach the unreached is a
cause for concern. Issues of outreach, especially to remote areas and less developed regions
continue to pose a problem. It has been observed that developed regions have more
organisations and that remote areas are invariably left out even by the voluntary sector.
Some districts / states are saturated with voluntary organisations, while there are pockets
where it is difficult to find even one good agency.
Al.48 The government does not have a uniform policy or pattern for supporting NGOs,
it varies across sector. Some departments have a range of grant-in-aid schemes for
NGOs, some others have developed mechanisms to involve NGOs in ongoing
programmes. Some officials view non-govemment organisations with suspicion and
others go out of their way to create opportunities for govemment-NGO collaboration.
For example, officials administering health and family welfare projects have expressed
concern over retired government servants, doctors and PSM professors setting up NGOs.
One GOI department has issued an internal circular to carefully scrutinise agencies set-up
by retired civil servants. On the one hand the government recognises the enormous
potential of NGOs and at another level it is also apprehensive about inherent problems of
accountability.
Al.49 There is a growing realisation that NGOs cannot possibly provide all the answers to
complex and vexing issues of decentralisation and development. Addressing the challenge
of reaching the unreached, GOI appointed the Ashok Mehta Committee in 1977 to enquire
into the working of the Panchayati Raj Institutions (PRI) and suggest measures to strengthen
them so as to enable an effective system of decentralised planning and development. This
committee did not see voluntary organisations as the answer to decentralised development
and called for the need to look at PRIs as political institutions that would delegate power to
bodies closer to the people and build strong accountability systems. NGOs, it was felt,
cannot substitute local self-government institutions.
Al.50 Government - NGO collaboration in the Health and Family Welfare sector has
been fraught with innumerable problems. At one end of the spectrum are agencies, which
have worked with missionary zeal in leprosy eradication, blindness and tuberculosis, and
at the other end are organisations that have taken grants to further their own commercial
agenda. While the former are widely admired and appreciated by the government, the
latter have been viewed with suspicion. In between are a host of agencies, charitable
Gulati and Gulati: Strengthening Voluntary Action in India: Health-Family Planning, the Environment and Women's
Development, Konarak Publishers, New Delhi 1995 (page 67)
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trusts, missionary institutions and so on, which have been working either with or without
government support. The dividing line between a profit oriented hospital and a charitable
trust is rather thin. A very large percentage of private hospitals have been registered as
charitable trusts6.
*
Al.51 Many commentators have argued that regulation and support of charitable and
voluntary efforts in health cannot be done efficiently without a mechanism to categorise
non-governmental institutions / agencies. Policy level interventions are needed to
introduce differentiated registration mechanism for non-governmental organisations
working in the health sector. Needless to add, this would have to be based on research
and survey of a specified range of agencies, their outreach, size, funding sources,
management (whether they charge for services and if so what is the proportion of free
services to paid services).
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Al.52 The Medium term Health Strategy for AP could play a catalytic role in initiating
debate on the above. Some base-line research followed by a working group to discuss
avenues for collaboration, exploring ways and means for categorise organisations on the
basis of the nature of their work, outreach and capacity, differentiated registration and
areas for support could be considered. Paying lip service to NGO involvement in the
absence of mechanisms to harness their potential to complement and supplement public
health services has been counterproductive.
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Al .53 Over the years it has become evident that the government perceives NGOs primarily
as service providers and not as partners in policymaking, strategising and programme
development. On the other hand many NGOs perceive themselves as catalysts in the
development process, providing services being just a part of a much larger identity. While
there may be instances of close collaboration between government and voluntary groups, by
and large the relationship has been fraught with mutual suspicion. Over the last decade there
have been efforts to allay suspicions and create opportumties for meaningful partnership.
The relationship between the two has been particularly stormy in health and family
planning.
Al.54 NGOs are not an undifferentiated mass - while NGOs involved in family planning
and population related activities have worked in close collaboration with the government, a
host of women's organisations, human rights groups, rural development agencies and the
like made it a point to publicly distance themselves from the family planning programme of
the government. The main irritant was a target-based approach that gave primary importance
to the realisation of method specific family planning targets. However, in the changed
scenario where targets themselves have been abolished, the distance between the two
constituencies has considerably reduced. Given new opportunities, it would be possible to
delineate specific areas of collaboration or partnership, namely:
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6 There is a lot of anecdotal evidence of such “trusts” receiving grants from MOHFW, GOI under the sterilisation ward
I hospital scheme, family planning services scheme and so on.
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Drawing upon micro level experiences in the non-govemment sector with a view to
adapt the generic lessons to state-wide programmes. Essentially this involves systematic
efforts to forge linkages between micro level experiences and macro policies and
programmes of the government. Government's resolve to move towards a holistic
reproductive health approach with an emphasis on quality of care provides a golden
opportunity to forge such linkages;
Given "hands on" experience of voluntary organisations, the government could draw
upon them to participate in planning, design and monitoring health sector programmes
and adapting them to different regions of the state. In this context the key issue is how
NGOs can be strategically located in government programmes, keeping in mind the
comparative advantage and specific expertise of voluntary groups.
•
Recognising that the entire weight of all service delivery programmes fall on the
shoulders of the extension worker (ANMs for example). Ensuring a good working
relationship between the community and service providers is a difficult task. NGOs
could be involved in building such bridges and help develop support systems for field
level functionaries.
e.
NGO-Government collaborations - some lessons:
Al.55 There is a wealth of experience in the non-govemment sector in the country.
Taking NGO models and “implanting” them into the government system has been a
major problem area. However, drawing generic lessons and creating a supportive
environment for replication has met with remarkable success in some parts of the
country. Notwithstanding a few successful efforts at replication, by and large we have
repeatedly failed to replicate micro-experiences at the macro level. At this stage we can
identify a few necessary steps for successful replication, namely:
1.
ii.
iii.
Ensuring appropriateness of replication: Successful innovations are based on
some basic principles, some specific factors and the people who made it
happen. When large systems attempt to replicate innovations, they fail to
distinguish the generic from the specific. This is essential in order to identify
the elements that can be replicated and those that cannot. Identifying generic
principles and adapting them to specific circumstances, regions, structures and
so on, are often ignored.
Standardisation: . Most governments are keen to standardise models. Even
when they genuinely try to replicate innovations, they expect to weave the
innovation around the existing administrative structures. Culture, social
structure, religion, terrain, level of development, administrative ethos, and
political sensitivities - all these factors determine the outcome.
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Creating cohesive team that shares the objective: One of the “secrets” of
successful innovations is that organisational objectives is the overriding goal
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of all its segments. Eligibility criteria and rules are not sealed in
straight]acketed norms without any decision-making powers at the functional
level. Vimala - I can’t quite follow the argument here When the government
attempts to replicate a “successful model” it is important to recognise that the
poor cannot be expected to understand and appreciate reasons ofstate. It is the
state that should create the enabling conditions for the poor. Administration o
a people-centred programmes demand a qualitatively different degree o
commitment and teamwork.
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V.
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Recognition of the need to “own” and identify with the “model__: When any
large system, government or otherwise, takes a “model for implantation, they
fail to recognise that the “secret” of successful innovations is that people who
have been central to its conception and birth are also given the authority to
implement it. There is a sense of ownership of the idea. Bureaucracies do not
see an organic link between the birth of an idea or plan and its
implementation. In most governments and large organisations a planning wing
draws up a blue print, the finance division the budget, while an anonymous
structure implements. Very little effort is made to ensure that programme
managers identify themselves with the “model” or the “concept .
Creating appropriate structures and management systems; Most of the
problems revolve around the people who administer a programme. Most
successful experiments attribute their success to careful selection of project
functionaries, creation of learning opportunities, training, avenues for
professional fulfilment and growth and above all commitment to work among
the poor. Aptitude and commitment are taken as the starting point. Sensitive
management involves:
a)
Appropriate rules, regulations and structures.
b)
Continuity of programme administrators, especially the leader.
c)
Dynamic and sensitive leadership.
d)
Anticipating and overcoming bottlenecks, ensuring meaningful
feedback - especially of problems.
e)
Affirmation and support to field based workers to sustain
enthusiasm and commitment.
Al.56 Discussions on avenues for meaningful collaboration invariably leads to
reiteration of the need to involve NGOs in planning, programme designing training,
monitoring and so on. Government officials plead their inability to do so on a large scale
- citing vast areas of the state without appropriate NGOs as a major bottleneck. As it
stands now, the government does not have before them a comprehensive listing and
rating of the range of non-governmental organisations working in the health sector.
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Available lists do not give policy makers and administrators enough qualitative
information for decision-making. We cannot even start to think of ways and means to
involve them without comprehensive information on their numbers, range, outreach and
quality.
Al.57 As a start, it may be useful to attempt a categorisation of non-governmental and
private institutions providing health care services - with a view to identify agencies and
organisation doing innovative work in primary health-care in rural / urban / tribal areas,
those with training capabilities, those with expertise in planning and managing large
programmes and so on. Such region-specific information could strengthen government
ability to initiate collaborative programmes in some areas.
Al.58 State-wide experience of working closely with NGOs and civil society
organisations like Self Help groups could be valuable in the health sector - and this needs
to be explored seriously and systematically.
6.
Challenges and Constraints:
Al.59 The overarching challenge faced by Andhra Pradesh is to improve the health and
nutrition status of the poor - the state cannot attain the goals enunciated in Vision 2020
goals without giving this issue the attention it merits. It is known beyond doubt that the
burden of health services disproportionately falls on the poor and non-availability of
financial resources remains one of the main reasons for untreated illness thereby resulting
in sharp increase in morbidity — especially in the last ten years. This burden is
compounded in a situation of unequal gender relations and inequalities in social situation
I status. The following issues can be identified as central to taking a broader,
developmental approach to improving health:
a.
The need to make clear links with the overall poverty reduction vision
of the government
Al.60 Limited linkages between health and other poverty alleviation programmes of the
government, even though access to good quality and reliable healthcare is identified as a
priority by poor women - as evident from literature on self-help groups in Andhra
Pradesh;
b.
The need to tackle health problems through a broader, multi
dimensional frame, not just through the health sector
Al.61 Other social practices exert a significant influence on health outcomes - age at
marriage (15.3 in AP), 23 % of pregnancies of 15-19 do not end in live births,
vulnerability of poor women to HIV and AIDS — given existing gender relations.
Al.62 Provision of services and infrastructure is a necessary not a sufficient condition there is a need to create enabling mechanisms where poor people are empowered
(through community action) and enabled (through financial and insurance mechanisms)
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to improve their nutritional status (through linkages with PDS) and access public health
services.
c.
The need to shift health resources to disadvantaged populations
Al.63 Nutritional status is of grave concern - influencing health outcomes, especially
among poor women and children. This is directly linked to maternal, infant and child
mortality. While there has been significant reduction in IMR from 123 in 1970 to 63 in
1998, IMR is still high in tribal areas (120).
A1.64 National Health Accounts, Beneficiary Impact Analyses and Public Expenditure
Reviews all need to be brought to bear on understanding current resource allocations and
how they can be reorientated
d.
Horizontal and vertical fragmentation (including duplication) within
the health system - across programmes and within different inputs.
Al.65 Many programmes and structures are in place however there seems to be little
backward / forward linkages within programmes and across vertical programmes. For
example yhe primary-secondary level interface is particularly bad and with each sector
there is little coordination between training, staff deployment, availability of equipment /
supplies that match the specialisation of staff etc..
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Al.66 At primary level, on the other hand, too many tasks have been focused on one
front line cadre. The Auxiliary Nurse Midwife (ANM) continues to be the primary
service provider but her multiple responsibilities include immunisation, safe delivery (pre
and postnatal check-up of pregnant women), community needs assessment, contraception
motivation and distribution, survey of eligible couples and maintenance of CPR registers
along with infectious diseases control. Non-availability of skilled medical personnel —
including nurse-midwives — remains the major bottleneck to universal access to first level
of care.
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Fragmentation across sector-wise programmes - poverty alleviation /
women’s empowerment, sanitation, water etc.
/_ of- programmes
r» are also engaged in health interventions, in parallel
Al.66 A number
with the health sector. Opportunities for inter sectoral / intra sectoral linkages to enhance
access to healthcare are yet to be explored seriously.
f.
The need to understand the emerging inequalities / different patterns
of health status - not just geographical but also socio-economic and
gender
Al.67 Evidence of greater vulnerability of the poor to communicable diseases, given
existing situation with respect to access to safe drinking water, sanitation and other public
24
health measures. Compelling evidence is available in tuberculosis and malaria
programmes of the government.
Al.68 Absence of socially disaggregated (and within each by gender) data in the health
sector makes it difficult to target services. There is a need to go beyond generic
categories of SC and SC and factor in income, education and power relations.
g-
The need to involve disadvantaged groups in improving access to
functioning / effective / quality government services.
A1.69 There is little space for informed debate on people’s expectations from the public
health system. We are yet to devise mechanisms to tackling issues of accountability of
providers, rights and entitlement of people and dignity and respect for the poor,
especially poor women. NGO experiences in the area of micro-planning and health
mapping are yet to tried out in the public sector - this is not only a big challenge but
could emerge as a unique opportunity in a district based RCH programme of the
government.
Al.70 If poverty, social justice and gender issues are to be brought centre stage in the
health sector then active citizens involvement in jpriority setting is critical. One of the
challenges facing the reform process
in the state iis to approach the problem of access
.
from below and explore how services can reach the needy - thereby integrating gender
and social equity issues into health sector reforms.
7.
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Potential strategies and approaches
Al.71 We note three key areas where strategic action is needed;
I
a. Pilots in the health sector - ensuring that learning from the many
innovative pilots is made available and informs the main system of health
care delivery
b. The creation of more effective systems for monitoring health outcomes
,I
c. The need for health sector representation in the development and
n
management of poverty reduction programmes / strategies emanating from
other sectors and departments
Al.72 Two specific areas for action, building on existing initiatives are:
a. Linkages with women s empowerment / SHG movement in AP: Given the
wealth of experience in AP with women’s mobilisation, the health sector
needs to seriously explore how existing women’s organisations,
federations and forums can be leveraged to enhance awareness about
health and nutrition issues on the one hand and enable poor rural women
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to gain meaningful access to public healthcare delivery services on the
other. Among the concrete ideas that could be explored are:
1.
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Community pharmacies run by Mandal level women’s
federations;
ii.
Group insurance for primary health care and
comprehensive maternity, disability, accident insurance;
iii.
Periodic health camps to create awareness and also enhance
access to curative care.
b. Building on the positive experience of IPP VIII and other micro initiatives
in urban areas, there is an urgent need to design similar programmes in
rural areas. For example the community link volunteers model could
provide the much-needed bridge between poor rural women and children
and the health delivery system.
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Items for Action:
A 1.73 These recommendations are made keeping in mind that reduction in maternal and
infant mortality cannot be achieved through interventions in the health sector alone.
There are no magic bullets or immediate solutions — involving the people in planning for
their own health and empowering them to take greater control of their lives is essential.
a.
Immediate
Al.74 Forge workable linkages with existing poverty alleviation and women’s
empowerment programmes, a) by creating a platform to systematically debate health and
nutrition issues — especially maternal and infant mortality — in existing women s groups /
federations and other community based groups formed in different sectors (SHGs,
APRLP, Velegu, Mahila Samatha) and b) by ensuring that government task forces,
working groups on poverty reduction have representation from the health sector.
Al.75 Implement information and education activities through existing forum / channels,
health mela and extension camps for diagnosis and treatment by using the methods and
experiences of community based groups in developing appropriate communications
strategies. Need to transfer responsibility and funds for health information / education
and other communication activities to women’s organisations / community based
organisations.
Al.76 Go to scale with positively evaluated experience with link volunteers (IPP VIII) in
rural and urban areas.
26
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Al.77 Forge workable links with ongoing government efforts to combat child labour
through education and awareness. Working children are not only the poorest but at health
risk - nutritional, occupational (cotton plucking, beedi rolling, stone quarry) and
vulnerability to violence.
i
Al.78 Gear the system to collect / process disaggregated information - by socio
economic groups, vulnerable groups and within each by gender. This will enable the
system to target services to the most needy. This can be done economically through more
effective use of existing statistical sources in the state and at district level and through a
selective, sentinel site approach to disaggregation.
Field level staff spends a
disproportionate amount of their time on detailed, routine data entry. The likelihood is
that most of this is not used in any systematic way for planning purposes. Nor are health
functionaries involved in making decisions on local priorities based on the data they
collect. Make use of NHAs, BIAs or PERs to understand existing resource allocations
and how they can be more effectively targeted.
A1.79 Develop the information base on NGOs operating in health and health related
areas, documenting their capacities. Use this to develop a systematic approach to NGO
involvement in health.
b.
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Al.80 Work with poverty alleviation programmes to design community based health
insurance schemes linked to SHGs / women’s groups. AP could emerge as the forerunner
in the country, given existence of 4.21 lakh SHGs in the state. Explore the possibility of
creating community pharmacies through SHGs.
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A1.81 Involve women’s groups and PRIs to take up annual health mapping and micro
planning (including evaluation of previous years plans / achievements) using PRA
techniques - leading to creation of Mandal level health plans. Link these to a
reorientation and simplification of the system of data collection at facilities level to create
meaningful information for local level priority setting.
A1.82 Plan adolescent (girls and boys) health and nutrition awareness programme by
interfacing with education department - valuable nation and state experience with Peer
Educators and Youth Forum could provide a good base. Especially valuable to combat
maternal and infant mortality and HIV and AIDS.
A1.83 Create a time bound plan to enhance the skill and technical capacity of ANMs who are the first level of caregivers in the community. Simultaneously, enhance pool of
community based (volunteer) health workers who can provide support to ANMs and
work as a link between the people and the health delivery system. Consider reorganising
the ANM cadre into a women’s health service - the evidence suggests that their skills
have been diluted by the move to multi-purpose working and the need to service larger
populations, resulting in a less effective and less popular service from the users’ point of
view. Address issues of human resource development for this cadre, in particular the
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need to create a proper career structure for ANMs (rather than the parallel structure which
has emerged de facto of male supervisors whose skill base is also relatively low). This
requires revisiting training content and length, catchment areas and criteria for promotion
and advancement.C
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Long Term
Al.84 Develop a long-term strategy to address social issues like early marriage by
forging links with the education sector to ensure that all children are retained in school at
least up to grade 10.
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Al.85 Develop a comprehensive, appropriately targeted nutrition strategy for the state,
beginning with the creation of a nutrition task force drawn from all the relevant delivery
sectors and research organisations
9.
Resource Planning
Al.86 Discussions with people involved in poverty alleviation programmes reveal that
there is really no shortage of resources for community mobilisation and nor is there a
shortage of avenues for credit to SHGs in AP. This has been identified as a priority and
the government has demonstrated commitment to make resources available for such
programmes. Forging linkages is more important that allocating funds in the health sector
for social mobilisation and health education. The question is one of targeting available
resources and ensuring a functioning healthcare delivery system.
10.
Avenues for Research
Al.87 Document and disseminate learning from other programmes / sectors and how
these experiences can inform the health sector.
A1.88 Study on the impact of SHGs and women’s mobilisation on health awareness,
health seeking behaviour and analysis of loans taken for health emergencies. This could
feed into the medium-term plan to forge closer links between health and poverty
alleviation programmes of the government.
Al.89 Commission research on occupational health of working children - including girls
working on cotton farms - pollination, plucking etc.
Al.90 Prepare a status report on NGO experiences in the health sector and those
working in other areas but with the inclination / capacity to work in the health sector.
Al.91 Synthesise existing knowledge on health status and health seeking behaviour
among tribal populations and identify priority information gaps
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References
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Department of Women and Child Development/UNICEF (2001) Multiple Indicator
Survey-2000. Andhra Pradesh (MIS)
Prasad, OSVD et.al. (1999) Study on High Incidence of Male Mortality due to TB in the
Chnchu Area.
Tribal Cultural Research and Training Institute, Tribal Welfare
Department, Government of AP, Hyderabad
World Bank (2000) Project Appraisal Document for the AP District Poverty Initiatives
Project, Washington DC.
Society for Elimination of Rural Poverty, GoAP (March 2002): Progress Report (June
2000 to March 2002, APDPIP, Hyderabad.
The World Bank 1999: If we walk together: Communities, NGOs and Government in
Partnership for health - The Hyderabad Experience by Kirrin Gill, Washington.
AP Mahila Samatha Society: 2001 People’s health in people’s hands; Hyderabad.
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DRAFT
Annex 2
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Support for Development of A P Medium Term
Health Strategy for Andhra Pradesh
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Government Health Care Delivery
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Marc Mitchell
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Annex 2
Support for Development of A P Medium Term
Health Strategy for Andhra Pradesh
Marc Mitchell, M.D.
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Improve Public Health Care Service Delivery
1.
A2.1 Over the past 30 years, Andra Pradesh has made remarkable gains in improving
the'health, educational and economic opportunities of its population through a senes of
investments and reforms to its public infrastructure. Yet, during the past decade many of
these improvements, particularly in health have stagnated, with the result that Andra
Pradesh now has fallen behind many of its neighbonng states in measures such as infant
mortality, immunizations rates, maternal mortality, and effectiveness of disease control
programs such as TB, Malaria, Acute Respiratory Infections, and Diarrheal Disease.
A2.2 There may be many reasons for the relative inability of the health system to
impact more effectively on these critical indicators of health. These include:
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The inability of the public health services to deliver services at the community
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level where they are needed;
The inability of health programs to link to communities and community
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spacing.
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The importance of social measures such as age of marriage, illiteracy, and
undemutrition that contribute significantly to the rates of infant and maternal
mortality and are largely outside of scope of the health system directly;
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The outdated and ineffective system of targets and incentives for specific health
activities such as malaria slides that have no impact on morbidity or mortality and
influence the behavior of health workers in ways that are counterproductive to
program effectiveness;
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The lack of motivation and accountability of health staff at all levels of the system .
leading to wholesale absenteeism by staff from their posts and little productive
activity even when staff are physically present;
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The general lack of confidence by the public in the government health facilities
caused by the chronic lack of doctors and medicines, and the poor motivation an
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often imperious attitude of health staff towards their clients, especially poor
women, or those who are from tribal areas;
a.
Current Approach
A2.3 As in most states in India, the delivery of primary health services in Andra
Pradesh has largely focused on the development of a comprehensive health infrastructure
based on facilities at the district, mandal, primary health care, and sub-center levels.
Considerable effort has been put into the improvement of these a facilities, particularly at
the district and primary health care facility level, and with the introduction of the APWP
structure for both District and larger CPC hospitals, there has apparently been
considerable improvement in the functioning of these facilities.
A2.4 Because of this facility based approach to health care, and the hierarchical
supervisory and administrative structure that accompanies it, each type of facility is
dependent on the effective functioning of the staff and systems at the next level up for
supervision and support. Thus, the ANM at the sub health center relies on the Primary
Health Center and its staff for supplies and supervision, the PHC is linked to the CPC
hospital for referrals and technical guidance, and the district hospital is meant to provide
both specialist medical services and administrative support to the entire system.
Unfortunately, due to acute shortages of staff, especially doctors, and confusing and often
conflicting supervisory structures, these linkages do not easily occur, and thus to a large
extent, each facility, and each service provider below the district level is effectively on
their own, with little guidance and often little support. The result is that peripheral staff,
confused about their roles, and frustrated with their inability to delivery effective services
do not adequately serve their communities.
A2.5 In an effort to focus attention on certain national priority programs, The
Government of India provides direct funding for a variety of Vertical programs such as
family welfare, malaria, tuberculosis, and other infectious diseases. These programs are
implemented through the state infrastructure, and rely heavily on the staff at the district
level for coordination and the multipurpose health workers at the community level. For a
variety of reasons, these programs are not working effectively. One problem is that the
state of Andra Pradesh has not fully funded the positions in these vertical programs so
there is a lack of staff, especially at the local level. A second problem arises at the district
level where the multitude of programs each compete for very limited resources with the
result that programs are not fully implemented and these priority programs are not having
the desired effect on disease control in the state. A third difficulty of these vertical
programs is that the current policy is toward integration of program activities at the state
level, so that the status of these vertical programs is confused, and it is not entirely clear
how they are meant to be integrated into the state program, particularly at the district
level where there are separate staff and resources for each program.
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A2.6 India for many years has emphasized the use of targets as planning and
management tools, especially in the area of family planning, but in other development
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areas as well. Unfortunately, the heavy emphasis on targets often means that staff place
undue emphasis on meeting the numbers rather than actually achieving the underlying
goals for which the targets were set. Certainly this has been the case in the area of family
planning where targets has m^ant pressure on women to have sterilization procedures
following their second child, with financial incentives provided to those who agree.
However, this strategy underemphasizes other elements of family planning or
reproductive health, so that there is virtually no information or demand for other types of
family planning and little emphasis on spacing births to protect both the mother and
child. Further, the targeting, done at particular times of the year draws off personnel from
its regular duties, so that other types of programs are often neglected at critical periods
and the entire system goes from crisis to crisis rather than a steady flow of services that
would be both more efficient and more effective.
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A2.7 An effective health delivery system requires the underpinnings of
oi good
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management systems in areas such as logistics, information, personnel, financial,
management and control and planning. While this initial study did not provide sufficient
time for a review of all these systems, some preliminary observations can be made.
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Record keeping, while copious, does not seem to provide mangers anywhere in the
system with the types of information they need to make the system work better.
There are several reasons for this which include the disassociation of information
among the diverse vertical programs, the lack of communication between different
levels of the system, the lack of data about the private sector activities (that account
for ’/. of all service delivery), the manipulation of data to show progress on key
targets, and the lack of data processing at most levels of the system.
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Personnel systems, based on the rules of the public service and dominated by the
unions provide little incentive for good work, and protect those who abuse the
system for their own benefit. There is little accountability, and staff generally are
poorly motivated and underperforming.
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The logistics system, recently revised and semi-privatized appears to be functioning
much better than it did previously with the exception of the lack of adequate
resources for drugs and supplies at the PHCs.
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The financial management system is being reviewed by another member of the
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b.
Constraints to Effective Service Delivery
A2.8 There is understandable concern about the relatively high rates of infant, child
and maternal mortality, low coverage of disease control programs, and apparent
dissociation between the recent economic development of the state and the plateauing o
health indicators. There may be many factors that explain this, but one is the relative
inefficiency of the system to reach its target population either through the integrate
programs run out of the PHC or the vertical programs run through the district medical
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office. One reason for this is the limited staff actually available at the community level,
including both ANM, the male multipurpose health worker, or any type of effective
supervisory system. Another constraint is the limited number of doctors who are
available at the RHC and who have the enthusism and resources to promote the activities
at the community level. Another problem at the community level is that despite the many
types of organizations present there such as self help groups, nutrition groups, parashad
health committees, and others, there is not a clear mechanism for these groups to link up
with the formal health structure and utilize the resources that could be made available for
better health.
A2.9 Because of the structure and rules of the public service system, promotion, and
assessment is based almost solely on longevity, personal contacts and in some cases cash
payments in exchange for preferred postings. For this reason there is little to no
accountability by public servants either to their clients whom they are meant to serve or
to their immediate supervisors who have little say over salary, promotions or placements
of staff. Managers at each level have little control over staff or resources at the next level
and little incentive to ensure that things run smoothly throughout the system. The
premium is on not causing trouble rather than on achieving results, and in any case, there
is little accountability throughout the system except in cases of gross mismanagement.
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A2.10 There remains a strong bias toward the use of financial incentives to influence
client behavior. These include incentives to deliver at a government health facility, to
have sterilizations after the second child, have antenatal care, etc. There is little evidence
that these incentives actually achieve the desired goals, and may make it more difficult to
help clients really understand both their options and rationale for the choices that they
make at the moment and in the future. In addition, it puts the health staff into the difficult
position of deciding on the entitlement to various payments rather than of providing
information and assistance.
A2.ll The role of the ANM has shifted considerably in the past decade leaving both the
community and the ANM frustrated. Originally conceived as a front line maternal health
worker able to perform deliveries, give antenatal and post natal care, and provide family
planning advice, the ANM today, in her new role as multipurpose health worker is
expected to also provide information on disease control, water and sanitation, nutrition,
and curative services to a wider population of approximately 5000 people with a shorter
training of 18 months (previously it was 24 months) and with virtually no technical
supervision. To a large extent, the dilution of her activities has distanced her from the
community which she serves, leaving her with little support and considerable frustration
in her ability to carry out her work. This difficulty is significantly compounded by the
fact that the doctor at the Primary Health facility is usually not present, and virtually
never comes to supervise the ANM, and typically there is no suitable building for the
ANM to work in at the village.
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c.
Short Term
A2.12 Although the relatively poor performance of the government health system of
Andra Pradesh will require fundamental systemic changes in the long run, there are many
specific targeted activities that could be implemented immediately that would have a
significant impact on key vital indicators.
A2.13 Perhaps the single most important change that is urgently needed is to support
linkages between the many community and women’s groups and specific health
programs. AT the present time, the PHC system is not reaching the communities and so
programs such as safe motherhood or malaria control are not having the desired impact.
Thus as a first priority, the community, self-help, or women’s groups that are active in
each community must be given both the authority and the resources to assist in their own
health programs. Examples of how this could be achieved are:
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Mechanisms must be developed to get basic drugs and supplies to the communities
such as chloroquine, ORS, antibiotics for ARI, and contraceptive supplies such as
pills and condoms. This could be done through a program of community
pharmacies, through enhanced use of ANMs or through some other mechanism. It is
a relatively simple matter to teach mothers and other members of the community to
recognize symptoms such as fever, cough and dehydration, and the dangers of over
use of drugs such as chloroquine, trimethaprim-sulfa or ORS are far outweighed by
the increased mortality of underuse. In the long run, trained providers should be
made more available through the PHC, but in the immediate term, one can simply
not wait for this to occur.
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Many villages have access to well water, but many of these wells become
contaminated during certain times of the year. It is a relatively simple matter to
make disinfectants such as chlorine available to community groups on a periodic
basis to reduce the incidence of water-bom disease and diarrhea in the community.
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Not all villages have the same public health problems, and communities need to be
encouraged and supported to develop specific, integrated disease control program
approaches based on local issues and priorities. In areas of high malaria or
encephalitis, programs that include vector control could be supported and managed
by the communities, while those areas with high incidence of TB could be trained in
the need for contact tracing and the DOTs program. The point is not to try to teach
each community about all of public health, but rather to identify the particularly
high priority disease problems for individual communities and teach local groups
specific activities to control these diseases.
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One way that these types of programs could be encouraged is through the; use of
ratings and prizes for those communities or community
<
, groups that achieve the best
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Potential Strategic Approaches
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results or undertake innovative approaches to health programs. Communities could
be rated in a manner similar to that being done for ARWH hospitals (ABC) and
annual awards could be given to the community group in each district that has the
best results or more innovative approach, with cash prizes given to the winning
communities. This type of publicity may contribute to the dissemination of new
approaches and foster appropriate competition among communities to achieve better
health results.
A2.14 A second immediate priority must be to regain the trust of the ANM’s by the
community and to make them more productive. In the past, when their role was clear as
part of the family welfare program, and their training and supervision was adequate, they
were a respected part of the community. Today, with their reduced training, their limited
supervision, and their expanded role, they are both frustrated and unsupported. To regain
their support, several actions are suggested:
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The role of the ANM must begin with a linkage to the communities she serves, and
this must be made explicit to both parties. Under the program of decentralization, it
must be the parishad that supervises the ANM rather than the staff of the PHC, and
this must be made clear at the outset. At the same time, the MOH must make dear
to the parishad what the ANM can and cannot do, and the ways in which the
community must support the ANM in her role in the community.
There must be developed a more realistic scope of work for the ANMs based on the
perceived needs of the community and the skills that the ANMs actually possess.
This would include family planning counseling and service delivery, included a
much stronger focus on spacing through use of pills, condoms, injectables, and
IUDs, and antenatal care. Further, as part of the antenatal care program, money that
is designated for pregnant women to enhance nutrition could be administered
through the ANM or the local mothers groups so that the funds are actually used for
this purpose rather than being dispersed after delivery. Other nutritional advice or
supplementation could also be given to pregnant women by ANMs.
It is also suggested that ANMs be given basic training in the treatment of common
health problems similar to that described above for community groups. Thus, they
could be provided with chloroquin for malaria, ORS for diarrhea, and trimethaprim
sulfa for acute respiratory infections.
Given the number of communities that an ANM must serve, and the lack of suitable
facilities for them to live, it is unrealistic to expect that they will live at the health
sub center which is most often a run down, rented structure without water or
electricity. Rather it would be more appropriate to have the ANM live in a nearby
town where there is suitable housing, and then facilitate her regular visits to the
communities by providing either transportation, or more likely some type of stipend
for public transportation.
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A2.15 The current program of safe motherhood is based on outdated assumptions and is
not working. The fundamental assumption that high risk pregnancies can be identified
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handle obstetric emergencies such as hemorrhage, eclampsia, infection, and obstructed
labor, and are able to provide emergency treatment including cesarean section. However,
in Andra Pradesh these types of services are not available even at the PHC, since PHC
do not provide Cesearean sections, and further the doctor is most often a sen . or i
reason, considerable rethinking is required about what to do about the high rates of
maternal mortality in Andra Pradesh. One short term option could be for each
community, depending on its proximity to a hospital, the availability of private vehicles,
and of telephone service might develop an emergency response plan based on local
conditions. This would mean that the local midwife or someone else in the village would
be able to recognize when to get help and an immediate response would e set in mo ion
that would transport the woman to the nearest hospital where appropriate action could be
taken. In those communities that are too distant or do not have sufficient transportation,
more intense efforts could be made to encourage “institutional deliveries in an
institution that can actually deliver emergency obstetric care.
IB
A2 16 Another immediate action that would have a profound impact on both maternal
and infant mortality would be the introduction of a reproductive health program in
Andra Pradesh. Unfortunately, the family welfare program in most areas continues to be
to encourage women to have 2 children as soon as they are married (often at age 15) and
then a sterilization. This approach leads to high maternal mortality and ^t mortahty
due to the young age of the mothers and the close spacing of the births. While the long
term solution to this problem must be more and better educational opportunities for girts
and stronger cultural inhibitions against teenage marriage, an interim step that would
have some impact would be to substantially increase the information an ayai a i ity o
temporary methods of contraception to all women but especially to adolescent girls.
There are numerous ways this could be done including the use of ANMs, teachers, and
youth organizations at the community level.
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A note on Infant Mortality
Perhaps the single most commonly used measure worldwide of the effectiveness of a
health system is that of infant mortality: the number of children who die from any cause
during their first year of life. One of the reasons that infant mortality is widely used is
that it is relatively easy to measure, and is a good summary measure of a wide variety of
elements that contribute to the health of a population. Unfortunately, it is a very poor
measure of many of the specific interventions of a public health program in the short
term, and is often misunderstood and misusedfor that reason.
To understand this point, it is important to understand that most infant deaths occurs
during the first few hours or days after birth and are the result ofprematurity, small birth
weights, difficulties that occur during delivery, or problems associated with fetal
development during pregnancy. In some countries, neonatal tetanus is also a significant
contributor to neonatal death. Thus measures such as childhood immunizations, feeding
patterns of children and effective treatment of childhood illnesses such as diarrhea and
respiratory infections, while important, will not change the patterns of neonatal deaths
that typically account for over half of all infant mortality. Rather, factors such as the age,
parity, nutritional status, immunization status (for tetanus toxoid), malaria parasitemia
and anemia of the mother will have a profound impact on the levels of infant mortality
and thus measures to reduce infant mortality need to focus on i..
the condition of the mother
well before she becomes pregnant rather focusing primaryf attention on either the
antenatal or neonatal period.
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Medium and Long Term
A2.17 Many of the changes that are needed for substantial improvement of the health
system and its impact on health indicators will require structural changes in incentives for
staff approaches to disease control, prioritization of resources, and changes in regulations
and laws that inhibit access to quality health services at the primary level, and will need
to be part of an overall restructuring of the health system as invisioned both in the Vision
2020 document and in the strategy developed as part 2 of this exercise. Further, many of
these changes have already been discussed fully in documents such as Impact and
Expenditure Review: Health Sector (parts I and II) by DFID, and The ECTA Situational
Analyusis 2001/23, August, 2001 by the European Commission. Thus, rather than going
into depth about what these changes might be, I will simplv highlieht some of the critical
areas that will need to change:
Perhaps the single greatest blockage to good care is the absolute lack of
accountability of the staff either to do their work effectively or even to be present at
their post. Promotions are based solely on years of service, those in the most senior
positions are simply marking time until they retire. They have no incentive to take
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risks that might improve the quality of care, and rather invest their time in preparing
for their post retirement careers. A better system must be put into place that makes
providers and managers accountable to their clients and their superiors and ensures
better services are delivered. At the same time, one must be more realistic about the
conditions of services of those doctors who are working in difficult conditions at
PHC or other types of rural facilities. Without proper schools for their children,
appropriate housing or water or electricity it is unrealistic that doctors places at such
posts will remain, and over the long term, efforts must be made to make these types
of services, especially schooling, available even in remote areas. Further, doctors
who do go to live in these remote areas must be given incentives such as fast track
career rewards for specialist service, or enhanced promotion opportunities within
the public service. Other types of rewards for working in difficult environments
might include choice in subsequent placements, conferences, and priority for
specialist training positions.
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The current emphasis on decentralization puts a very high premium on the capacity
and commitment of the DHMO to make the system work effectively. Yet these
doctors are not trained for the position in areas such as management or public
health, and typically this position is the last before senior doctors retire after long
years of service. There is a critical need for younger, well-trained, energetic
DHMOs in these positions. One mechanism to do this would be to require specialist
training in public health, and to make public health management a specialist
position with all the rank and privileges of other specialists.
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Overall, the entire health system is highly reliant on doctors at every level. Yet,
both in India and in other countries, studies have shown that doctors are often
unwilling to go to remote areas, do the more tedious tasks required in primary care,
and are less sensitive to the needs of their clients, especially those who are too poor
to pay for services. Many of the tasks done by doctors in India could be done more
cheaply and better by nurses or other non-physician providers, and this type of
approach to many elements of service delivery should be considered.
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Over the years, India has come to rely on the use of targets for many of its
development goals as a way to make clear its priorities. However, as has been
clearly demonstrated in the area of family planning in India, these targets often lead
to inappropriate behaviors by staff driven to meet their monthly or yearly quotas.
Further, because of the high pressure to make their targets above all else, staff often
provide unreliable information about their actual numbers so that planners do not
have accurate information about what is actually happening in the field. Rather than
the reliance on a small number of targets in areas such as sterilizations, a more
sophisticated array of performance measures must be constructed that give a better
measure of actual performance and are less easily misreported by staff.
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As discussed above, the family welfare program in Andra Pradesh is basically to
offer incentives to women to have a tubal ligation at an early age after they have had
their desired number of children. This is reinforced with cash incentives. This is the
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antithesis of a reproductive health program that provides women with choices about
the timing and number of children, and services regarding all aspects of
reproduction. A complete rethinking of the way that reproductive health is actually
practiced and delivered in Andra Pradesh should be considered with a major
retraining of staff at all levels in terms of how to best meet the needs of their clients.
Over the long term, this approach would have a dramatic impact on infant and
maternal mortality, incidence of sexually transmitted disease, and the education and
productivity of women in the society.
One of the problems faced at most PHCs is the lack of adequate supplies of drugs
especially antibiotics. This results in lack of confidence in the system by the
population and the inability of PHC personnel to give treatments for priority
illnesses such as respiratory infections, sexually transmitted disease, or maternal
sepsis. While it is recognized that the funding for drugs is limited, at present a
disproportionate amount of the total pharmaceutical budget goes to tertiary level
hospitals that serve only a very small segment of the population. Further, the net
effect of the current system is that the poor, who primarily use PHC facilities have
to buy their drugs, while the middle and upper classes who are the more frequent
users of tertiary care do not pay. This trend should be reversed, with higher co
payments for drugs at tertiary care levels, and with a reorientation of the budget for
pharmaceuticals to place a higher percentage at the PHC level.
The current program for institutional deliveries at PHCs is not realistic for several
reasons. First of all, there are not enough beds, and further, PHCs, under the current
plan cannot perform Cesarean sections since there is not provision for anesthesia at
these facilities. Further, it has been repeatedly shown that the high-risk approach to
identification of potential obstetric problems does not work and should be
abandoned. If Andra Pradesh is to significantly reduce maternal mortality, a
rethinking of the approach to institutional deliveries is needed where the emphasis is
on how to save lives and have safe deliveries rather than emphasize unrealistic
strategies that look good on paper but do not work..
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The current disease control programs seem to put a higher emphasis on
surveillance than on treatment. While surveillance is obviously important, a greater
emphasis on sentinel surveillance may free up resources to place higher emphasis on
treatments or personal protection strategies such as the use of impregnated bednets
for mosquito control. Again, the emphasis must be on the reduction of morbidity
and mortality rather than unrealistic strategies that aim for eradication of disease.
Furthermore, the entire question of how the vertical disease control programs are to
be integrated into the primary health care system needs to be reconsidered at the
state, district, PCH and local levels.
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DRAFT
Annex 3
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Support for Development of a Medium Term
Health Strategy for Andhra Pradesh:
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Governance Aspects of the Health Systems In Andhra Pradesh
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Annex 3
Governance Aspects of the Health Systems In Andhra Pradesh
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This note focuses on the governance aspects of the health system in Andhra Pradesh;
This is a preliminary paper for discussion and not a complete commentary or a detailed
analysis of the situation. It is derived from a review of documents, a senes of meetings
and two field visits. Much more analysis will be necessary to strengthen some ot e
hypothesis and research required in some cases. This sets a base for discussion and the
authors are happy to know of any gaps in understanding.
A3.1 The Government of Andhra Pradesh has produced a vision 2020 document, which
sets out clearly the health outcomes that the Government seeks to achieve by yea^
It also sets out some important governance principles which are to be used in achieving
these outcomes. The GoAP has set up a task force on good governance and also
established a cabinet sub-committee on administrative reforms. Some key statements ot
intent in the Vision 2020:
A SMART Government - Simple, Moral, Accountable, Responsive and
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Transparent
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Refocusing Government priorities and spending to focus on key pnonty
development areas (like basic education, primary healthy care....)
Reducing administrative and other non-developmental expenditure and
leaving market forces to govern areas where state intervention is not
required;
Decentralising government and increasing participateon in planning and
decision making;
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Introducing electronic government to demystify procedures and impr
citizen-government interface;
Strengthening policy making capabilities and improving performance in
the public sector
...
Talking a lead in persuading the Central Government to initiate regula ory
and other reform;
....
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Undertaking a range of fiscal reform initiatives (prioritising spending,
efficient,
better management of expenditure, making tax administration
<-----------encouraging private sector participation...)
A3.2 Andhra Pradesh state health system has been built over time, with changes being
made continuously to help function better. Several sub-departments and institutions aye
been created over time, with varying roles and resources, to implement or suppo pa
the system. There are multiple layers of management, sometimes with cross cu mg
roles. The existing health system is complex, but largely designed to be meet emerging
needs.
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A3.3 The health department has a history of carrying out several changes (small and
medium) introduced by the state government to improve effectiveness. Some have been
successful, some not followed through in implementation and others very much in paper.
The department has several external limitations - two crucial ones being the centrally
sponsored schemes and their design which sometimes offers less flexibility and more
vertical structures and secondly on human resources, the department will have to operate
within the broader civil service rules1 of the state.
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A3.4 The Health Department was set up in 19222. The Andhra Pradesh Government
operates through 272 departments / sub-departments 3. The Health Department has about
10 directorates (or sub-departments):
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Directorate of Health Services (DHS)
The Commissionerate of Andhra Pradesh Vaidya Vigyan Parishad
(APWP)
Directorate of Family Welfare (DFW)
The State AIDS Control Society (SACS)
Directorate of Institute of Preventive Medicine (IPM)
Directorate of Insurance Medical Services (DIMS)
Directorate of Drug Control Authority (DCA)
Directorate of Indian System of Medicine and Homeopath (ISM)
Directorate of Medical Education (DME)
Autonomous universities and institutes (three)
A3.5 Primary Health Care is provided by the DHS. Secondary and tertiary health
services are provided by the APWP, a separate legal entity. Directorate of Family
Welfare and the State AIDS Control Society implement the centrally sponsored schemes /
programmes (and a few of the state governments’). Directorate of IPM is involved in
production of vaccines, implementation of PFA and diagnostic services. Directorate of
Insurance and Medical Services operates the Employee State Insurance hospitals and
scheme. Directorate of Drug Control authority (DCA) is the regulatory authority for
drug control. The ISM directorate manages the Indian System of Medicine. DME
manages medical education along with three autonomous universities and institutes.
A3.6 In a predominantly ‘technical’ department staffed by medical professionals, health
management plays a crucial role, especially in a important function of the government public health provision. Governance aspects of the health system has a vital role to play
in ensuring equity and availability of services, especially efficiency and effectiveness of
services delivered. The next few pages analyse the above issues in AP’s health systems
context, suggest recommendations (short and medium term).
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1 Except in independent Societies
2 Some parts of it operational from 1802
3 Some times referred to as Directorates
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Analysis of the Situation
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Role and Strategic Balance
The purpose of the Health Department could be articulated as:
Providing quality, accessible, equitable, affordable and guaranteed health services
to the poor, both in rural and urban areas.
Facilitating, partnering and providing regulatory frameworks for private sector
and civil society health services.
The role of the department broadly are:
Service provision, esp. to the poor and marginalized
Infrastructure and facility provision
Quality assurance - of service and infrastructure
Targeted subsidies and safety net for high cost Medicare for the poor
Facilitation of private sector and civil society in health care
Regulation of Medicare to make it ethical and equitable
Key outcomes would be:
Reduced mortality and morbidity
Satisfaction of the users of public services
Regulated private medical care that is ethical
A3.10 Of the above, the focus of the department is on infrastructure and service
provision. Little is being done in other areas. There is a need to bring in a coherent
strategic balance within the department - both in terms of resources (time, budgets and
personnel) and management attention. Future planning will need to balance these issues
and look at the best way of attaining the purpose. This may mean shedding a few
activities like manufacturing vaccines, some of which are higher price than the private
and moving into more strategic areas. Currently the Government is involved in complex
activities surrounding health. Ways will need to be found to do less, but to do more
strategic aspects. Primary Health care, which is a key component has been under
performing for variety of reasons. With the establishment of the PRI institutions, the
department has the opportunity of devolving this part of health care (which is managed in
an average manner), while taking more strategic and support responsibilities. There is
substantial scope to rationalise activities within the department.
A3.11 Government has largely left tertiary care to the private. It also needs to have a
plan of how it will involve the private and civil society in other parts of the health
delivery system, without losing sight of its primary responsibility towards the poor and
their Medicare needs.
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A3.12 The department follows historical budgeting. The sub-departments submit their
budget and the department takes an overall view (with the Finance Department) and
sanctions fixed budgets to the sub-departments. The line items are fixed and very little
flexibility exists4. Nearly 70-805 % of all costs salaries. Other fixed costs include rent,
electricity, etc. Barely about 5-10 % are controllable costs. Programme costs which
include drugs, actual service delivery are still low. The function of planning for health is
limited to budgeting. Strategic planning is limited to the Secretariat and Directorates,
with little participation from various ranks. Most activities are carried out based on
historical basis and new activities are added based on state or centrally sponsored
schemes. Budgeting is mainly historical, with little innovation or flexibility. Most of the
changes to the department’s working have been ideas and suggestions from the
Secretariat / Directorate, which are then followed through by other arms of the
Government. This very important function is given least importance in terms of time.
Problem resolution is ad hoc and some critical issues (like private practise and its effects)
go undecided for several years.
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Reform orientation
A3.13 The Government of Andhra Pradesh is known for its reform orientation. The
Health Department in particular has been open to reforms. The Vision 2020 - provides an
overarching framework. Between 1983-88 the government initiated several reforms in
the health sector. There is emerging evidence of impact. It is significant that these
reforms were not under pressure from external donors or the Bank, but internally initiated
and funded by the Government.
A3.14 Leadership quality and commitment to change, both at the political and
administrative level is energetic and enthusiastic. Willingness to change and try new
ideas exists at almost all levels. There are already several initiatives introduced, some of
which are bearing impact. Few examples of initiatives - Introduction of user fees, the
autonomy for retention of user fees, hospital autonomy, performance indicators for
outcome, incentives for better performing hospitals, increased allocation to Primary
Health Care (PHC) and formation of Advisory Bodies at various levels. The history of
reform orientation and the current enthusiasm to change is a useful base to begin.
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A3.15 There is a wide range of poverty alleviation programmes and initiatives in the
social sector (primary education, child labour), food security etc. Learning from these
experiences are available for the Government. The strong civil society base - 4.21 lakhs
women's SHGs (51.8 lakhs members) and 1300 Crores of corpus are major strengths.
The voluntary sector resource base is large - Government already working with 200-300
NGOs in the health & family welfare sector. Other women’s empowerment programmes
opportunities
- government and non-govemment and their extensive coverage are great
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for making the Government more responsive.
4 Except in vertical programmes of HP/ & TB where some flexibility exists under the Societies
5 Quoted in several discussions. Actual figures need to be verified and most accountants assure is very near
this figure of 80 %
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A3.16 The reform process in Andhra Pradesh has been in fits and starts.
Some
initiatives have been followed through with considerable thought and action (hospita
autonomy, user fees), some with limited follow through (Advisory Boards) an some
others with limited thought, introduced and withdrawn (meritocracy).
A3.17 The reform process is positioned interestingly - with opportunities ahead. There
is also the need to carefully plan, consult stakeholders widely, increase the remit of the
department in some cases (like regulation) and make the department more manageable by
reducing structures and functions that are less than effective.
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Political Systems (representation & influence)
A3.19 In 1994, GoAP enacted the AP Panchayati Raj Act. Going with the 73 and 74
Constitutional Amendments, the AP Government has made some attempts at devolution.
Decentralisation and devolution has been rather slow in the State of Andhra Prades .
Currently there are 21943 Gram Panchayat (GPs), 1095 Mandal Panchayat (MPs) and 2
Zilla Panchayat (ZPs). They have an extremely limited role to play in representing the
aspirations of the people. The GoAP has decided to bring field staff of fourteen line
departments with the PRI structure. This move has been in paper and the implications of
it not fully discussed.
A3.20 The PRI elections have been held regularly. Last election was held about six
months back. Some positive developments include appointment of Panchayat Secretary
to assist the GP Sarpanch and provision of other executive officers for running the PRIs.
A3.21 Gol schemes like food for work and other schemes meant for PRIs provide some
revenues to the PRIs. The GoAP provides about Rs 332 crores to the PRIs as Grant in
Aid, based on a per capita formula recommended the State Finance Commission. Omer
than this the GPs are allowed to raise their local resources through Professiona ax,
Property tax. Advertisement tax, etc. The revenue generation ability varies from GPs.
Some which are closer to main roads and which are ‘substantial’ in size are able to raise
revenues through taxes. Even these GPs are not self sufficient. Many of the smaller and
remote GPs face a credibility problem in terms of collection of taxes, due to oca
opportunities being less. Local community members trust in their abilities to run t e
local resources may be limited.
A3.22 In health, the concept of Advisory Boards is a step forward in representation. But
without control over the budgets and staff, the PRIs will have an extremely limited ro e to
play in influencing or directing the local health resources to serve their needs.
A3.23 The political space for the PRI leaders and that of local MLAs is undefined.
Hence there are potential conflict areas. For example the local MLA and the CEO of ZP
are in the Advisory Board of the District Hospital. Both are elected representatives.
Their roles will need to be more sharply defined.
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A3.24 The limited nature of PRI empowerment has meant weak PRIs, with limited
resources and activities. This also means low credibility. Even within some of the
activities are devolved to PRIs, there is a tendency to take back in the name of efficiency,
or provide supervision through district collectors or subvert the process through GOs or
other mechanisms. The chain of ‘Low abilities of PRIs, therefore lesser devolution and
more supervision’ needs to be broken for better and effective devolution, accompanied
with capacity building and provision of adequate powers.
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A3.25 Corruption is a worrying aspect of the PRIs, especially to the Government. As
institutions, they are yet to take off and are far off from political maturity. Hence the
Government has also taken more and more steps to restrict PRI functioning, in order to
avoid corruption. One case in point is the GO restricting purchase of bleaching powder
and bulbs to a set % of the total budget. This GO was issued because the GoAP felt that
there was misuse of monies in these heads of accounts. Such pro-activeness though
appreciable, weakness the local institution further.
A3.26 The seriousness of the GoAP on devolution is difficult to judge. Many of the
reforms that the government is aiming can be more effective if the devolution process is
managed better.
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A3.27 Reg. Decentralisation - please see note on subject by Dr. Tom Bossert (Annex ?)
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d.
Accountability and transparency
A3.28 To improve accountability, local advisory boards have been set up by the
department. These advisory boards consist of community representatives, the department
staff, elected representatives and civil society representatives. These boards have been
formed through a GO and are supposed to operate at sub-centre, PHC and hospitals. At
the district hospital, a separate Society has been formed with similar representation. The
advisory bodies have been formed in 2001 with a view to encourage local participation
and ownership. It is not clear how effective these bodies have been and how much of
inputs have gone into building these bodies. Discussions reveal that the effectiveness of
these bodies vary substantially. Many are not fully aware of their roles and rights.
Meetings are not regular and there is still confusion on the role of the Advisory Bodies
vs. a vs. established monitoring and accountability mechanisms. For example, the role of
the District Hospital Supervisor who is in-charge of the CHCs and Area Hospitals vs. a
vs. the Advisory Board. The role and effectiveness of the Advisory Body needs to be
studied more in detailed during the next phase.
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A3.29 Though Advisory Bodies provide for participation, it is not designed for control
or remedial action. The current situation which many studies, field visits have
highlighted is the vexed problem of non-availability of doctors, especially for
emergencies and the complete lack of accountability of all PHC & Sub-centre staff to the
community that they seek to serve. Here the past experience of the Government is
relevant. In 1970s the system of the Rural Dispensaries (now PHCs) were reporting to
the Block Development Office. This meant local community control over their resources.
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esp. human.. In many of the interviews, the department staff interested in local level
community control feel that this system ‘worked’.
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A3.30 Without the involvement of local communities in the management of the PHCs
and structures below, it is unlikely centralised control mechanisms will work.
Goal of
guaranteed and quality services can happen only if the Government devolves (see section
on decentralisation for more details).
A3.31 In the case of district hospitals, the societies have been empowered to collect user
fees (within a broad charter) and other revenues and retain them for local use. User fees
is still a very small percentage of the total costs (about 2-3 %). This move by the
Government of guiding the hospitals to collect user fees and also allowing them to use
the resources locally is a very positive move. Such mechanisms need to be strengthene
further through other support mechanisms, which will enable the hospitals to move
increasingly towards better efficiencies.
A3.32 The quality of public health service in AP is still poor compared to rest of India.
Some key statistics from a study of public services - State of India’s Public Services Public Affairs Centre, Bangalore:
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Only 61 % of households feel that they have easy access to health care (National
average 73 %). AP is one among the lower ranking states
• Only 59 % report paramedics available during first visit to Government Health
Centres. 23 % report paying bribes to access Government health care facilities.
• In the overall ranking of performance of Government health care services (using
several parameters), AP is one among the lower ranked states.
A3.33 Quality of service delivery, customer orientation, measurement and reward and
disincentive systems are not in place. Advisory Board, though a positive direction, wi
need to be supplemented with independent data on customer satisfaction studies, which
are conducted on regular basis on quality, access, equity, costs of health services, both in
rural and urban areas. Internal information systems will be insufficient and inappropnate
to address this issue. There has to be mechanisms in place which will flag issues of staff
availability, quality, etc in a more systematic way - for both Advisory Body and
Government to take remedial action on.
A3.34 The current system geared for service provision - not guaranteed service delivery.
To provide guaranteed services, starting from policy statements (E.g. of Government
assurances of medical personnel 24 hours), operational systems, training and severa
other initiatives will need to be in place. Only then will the government ensure
guaranteed services to poor and also know when and where it is not happening.
A3.35 Corruption is a grave challenge to the department’s work (like in other parts of the
Government). It appears that there is corruption involved in recruitment, trans ers,
procurement, travel, training, incentives paid to communities. Many of the posts wit in
thp
Hpnartmpnt are available for a nrir.P
the department
price. This has aonarentlv
apparently lead tO
to Severe de-motivation
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of staff, especially those who are unwilling or unable to pay bribes for their promotion or
transfer. For the department to be effective, ways will need to be found to tackle the
issue.
A3.36 MIS for each programme and directorate varies. While reporting systems at
District to state has changed over the years, record keeping and MIS at the PHC and sub
centres have changed very little over the years. Being a hierarchical structure, every level
is supposed to supervise the next level. Supervision and monitoring are through targets,
reviews and field visits. The department is heavily oriented towards quantitative targets.
Recently performance indicators at outcome level have been introduced. Reviews of
health department are usually conducted along with other departmental reviews (by the
Collector, the Chief Minister). Health is usually reviewed in the last part and according
to department staff not allotted sufficient time
A3.37 Performance assessment systems for both individuals and institutions exist, the
later being a recent development, mainly for the APWP hospitals - A comprehensive
hospital information and gradation system, based on indicators . Other parts of the
department are usually measured based on quantitative targets. The performance
indicator led performance assessments are taking root now. In the case of individuals, the
annual appraisal exercise is the route for performance assessment. The appraisal system
is not used for increments, which are routine in nature. The appraisal mechanism is
weak, with many of the critical parameters to evaluate performance missing. Though
meritocracy was tried out briefly, experience was not successful. It would be useful to
examine why it failed. Currently, promotion is based entirely on seniority, to most posts.
Individual performances have little relevance as there is little reward and punishment.
A3.38 System for internal learning needs to be strengthened. While measuring
performance, reviews are important to know how far we have travelled, important aspect
is the ability of the department to learn from its successes and failures. An atmosphere of
embracing error and learning from mistakes is very essential. Current functioning only
encourages people to hide mistakes, not learn from them. In many senses, mistakes
made in one district are not passed on to others, and is repeated in other districts. Sharing
and learning atmosphere is critical for the department to be effective and learning
systems will need to be instituted.
A3.39 The department also plays a limited regulatory role. The Prevention of Food
Adulteration Act is implemented by the department, through IPM. There are a number of
Food inspectors whose job it is to test samples and prosecute offenders. The other
regulator is Drugs Control Authority (DCA). The department’s regulatory role for the
private sector health system is yet to be planned.
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Focus on Poor and Marginalized
A3.40 Please see note on Social Development written by Ms Vimala Ramachandran and
Dr. Hillary Standing (Annex ?)
2.
Key Management Issues
A3.41 Management aspects within the health systems have a vital role to play in
ensuring efficiency and effectiveness. Broadly the areas covered are planning,
monitoring, human resource, financial management and logistics.
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Staffing
A3.42 The State Government has frozen all recruitments and any new appointments
require special clearance. All new appointments have been on contract basis at various
locations. The contracted staff are paid about 907 % of the basic salary of the permanent
staff salaries. It is not clear how the contracting aspects have been thought through (in
terms of legal and other risks for the Government). As transfers effected were many, the
department froze transfers.
A3.43 Each of the sub-departments are headed by a Director. In case of HIV/AIDS, the
programme is housed in an independent Society. Other than this, all others are sub
departments of the Government.
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A3.44 The Directorates report to the Secretariat - Health Secretary. Each Directorate is
organised differently. The structure is hierarchical, with matrix like structures at the
District level.
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A3.45 Much of the structure is for:
• Public Health Service delivery in rural areas
• Vertical programmes like HIV or TB
• Teaching institutions and hospitals attached to them
• Hospitals (mainly secondary care)
• Allied services (diagnostic, vaccine production)
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A3.46 The staffing of the directorate and the district structures have been built more out
of history .than any focus on its role. To fulfil its role, there Government will need to
examine structures which are more facilitatory. Past programmes especially vertical
programmes have lead to specialised staff being appointed and the Government is
carrying substantial excess staff on this count. While Govt has been rationalising its
working at State level, there has been very little changes at the District. For example,
with the leprosy problem reducing, the focus on the programme at state level has come
7 Which increases to 95 % in year two and then 100 % in year 3
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down. Deputy DM&HOs assigned have also been given additional responsibilities.
However Leprosy workers continue their work in a limited fashion.
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A3.47 Some positions have short supply, and others excess. Technical positions,
especially of doctors in short supply. In the case others like support staff they are in
excess. There are close to 1000 posts vacant in the state. In one district, there are about
81 support staff in the DM & HO office alone. Clarity at the district level on overall role
is also necessary. Without a careful functional review, it will not be clear how much
excess or under staffing is there. In the case of DM & HOs, there are 12 of the 22 posts
vacant. This appears strange given the fact that there is adequate amount of Deputy DM
& HOs available for promotion. One reason some observers point out is corruption.
A3.48 Government appointments are banned and all new (necessary recruitments) are on
contract basis. The contract staff get about 90 % of the gross salary of a full time
employee. Contract staff should be paid higher, as it is not a permanent position. Where
it has been difficult to attract staff (e.g. PHC Medical Officers), it appears illogical to pay
even lesser than the Government scales, which itself is perceived to be low paying.
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A3.49 Transfers, like recruitment is also banned. But most parts the department
circumvents this problem by deputing persons to different locations. Staff report that the
system of transfers have been politicised and is a major source of corruption. On the
other hand, transfers are inevitable process of management, however minimal they are.
The department will need to work out mechanisms to solve this problem.
A3.50 The Government needs to carry out an exercise to identify ghost workers, as this
is a strong possibility due to years of supply led staffing management there may be
workers on roll but not working in the field.
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A3.51 Several studies and experienced persons opine that low motivation is one of the
key problems faced by the department. As in other parts of the Government, performance
is not rewarded, and in fact punished with more work. Promotion is based on years of
service. By the time a person reaches supervisory position, it takes 10-12 years of
service. There is little incentive or disincentive - treating all individuals in the same
way. In the past, the Government had made an attempt at meritocracy and it is
understood that the experiment failed (more investigation needed). The recent efforts of
grading hospitals in APWP along with other initiatives to separate the performers and
die non-performers is very good start. This will need to move further in recognising
individuals who perform and those who don’t. There are examples (at least in APWP)
where non-performers or persons absenting themselves have been terminated. Such
action within department has been rare, showing that there is a need to build both the
incentive and the disincentive systems strongly. This is an area where changes will have
cross departmental implications.
Working rules cannot be changed only for one
department. But change will not happen if it does not start somewhere. Solutions will
need to be found to get around this problem.
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Training
A3.52 With over 500,000 Government staff, AP Government is attempting to
systematise the training aspects. There are several agencies which focus on imparting
training. The ones which address the Health Department needs can be divided into two
parts - within the department and outside institutions. Below is a partial list of important
organisations and departments offering training for health department:
Details
Within the departmental
structure________________
Independent
Central
Government organisation
Wide range of technical and
some managerial training
programmes
Dr. M. Channa Reddy HRD All Government staff and Independent organisation of
the State Government sometimes Ministers
Institute
identified as the ‘apex’
training institutions.
Main HRD and rural
National Institute for Rural Different levels.
development related.
Development (HRD Wing)
Multi-purpose Private and NGO based.
Nurse / ANM training ANMs,
Multiple
training
workers
colleges
institutions. An EC study
estimates about 140 of
them.________
With at least 5 years
Administrative
Staff Mid level managers
experience
College of India (ASCI)____________________ _
Who it trains ?
Trains supervisory staff and
other district teams_______
Indian Institute for Health Health (esp. RCH) and
and Family Welfare_______ family welfare staff
Institute of Health Systems Different levels of health
functionaries and others
Name
District Training Team
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A3.53 The current structure has District Training teams (in all districts) which are
headed by a Deputy DM & HO level staff, with at least 3 members working with them.
There is training infrastructure at the districts and the district training teams use to train
staff of the department, mainly in medical and technical matters.
A3.54 Training is a very important component which has not been given sufficient
attention. The training needs of staff are not scientifically and systematically measured
and a broad action plan in place. Training is more an ad hoc effort, with no clear linkage
to the jobs that they do. Also training is not co-ordinated with other parts of human
resource management - consequently there are persons trained in advanced courses who
are about to retire or get transferred, supervisors are not consulted before their
subordinates are nominated (supervisors refuse to relive their staff for training) and so on.
A3.55 Training needs of staff at different levels are complex. In health department, there
is technical training (skills required for their jobs), managerial and administrative training
for management esp. supervision. In most cases, the ad hoc trainings conducted cover
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the technical aspects. Even here there is a lot that can be done to improve the training
quality and assessing impact. The most important management skill of supervision is not
being imparted in a regular basis. Most supervisors, especially those in highly complex
functions such as the DM & HO do get regular management training. Consequently, they
apply only their long experience in technical matters in managing their unit.
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A3.56 Training institutions in Andhra Pradesh are fairly strong especially in the
technical and HR functions. In Management and administrative aspects there is a need to
develop health system oriented training programmes, that affect real issues on the ground
(one example has been already developed by HIS). The demand for training supervisors
and the technical staff on management issues is great and mechanisms to understand and
address these needs required.
A3.57 There is also a need to integrate career growth, transfers, promotions and training.
Without training getting integrated with the position, there may be substantial wastage of
time in training the wrong persons in the right skill or the other way around. Each post
will need to have specific skill requirements and as and when these positions are
occupied, training needs to be made pre-requisite.
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A3.58 Attention needs to be given to induction training, wherein new recruits are
adequately trained before they are positioned. In some cases this is happening through
the existing training institutions in AP. There is scope to improve this. Joining
procedures will need to be modified to include training as a pre-requisite. Departmental
training needs assessments and plan need to be systematised.
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Support services
A3.59 There are various support services that the department uses:
•
•
•
Transport
Training
Diagnostic
A3.60 Transport is handled by a Deputy DM & HO specifically posted for this purpose
at the District level. These officers are charged with providing transport facilities for the
departmental staff. This includes personnel mobility, ambulances, mobile clinics, IEC
vans, etc.
A3.61 For Training - see para on training. Diagnostic - This service is largely provided
by the area and district hospitals. There are diagnostic services run by IPM at the state
level. The Government should critically examine the possibility of outsourcing these
services so that it can concentrate on its core functions.
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Work culture
A3.62 The work culture of the health department is of grave concern. The
overwhelming atmosphere is that of bureaucracy, low customer orientation , lack of
motivation, chaotic methods of working and poorly managed schedules (and therefore
low individual productivity). Corruption is well known and accepted part of the system.
A3.63 When new responsibilities are assigned, most of the staff complain of overwork.
It is true that some of the staff have multiple responsibilities and cannot do complete
justice to their role. There are many who are under worked too. Only a careful work
study (as part of a functional review) will provide answers on work and time aspects.
A3.64 Staff members and other observers point the Government way of doing things the systems for working to be extremely restrictive, process oriented than output and
rejects innovation or quick action. Combine this with audits, which concentrate on
vouchers, giving little credence to the function and are seen more as a fault finding
mission. Genuine actions are suspected for foul play. Speed and innovation are main
suspects for ‘other interests’. As one staff member put it eloquently - "if I have to do
anything, especially something innovative, I have devise the most devious methods and
plot in Machiavellian way and manipulate people and systems to get it done. Not always
do I have the energy and motivation to do it. And if I get caught doing something useful,
I may also be punished'
A3.65 Most staff at supervisory level, especially DM & HOs feel that they spend
inordinate amount of time waiting for bosses, who summon them on short notice. Time
spent on waiting in corridors and in meetings are probably higher than time spent on
supervision. Also ad hoc querying is another major time waster for staff down the line.
A3.66 The health department has multiple stake holders, reference points and review
parameters. The ability to interact with multiple stakeholders, while updating its
knowledge on technical matters, being sensitive and responsive to needs of the
community are skills which will need to be build more systematically.
A3.67 The role of medical profession within the health department has always been a
point of debate. From the period where the department was oriented in service delivery to
a point where there are facilitatory roles, the transition of roles need to be managed
better. The medical professions role in department, perceptions and mind blocks
surrounding a larger perspective of health care for state (which is more than plain
medical) needs to be examined further.
A3.68 Many feel that the sub-optimal performance of the department is borne out of the
work culture, cynicism that nothing will change and the realism that nothing much has
changed over years. This will need to be addressed, if effectiveness has to be improved.
3.
Recommendations
8 A recent EC study found that out of 13+ PHCs visited unannounced, none had any staff in the hospital.
)
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A3.69 The department has initiated several changes. Many of them are excellent in their
approach and needs to be continued. Some are in the right direction, and improvements
will make them better. While introduction of some of the changes will require
substantive research and piloting.
tt
A3.70 Interventions clearly valuable now and can be implemented immediately:
•
Indicator led performance monitoring system. Targets like family planning needs
to be comprehensively introduced for other areas of health care, so that a balanced
review of performance is possible9. Removing the targets - especially those
which are input based. Substituting them with more comprehensive targets based
on outcomes. Review mechanisms at various levels, which are not pushed from
top.
•
Advisory boards. Systematic strengthening of their capacity and realisation of
their roles. This would involve upgrading the selection process to assure
transparency and representativeness of members, special training programs to
clarify tasks and responsibilities of advisory board members, and greater
involvement of the community in selection of members.
•
Contract employment. Government could consider a higher mark-up salary for
contract staff to make contract attractive. Also have variable mark ups, based on
demand and supply for the specific position. (For example for doctors, the mark
up could be 1.5 in disadvantaged areas, whereas for posts where there is adequate
supply .9)
1
•
User fees in hospitals and their retention for local level use - Measures to increase
collections and providing better quality of service10. Training in collection
methods, motivational incentives, and development of improved reporting system.
•
Introducing e-govemance and right to information on health
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A3.71 Interventions which could be implemented through pilots in selected
districts:
•
Select two to three pilot districts (modest performers - neither best nor worst) to
develop an exceptional administrative structure and local participation process to
pilot major changes in these processes. This could be achieved through the
creation of a “district corporation” and the transfers of personnel selected by merit
criteria.
^Right now, a skewed imponance on family planning
Focus here is not coverage of costs - but on collecting contributions so as to make ‘customers’ demand
better services.
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In these districts responsibility of running PHCs and sub-centres would be
transferred to Mandal Panchayat (along with funds and staff). The pilots would
provide technical assistance support the Mandal Panchayat in take over and
management but be designed for sustainability, transparency and monitoring.
•
In the pilot districts, create a single district level health society (which
encompasses all activities of the department). This society will encompass all
activities of health within the district and will work closely with the private sector
and civil society. This would be developed along with a policy on guaranteed
services (on lines with Citizens Charter)
•
In the pilot districts, the seniority promotion system would be replaced with a
performance based incentive and merit promotion system to be designed with
attention to transparent objective and negotiated (between supervisor and
supervisee) methods of merit judgements. In addition the pilots would develop
capacity building based on TNA and TQM, including independent surveys on
customer satisfaction, doctor availability and community evaluation of PHCs.
•
In the pilot districts, a new referral/counter-referral system - between the primary
and secondary sectors — would be developed. In addition, feedback systems at
sub-centre and PHC level to the PRIs and department
•
In the pilot districts, implement flexible budgeting at district level with some
earmarked budgetary ranges for priority programs and upgraded financial control
systems.
These budgetary processes would also include planning and
implementation monitoring.
•
In order to develop these pilot programs an initial comprehensive functional
review will be necessary - feeding into administrative and staff reforms.
•
For upgrading training programs the pilots would be used to develop management
modules and training. Developing and implementing a supervisory course (at
each level, focus on management). Review of curriculum of medical profession
(inclusion of public health and administration in more stronger ways)
•
Developing of a computerised monitoring system for the department.
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A3.72 Areas of intervention where additional data and analysis are needed to
develop strategy
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Performance indicators - How they warp performance at field level
•
Transparency initiatives — how to make health department transparent
•
Financial control systems and their effectiveness
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Human resource shortages - A comprehensive strategy to address them
•
Training Needs Analysis
•
Management abilities and capacity building requirements of PRIs to manage
health institutions
•
Detailed study of functioning of health department, with relevance to its role and
objectives (rural and urban).
•
Recommendations on rationalisation of functions and outsourcing.
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Annex 4
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Support for Development of a Medium Term
Health Strategy for Andhra Pradesh:
Report of Decentralization Team
Thomas Bossert and N. Shiv Kumar
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Annex 4
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Support for Development of a Medium Term
Health Strategy for Andhra Pradesh:
Thomas Bossert and Shiv Kumar
1. Decentralization Issues
A4.1 Decentralization is a means toward the ends of improving the equity, efficiency,
quality and financial soundness of a health system. We should not be pursuing
decentralization if it will not achieve these ends. Experience in many countries shows
that decentralization can be designed to achieve these objectives if it is done in ways that
assign appropriate degrees of responsibilities and powers to appropriate levels of
administration and appropriate arenas of local accountabilities. The trick is to define
“appropriate” in each of these cases.
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A4.2 If the decentralization process is appropriately designed and implemented it is
likely that it can improve the delivery of services and result in improved performance
indicators for health status. It is a systematic change that can contribute to the
operationalization of performance of programs designed to improve health status. There
are five basic reasons that decentralization can improve health status:
•
First, centralized systems tend to impose rigid programs that are often not fine
tuned enough for addressing major local health problems. Localities have
different sets of health problems that local health officials know better than the far
away bureaucrats of central offices. Given greater choice over local priorities
local officials can make more appropriate decisions to address local health
problems.
•
Second, most management studies show that large centralized organizations rarely
can develop local management skills to make more efficient use of scarce
resources leading to waste and make available savings for priority programs.
Decentralization of management decisions can encourage local health
officials to make more efficient decisions that allow saving resources for
more appropriate health programs.
•
Third, centralized systems discourage innovation and staff initiative leaving
health officials with low motivation and low morale. Decentralized systems can
encourage local staff to take initiatives to solve local health problems in new
ways. Having authority and responsibility is often a motivating experience
that is more important than material incentives.
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•
Fourth, decentralization by allowing local participation through committees and
local governments encourages accountability of local officials to norms, standards
and local priorities. Community participation has little impact if the community
does not have some control over important decisions. Without decentralization
there is little chance that community participation can be more than a simple
extension of health service through “free labor”.
Many countries have
experienced “participation fatigue” where community participation soon falls off
since there is little encouragement for local decision making. With greater roles
in decision making, community participation can make the linkage between
communities and health services into a valued and meaningful interaction
and can hold local health staff accountable for attendance and responding to
local priorities, and transparent and corruption-free service. This meaningful
participation can build the important trust and exchange between health staff and
the community that is now called “social capital” (see below) that are key to the
changes in social behavior needed to improve health status.
Fifth, decentralization to local governments can be a significant means of
mobilizing additional resources from local taxes and other local sources.
When local governments take additional responsibility for health services they
often learn that their communities will hold local officials accountable for
providing better health services. This democratic political dynamic often
encourages even the poorest communities to allocate additional resources to
health care services. If the system remains centralized local officials can often
simply blame the central government for failures and resist shifting local
resources to health services.
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A4.3 In sum, decentralization is an organizational reform that, when done in the correct
manner, can result in improved health status by prioritizing local health problems,
encouraging efficiency and savings that can increase resources available for priority
health programs that address health status problems, motivate staff to solve local health
problems, and allow meaningful community participation that can result in more
accountability, increased mobilization of local resources and better linkage between
health services and the community that is essential for the social behavior needed to
address health problems.
A4.4 In this report we will briefly describe the current type and degree of
decentralization in AP, raise key issues and constraints of the current system, specify
areas where existing information needs to be supplemented with new studies and describe
some activities of short and longer term that would overcome problems and develop the
appropriate degrees of responsibilities and powers to be assigned to specific levels of
administration and government.
A4.5 Decentralization raises three fundamental questions: who gets new responsibilities
and powers and what kinds of responsibilities and how much power is transferred to
them. To answer the first question about who gets new responsibilities we distinguish
between the transfer of responsibilities within an administrative structure such as the
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Ministry of Health (often referred to as deconcentration) and the transfer of
responsibilities to elected and executive bodies of local governments (devolution). The
first type may also involve some participation of local representatives - NGOs or
community committees. Devolution however involves increasing the responsibility and
accountability to local governments and their elected representatives and often includes
the ability to mobilize local tax revenues.
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A4.6 To answer the questions of what responsibilities and how much power we use an
approach called “decision space” which assesses the range of choice (from narrow to
wide) allowed for each of a series of key functions (in financing, service organization,
human resources, targeting and governance).
A4.7 Recently the concept of “social capital” has been introduced as a factor which
might affect the effective performance of government projects and strengthen democratic
practices. This concept overlaps with social organization parts of this report in that it
emphasizes the importance of the involvement of the population in voluntary associations
and the development of trust in public institutions. We will discuss the relevance of this
concept in relation to the governance issues of decentralization and more broadly the
organization of the ministry.
2. Current status of decentralization in AP
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A4.8 Decentralization in AP involves processes and responsibilities shared between the
state government, the central national government, district offices of the ministry and of
the district collectors, health advisory committees/societies for facilities, the municipal
governments and corporations and the three levels of panchayat raj institutions (PRI).
a.
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Role of central government of India in health
A4.9 While health is seen as primarily the responsibility of state governments in India,
the central government plays a strong role in defining some of the key functions by its
control of the civil service rules, its training and promoting of IAS officers who staff key
positions in state government. It also controls some grants to the state for specific budget
lines and for specific programs that influence health administration and programs and can
impose hiring freezes on permanent public staff positions. In addition, specifically for
the health sector, it controls and finances major vertical programs such as immunization,
TB, HIV/AIDS, leprosy, and malaria. In the case of the HIV/A IDS vertical program the
central government funnels funds through societies involving civic society rather than
through the state government administration and in the case of the TB program that
imposes vertical requirements on district health office including the requirement that
personnel be assigned full time to TB program activities. These mechanisms of control staffing, training, financing of specific vertical programs impose significant limits on
what a state can do and provide a template of bureaucratic structures that may impose
major constraints difficult to overcome at the state level if a state reform involves
changes in administrative structures and financing.
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A4.10 On the other hand the central government has promoted devolution within the
states through a recent constitutional amendment which charged the states with
increasing decentralization in rural areas through a three tiered system of panchayat raj:
the district (or z....) panchayat, the mandel (formerly “block”) panchayat and the gran
panchayat.. This amendment has been applied differently in different states with some
states - Kerala and Gujarat in particular - moving ahead rapidly in devolving a wide
range of responsibilities to the local PRIs. AP has not moved very far in this devolution
of authority, responsibility and accountability as will be seen below.
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AP State level “decision space”
A4.ll Since health is on the “state list” of responsibilities there is considerable formal
choice allowed to state officials in many functions. In financing, the state can decide its
own health budgets with an allocated portion of national government revenues and with
local state taxes. The state decisions on allocation of state budgets assigned to health
have been declining from 4.4% in 1994-5 to 3.4% in 2000-1. Within the health budget
the state also has the power to assign resources to different budget heads (salaries, etc.).
This authority however is limited in practice by the large current assignment of funds to
salaries (70%) which is difficult to modify in the short term. There are also other
mechanisms of “matching grants” from central national authorities and from international
donors like DFID and World Bank loans which require assignment of state resources as
counterpart funding. The actual range of choice over the short term for state decision
makers may in fact be quite limited - perhaps in the 10-20% range. This is particularly
important if the general funding sources are likely to be limited over the medium term.
A4.12 The state can define the organization and rules of service delivery within some
general guidelines from the national government. The existence of vertical national
programs has had a significant impact on the fragmentation of administration and the
inefficiencies of district management as will be discussed in our report on management.
However, the role of different types of facilities and how they are organized appears to
have been flexible enough to allow for the creation of a semi autonomous administration
of secondary hospitals and some clinics under the APWP.
A4.13 The state also has some flexibility in human resource management. There is a
separate state civil service cadre and the state can hire and fire many different categories
of staff. Promotion policies also appear to be a province of the state government with
past experiments briefly initiating merit promotion replacing the tradition of seniority,
(this experiment was apparently reversed by political and union pressures) However, the
promotion rules of both the state and the national (IAS) civil service severely the range of
choice for key positions in the bureaucracy. Most positions must be filled by the most
senior official in the promotion pool rather than by merit or by ability to fill new policy
requirements.
A4.14 The state may define the priority target populations and can use mechanisms such
as the state “white card” system to define populations to be favored by different policies
and subsidies.
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A4.15 State role in defining how the health system is to be governed have resulted in
different states assigning different roles to panchayat raj institutions, municipal
governments and roles of involving civil society in committees and societies. However,
the central government can make requirements for staffing (such as in the vertical TB
program) and in general the state governments have not varied from the staffing patterns
established by central IAS rules. In some ways, state control over the districts m the
short and medium term is restricted by the authority vested in the LAS officers who fill
the most powerful position of District Collector and who impose national policies on the
districts through that authority.
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A4.16 Overall, compared to other health care systems we can say that the state decision
space” is in the “moderate to wide” range of choice for almost all functions - not as wide
as some other countries and not as narrow as most.
State Decision Space - For Discussion
[this is based on rapid analysis and should be revised after review!
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Range of Choice
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Functions____________________
Finance
Sources of Revenue
Allocation of Expenditures
Choices about Fees and
______ Tariffs________________
Service Organization
Required Programs/Norms
Hospital Autonomy
Drug Supply and Logistics
Systems
Insurance Plans
Payment Mechanisms to
Institutions
Contracts with Private
__________ Providers__________
Human Resources
Salaries
Contract Staff
______ Civil Service___________
Access Rules
______ Targeting
Governance Rules
Local accountability
Facility Boards
Health Offices
______ Community Participation
Moderate
Narrow
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Wide
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
c.
Level of state resources and allocations to local levels and mobilization
of local resources
A4.17 Decentralization often involves changing the allocation rules for resources in the
health sector. One of the central issues of allocation is to assess the level of local funding
in relationship to higher level funding. In AP the state controls an increasing proportion
of the total public sector funding for health (from 55% in 1995-6 to 68% in 2000-1) with
the National Government controlling the rest through grants and schemes for specific
vertical programs, (see Annex on Financing) Of the state portion, only a small percent
comes from local tax revenues with the rest coming from intergovernmental transfers
from the national government.
A4.18 The state allocates approximately 60 % of its health budget to primary care, with
40% to secondary (APWP) hospitals and tertiary care. Around 70% of the budget is
assigned to salaries - not an excessively large amount compared to other countries but
one that limits the resources available for drugs and other operating costs as well as
limiting investments to those primarily funded from outside loans and grants.
A4.19 An important issue is how the state (and national) governments assign resources
to the different districts. Financial assignments to districts from some funding sources
are reported to be formula driven — based largely on population size, (for more details on
allocations to districts see Annex on Health Financing) With a variety of funding sources
from the central and state governments it is difficult to assess the actual total funding that
is assigned to each district and difficult to assess the real expenditures to determine how
well the current formulae are implemented. Since the budgetary process has been
described as based on historical budgets, it is likely that the formulae have been distorted
over time even if a formula was initially used for assignments. It is also likely that there
is considerable variation in the per capita allocations to each district. None of the
formulae take into account the variations in the size of the population that is covered by
private providers so that districts with higher use of private sector will end up with higher
per capita public resources for the population that is served by the public facilities. Since
wealthier districts are likely to have higher use of private sector, this means that the
public facilities in these districts will have more resources per capita served than will
poorer districts.
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A4.20 Municipalities are expected to contribute to health systems by supporting water
and sanitation activities and in most municipalities funding a health center which
provides services and programs similar to the Primary Health Clinics in rural areas.
Municipalities assign budgets to health and within the health sector according to state
guidelines and their budgets have to be approved by the state. It appears however, that
these guidelines are not strictly enforced — with many municipalities spending more on
salaries for municipal workers than the guidelines allow.
A4.21 In rural areas there is a general impression that there are few possibilities of
mobilizing local tax revenues for health care. The tax base at the district and municipal
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levels are very limited and tend come mainly from property taxes. Local democratic
processes tend to discourage raising local taxes. Funds at the community level tend to be
focused currently toward traditional functions of sanitation and water supply and have not
normally been allocated to health systems. However, there have been some reported
cases of effective mobilization of local community resources for health systems. There
were distinct rankings of panchayat raj according to size and wealth which suggest that
some areas may have significant resource base that might be tapped for health (such as
areas with minor minerals which are taxed). A project designed to strengthen local
community organizations around health was quite effective in making health a
community priority and quite unexpectedly the community agreed to take on 50% of the
costs of running the local health activities from local funds. These models suggest that
some poor communities can prioritize health care and provide resources and that some
wealthier communities may have sufficient funds to be expected to take on more of the
burden for funding health services if they are given a role in controlling those services.
A4.22 A concern in decentralization as pointed out in the Annex on Health Financing is
that localities with more resources may increase their funding for health at rates that
increase inequalities among localities. While this may occur in some situations, there are
mechanisms to allow for local mobilization of resources and provide compensation to
improve equity. State and national grants can be based on a formula that takes into
account some of the local capacity to collect local taxes and favor the poorer districts.
Also a system of matching grants from state and national sources can be used to
encourage mobilization of local matching funds and the matching requirements can be
adjusted to the local capacity to mobilize resources. For instance, matching grants can
require higher percentages of local counterpart funding from wealthier communities and
low percentages from poorer communities.
“Decision Spaces” below the state
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District “deconcentration”
A4.23 A District Health Advisory Committee has been created in the process of
decentralization of the ministry. This committee is made up of the DMHO, the District
Collector, District Revenue Officer, Hospital Superintendent, the local MLA, the
president of district panchayat and representative of NGOs. It is a mechanism for
coordinating health and other sectors under the District Collector and an arena for the
participation of some key local health stakeholders such as the Nursing Home societies,
IMA, and other NGOs and an elected representative from the district panchayat raj.
A4.24 It is difficult to assess how effective these committees are in increasing the
accountability of the health system to the local population and interests. It seems likely
that the DMHO and District Collector dominate the agenda and control the meetings in
most situations. Since most of the participants are unelected, and those that are not exofficio members are chosen by the District Collector that local “voice” in these arenas is
quite limited.
A4.25 A similar mechanism of local accountability is introduced into the APWP
structure at the facility level where the hospital advisory committee includes the District
Collector, MLA, President of Panchyat, President of local IMA, Superintendent of
Hospital and representatives of NGOs.
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A4.26 The decision space” at the district level varies by function and institution.
A4.27 For financing functions, the DMHO and his team have little control over their
budgets - they submit budgets to the state on the basis of the historical budget plus minor
percentage increases. These budgets are returned to them with strict budget “heads” and
they do not have the ability to transfer funds from one head to another. The facilities
under DMHO do not generate funds (no fees for these facilities) and there is no
consistent mechanism for other local contributions. By contrast the APWP hospital
boards are assigned a budget and are allowed to manage its line items throughout the
year. They also collect and retain fees (around 5% of total non-salary budget) and can
allocate them with few restrictions.
A4.28 Decisions about service delivery are also quite limited for DMHO since many of
the norms and standards are established either by central or state venicai programs. By
contrast the APWP hospitals are given some flexibility to define programs as long as
they are within the norms of hospital standards. The hospitals are also ranked by ability
to achieve several performance indicators and are given incentives or sanctions based on
achievement of these objectives that are defined by the state level APWP.
A4.29 Human resource decisions allow some choice to DMHO who can hire and transfer
(but not fire) paramedic staff (ANM, lab technicians, etc) in the district. The DMHO also
can transfer medical staff within the district for disciplinary purposes (see management
section). Apparently however, the DMHO cannot force medical staff to take positions in
rural health centers, except for formal disciplinary purposes.
A4.30 In APWP, human resource decisions are made by the hospital board and
Recruitment decisions have been left to the boards and have not been reversed by the
state APWP, even though it has the appointment authority. However, firing decisions
are retained by APWP and have been exercised in a significant number of recent cases.
A4.31 Again, however, the seniority rules limit the range of choice over hiring staff for
key positions, leaving transfers and bureaucratic delays as the major mechanisms that
district teams have for managing human resources. Bureaucratic delay - sitting on files is apparently a major means of displaying displeasure with an official and a mechanism
used for exacting unofficial payments for staff assignments.
A4.32 Since hiring for permanent staff has been frozen — or rather severely discouraged
requiring a major effort to get state approval for exceptions — the districts have been
encouraged to hire new staff on contract. However, the terms of contracts are set at the
state level and the low salary levels and lack of benefits has limited the ability of districts
to attract new staff.
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A4.33 Rules for targeting and for governance structures are defined at the state level.
However, the selection of members of the health societies and committees appear to be
the province of the DMHO with the District Collector.
District Decision Space — Illustration for Discussion
[this is based on rapid analysis and should be revised after review]
Range of Choice
Functions____________________
Finance
Sources of Revenue
Allocation of Expenditures
Choices about Fees and
______ Tariffs________________
Service Organization
Required Programs/Norms
Drug Supply and Logistics
Systems
Payment Mechanisms to
Institutions
Contracts with Private
__________ Providers__________
Human Resources
Salaries
Contract Staff
______ Civil Service___________
Access Rules
______ Targeting _____________
Governance Rules
Local accountability
Facility Boards
Health Offices
Community Participation
ii.
Moderate
Narrow
Wide
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
PHC and Sub-centre committees
A4.34 PHC have their own health advisory committees that involve the elected
representatives of the mandel panchait raj and other community members as well as the
PHC doctor. These committees do not have much of a role in decision making at the
PHC level - nor does the Doctor. However, they are a venue for linkage with the local
NGOs and local elected officials and have been effective arenas for mobilizing local
labor. In some cases local elected officials (MLA) are able to provide additional
resources for renovation and other small capital investments.
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A4.35 In general, however these committees have mainly been used to mobilize
communities for health activities and not to engage the community in local decision
making, accountability or monitoring.
A4.36 In sum, in these sub-district advisory committees there is little decision space and
almost no control of resources — either from ministry or from local sources.
iii.
The Panchayat Raj Institutions
A4.37 In rural areas there are three PRIs functioning: the district, mandel and gran
panchayats. At each level there are elected officials who choose their leader or president
and a counterpart from the state administration. Very little control of the assigned 14 line
department activities have been shifted to these institutions. They have some local own
source revenues and some assigned revenues but no funds have been shifted from
department budgets and no responsibilities have been shifted to date. There is discussion
oi shifting control of some personnel salaries and some supervisory responsibilities but to
date nothing has been approved. In the health sector this might mean that the budgets for
the paramedical personnel at the health center, sub unit and health post levels would be
transferred to the PRIs. Currently however, while the PRIs have taken some initiatives in
water and sanitation activities that may support some health ministry activities, there is
no official role.
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A4.38 The PRIs have had a historical precedent in AP. Reportedly 20-30 years ago
there were Block entities which controlled PHCs. They controlled the budgets and
personnel. This experience is reportedly to have causes major problems between the
administrators of Blocks and the DMOs since the administrators who held the budgets
and authority were of a lower civil service rank than the doctors. Graduallv this authority
was centralized at the state level.
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A4.39 In the urban health systems run by the 110 municipalities and seven municipal
corporations (excluding the Hyderabad Commission) there are significant responsibilities
shined to the municipal budgets. Budgets are assigned according to a formulae based on
population and poverty indicies according to seven municipal categories: corporation,
selection grade, special grade, and grades 1-3. The municipalities are allowed to collect
and retain certain fees such as water fees. Municipalities are administratively managed by
an IAS Municipal Commissioner who reports to the state Municipal Commissioner.
There is also and elected municipal council or corporation which approves budgets and
provides some local accountability.
A4.40 Municipalities have traditional responsibilities for sanitation and water supply as
well as funding around one urban health clinic in each municipality. There are 80 urban
health clinics in the state which are similar to Primary Health Clinics in rural areas.
While administratively under the Municipal Commissioner, these clinics are supervised
also by the DMHOs of the Ministry of Health and Family Welfare and are expected to
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complete the norms and activities assigned by the state and national programs. They
report their utilization data through the Ministry of Health and Family Welfare districts.
Their financial reporting however it through the Municipal Commissioner.
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A4.41 Municipalities have some control over their budgets and human resources. There
are state guidelines for assigning a percentage of budgets to health and limiting
expenditures on administrative staff. These guidelines however appear not to have been
enforced up to now. However, municipal budgets must also be approved by the state
which may limit their range of local choice. Municipalities also have some role in local
taxation. The municipal council must approve any new taxes - which municipalities
appear reluctant to do. However, the state may change the tax rates for existing taxes,
forcing the municipalities to collect more revenue. Recently the property tax rate has
been increased by the state, increasing local property taxes by around 30%.
A4.42 Municipalities may hire staff if they respect state defined merit hiring practices.
The Municipal Commissioner sits on the hiring board, imposing a powerful state
appointed official in this process.
e.
A4.43 Human resource organizational skills will be discussed more in the management
section. Here we focus on skills and capacities required for decentralization of several
key functions. Technical skills in public health and disease specific activities are a
general concern in centralized and decentralized systems. However, decentralization that
involves greater responsibilities in financial and human resource functions requires
significant upgrading of skills in financial control, financial decision making, human
resource management and in leadership and diplomacy in working with local civic groups
and elected officials. As we note in the management section these skills are not generally
well developed in any of the training programs - pre-service, induction and continuing
education. The training program for APWP officials seems to have been more
developed than others in these senior management issues.
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A4.44 Furthermore, the process of promotions by seniority has not encouraged the
promotion of effective managers or leaders — indeed as staff are promoted to managerial
positions late in their career, the managerial positions tend to be held by officials near
retirement. These officials have an incentive to maintain the current system and not to
make any risky decisions that might lead to disciplinary actions that would affect their
pensions.
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f.
Social capital
A4.45 As is noted in the reports on social organizations, there appear to be quite a
vibrant number of community organizations that are currently mobilized around health
issues in some measure. It is clear however that these groups are not strongly “linked” to
the formal government and health system mechanisms. With some major exceptions,
they are not currently encouraged by the health system officials. The central exception is
■
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Human resource capacities for decentralization at local levels
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the HIV/AIDS program which has given voluntary organizations a major role by the
central government in receiving and controlling funds and in directing activities.
However, even the HIV/AIDS societies are controlled by a board convened by the
Secretary of Health and Family Welfare - which until recently met very infrequently. It
is generally believed that if there are better relations between the community
organizations and the public health organizations that this can be a means of building
“social capital” and the trust necessary to encourage social changes that can result in
better health status.
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Current studies
A4.46 There is one study of decentralization in the health system that compares AP with
Gadjarat completed by NIRD for DFID. We were unable to assess the quality of this
research. There are reports on different aspects of the system - especially panchayat raj —
but none of them have done a systematic review of the situation.
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Performance Systems and Indicators for Decentralization
A4.47 With the current emphasis on performance indicators, those activities that do not
have clear indicators may be left aside in the focus on the indicators that are monitored.
Therefore if there is a priority on developing and implementing greater degree of
decentralization, on local accountability and on greater involvement and linkage to the
civic society organizations, performance indicators for these activities need to be
developed. There does not seem to be a system for assessing the degree or effectiveness
of decentralization. There are no reporting requirements to systematically assess the
health advisory committees and societies. Nothing to determine the actual membership,
the representativeness of the participants, participation levels in meetings, satisfaction of
participants, and their impact on decisions.
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A4.48 As will be noted in detail in the management section, there is little information on
the training and capacities of local health staff in management, financing, leadership and
diplomacy skills required for effective decentralization.
3.
Issues and Constraints
a.
Financing mechanisms need to be revised
A4.49 It is likely that the current allocation of funds to districts is not equitable among
districts and may favor the more advantaged districts. The current formulae seem to be
implemented in various ways and certainly do not account for the population that is
served by the public facilities. What is needed is a “needs based” formula that
compensates for inequalities in need for public sector services.
A4.50 There are few incentives for local officials to provide own source revenues for
health care. Health is seen as a state responsibility and not one that requires local tax
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revenues. Incentives could be put in place to encourage local authorities to match grants
and to take on greater responsibility in return for greater choice over health services.
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b.
Limited “decision space” at the district level
A4.51 Despite some increase in decision making powers at the district level there are
still several formal and other informal control mechanisms that have limited the range of
choice. In some cases these limits are likely to be good in that they will prevent ill
advised decisions from being made and in other cases it is likely that widening the
decision space can make for greater accountability, more flexible and efficient decisions
and potential for mobilizing local resources.
A4.52 In particular, district managers should be given greater control over their budgets
so that they can make transfers from one budget head to another during the year. Greater
control over hiring, firing and transfers should be made, within a system that has clear
norms for merit recruitment and promotions. More flexibility on local priority setting,
monitoring as well as a role in accountability and promotion of health staff might
encourage greater local participation and greater mobilization of local financial resources.
r1'
A4.53 There are however, some constraints on budgetary processes and human resource
management imposed by national and state laws making it a long process to change these
constraints. Political will to make changes in control of human resources and to shift
budgetary allocations to panchayat raj will be needed. An exception may be made for a
pilot effort to demonstrate the effectiveness of significant increase in decision space in
the areas of finance and human resource management. It might be possible to make the
medical officers ex officio members of panchayat raj health committees in order to
overcome the historical problem of having to report to administrative officers who are of
inferior status.
c.
d
II
PRI and Committees/Societies and Social Capital
A4.54 With so much of the decision space limited by central and state rules, there is less
incentive for local governments and civil society groups to participate in local arenas of
governance in the health sector. Until greater powers are transferred to local panchayat
raj there is likely to be little incentive for local officials to mobilize new resources or
reallocate budgets to the health sector.
A4.55 The current proposed transfer of responsibilities to the PRI has some possible
negative effects. Control of hiring by local communities without proper safeguards and
enforcement could result in the hiring of unqualified personnel and the introduction of
new venues for patronage and political influence in staffing decisions. Supervision by
technical staff is still an important requirement for upgrading quality and skills of local
health staff and should not be entirely turned over to the PRI.
A4.56 It may be that local communities that have greater unity and trust among the
members and greater experience of voluntary organization - such as larger numbers of
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effective participatory NGOs- may have greater “social capital” and be able to participate
more effectively in local decision making through health committees/societies and
through the panchayat raj.
d.
B
Human resources capacities for decentralization are weak
A4.57 The current level of skills in the key capacities of financial and human resource
management and skills of leadership and diplomacy for engaging the civil society are
lacking. Current training in these areas have not been taken full advantage of and the
level of these courses needs to be upgraded. The models provided by AP WP may show
the way toward an expanded training program. Distance learning methodologies may
make it possible to provide some of the training to staff in the field so that they do not
have to travel away from their work for long periods.
4.
Suggested Studies for Phase II: What do we need to know
more about?
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a.
Current allocations of finances to districts, municipalities, and
panchayat raj institutions
A4.58 There is no clear understanding of the levels of funding available at the district,
municipal and panchayat raj levels. While funding from some sources are said to be
based on formulae it is not clear what the formulae actually are nor if they are being fully
applied. With so many different sources and with little clear idea of the portion of the
population in each district that is served by these public services, it is necessary to have
an overall assessment of the distribution of resources to each district. This analysis could
be followed by development of a “needs based” formula to compensate for variations
among the districts and to lead to more equitable funding.
b.
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Legal and regulatory restrictions at the national level
A4.59 Investigation of legal and regulatory restrictions on budgetary and human
resource decisions that are controlled by national government and cannot be changed at
the state level
c.
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Details of actual ‘‘decision space”
A4.60 Need to have a clearer and more systematic study of actual practice of “decision
space at district level - could be done by a survey instrument based on other studies
implemented by HSPH
d.
Assess other experiences in India
A4.61 Comparative analysis of decentralization in other more decentralized states like
Kerala and Gajurat.
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A4.62 Studies of current local government budgets and proposed increases to PRI
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Assess options for mobilizing local resources
Assess current human resource capacity and skill needs
A4.63 As part of study on management, assess human resource capacities in skills
needed for decentralization (see Governance Annex for details)
g.
Assess current capacity to train human resources in needed skills
A4.64 Review and evaluate ASCI program for APWP and other training programs (see
Governance Annex for details)
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5.
Possible Options
a.
f
Immediate
A4.65 Pilot in 2-3 districts with greater decision space allowed at all levels - including
health committees/societies. This pilot would experiment with transfers of budgets for
personnel and some supplies to the panchayat raj, shifting some accountability and
incentives for performance to these institutions, placing medical officers ex-officio on
panchayat raj health committees, and other innovations. It would also expand local
authority of the municipalities in the districts. It would involve major new capacity
building training of the district staff and of participants in health committees/societies,
municipalities and panahayat raj. (see Governance Annex for additional details)
A4.66 Increase the number and representativeness of local civic society groups and
elected representatives in health advisory committees/societies in all districts
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A4.67 Provide “matching grants” and greater responsibility for decisions at the local
level to encourage use of local tax revenue mobilization for health in municipalities and
wealthier panchayat raj.
A4.68 Introduce more equitable “needs based” formula accounting for use of private
sector and indicators of disease patterns
A4.69 Develop appropriate performance indicators including indicators of
decentralization and participation of civic society
b.
Medium and long term
A4.70 Develop major high quality management training program for district level
officials (perhaps based on ASCI program for APWP)
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B
A4.71 Introduce legal and regulatory reforms to create new system of merit recruitment
and promotion in the state human resource system.
A4.72 After review of pilot districts effectiveness, replicate the effective models in a
phased sequence, including specific training programs, to eventually cover all 22
districts.
B
A4.73 Combine with initiatives of good governance and PRI reform.
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DRAFT
Annex 5
Support for Development of a Medium Term
Health Strategy for Andhra Pradesh:
Private Health Care Provision in Andhra Pradesh
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Peter Berman
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Annex 5
Private Health Care Provision in Andhra Pradesh
nj
Peter Berman
1.
Introduction
A5.1 This paper is one of a set of background papers to support development of a
medium term health sector strategy and expenditure framework for the state of Andhra
Pradesh. It is based on a brief field visit to the state and review of recent studies and
papers. Because of the limited time available for this exercise, it is not intended to be a
comprehensive analysis but rather an initial review, with recommendations for short and
medium term strategies that could be followed. Development of several of these
strategies would require further investigations.
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A5.2 The focus of this paper is on private health care provision, its role in Andhra
Pradesh’s health system, and the potential for enhancing its contribution to improving
health outcomes in the state. A separate background paper on government health care
delivery by Dr. Marc Mitchell combines with this one to cover the area of health care
organization.
A5.3 The next section of this paper discusses of how to define private health care
provision and a proposes a notional typology of providers that may be relevant to Andhra
Pradesh (A.P.). Information is not available on all the different types of providers. The
third section presents what is known about the numbers and distribution of private
providers in A.P., based on several recent studies. The fourth section summarizes recent
evidence on the role of private health care providers in A.P. and compares A.P. with
other states. This includes evidence on health expenditures and the shares accounted for
by private providers and health care utilization, including inpatient treatment, outpatient
treatment, and public health and preventive services. The fifth section describes several
innovative programs by state and district governments to involve private providers in
priority health programs and also discusses the views of several key stakeholders. Finally,
the last section proposes several short and medium-term strategies that might be
developed to enhance the positive contribution of private providers to State health and
financial protection goals.
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2.
Private Providers in A.P.: Some Definitions
A5.4 The concept of “private” providers is essentially one of ownership and is usually
defined as a negative. Private providers are those who are not owned by government.
However, this simple notion is sometimes complicated by the fact that providers in
government-owned facilities sometimes engage in private activities, for example, if a
PHC doctor were to charge private fees for services delivered in the PHC. In essence, this
activity is outside of government ownership - the PHC doctor is acting in a private role.
A5.5 Private providers come in many sizes and shapes. A locally-relevant typology is a
useful basis for policy development, since not all private providers are relevant to each
specific health program or priority. A typology should consider at least three elements:
the type of health care organization (e.g. its size and complexity), the system of medicine
followed, and the incentive or motivation regime that drives provider behavior (this is
usually related to ownership and the for-profit, not-for-profit orientation)1.
A5.6 A.P. (and India more generally) has a particularly diverse set of private providers,
touching on all the dimensions just cited. One convenient break-up is that between
hospitals, ambulatory care clinics and practices, and free-standing diagnostic facilities.
Hospitals are identified as facilities which provide inpatient services, whereas ambulatory
care clinics and practice provide only outpatient services - acute illness care and personal
preventive services. Diagnostic facilities are intended to provide only supportive services
- tests and investigations as requested by a hospital or ambulatory care clinic. In A.P.,
diagnostic facilities may also sometimes function like ambulatory care clinics. The
following table proposes some of the key provider types in A.P.
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1 Scman. P. and R. Rannan-Eiiya. “Factors Affecting the Development of Private Health Care Provision in Developing Countnes.
Phase Review ot Concepts and Literature, and Preliminary Field Design," Major Applied Research Paper No. 9, Health Financing
and Sustainability Project, Abt Associates, Inc., Bethesda, MD, October 1993.
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Table 1: Typology of Providers in Andhra Pradesh
Type of Organization
Hospitals
Ambulatory
Care
Clinics and Practices
Ownership and System of
Medicine__________
Government-owned
E.g. CHCs, PHCs, SCs
E.g. APWP hospitals
Allopathic______
ISM
ISM Govemment-run
Indian Systems of Govemment-run
clinics
_____
hospitals________
Medicine_______
Not-for-Profit
Private
Owned
primary care
NGO hospitals and NGO
Allopathic
clinics
and
programs
run
by
other
those
societies________
Indian Systems of ISM hospitals run by NGO and society-run
ISM clinics?__________
societies?
Medicine________
Private For-profit Owned
and Physicians clinics and
Private hospitals
1
Allopathic qualified
physician
individual
nursing homes;
practices
Allopathic unqualified2
Other
systems
medicine qualified
NA
of For-profit ISM hospitals
Other
systems
of NA
medicine unqualified
Free-standing
Diagnostic Facilities
NA
NA
NA
NA
Facilities
with
diagnostic
equipment
(e.g. x-ray, ultrasound,
CT
scan
and
laboratories.__________
NA?
RMPs, LMPs, all types
of “village doctors”
allopathy,
practicing
including those who
allopathy
practice
with
other
combined
systems.
For-profit ISM clinics NA
and individual practices
of ISM doctors._______
ISM practicioners who NA
have not completed
formal
qualification,
including those who
practice ISM combined
with allopathy.________
NA = not applicable
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2 The term ‘unqualified” can be misleading. Elsewhere I have described these providers as “less than fully qualified” (LTFQ) (see
Berman, P. “Rethinking Health Care Systems: Private Health Care Provision in India” World Development. 26(8): 1463-1479, 1998),
recognizing that some of them have significant practical training. This is confit med by the recent study by the Institute of ea
Systems, discussed below.
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A5.7 Within a typology like this it may be important to divide some of the key .types
even further. For example, there is clearly a huge difference between APWP’s district
hospitals with hundreds of beds and personnel and small private nursing homes in a
physician’s house with 5-10 beds and one or two nurses.
A5.8 There are some important categories of this typology for which even basic data
are not available. There is almost no information on unqualified allopathic providers
beyond a small study done by the Institute of Health Systems in 2000. There is no
comprehensive list of private for-profit qualified clinics and individual practices in the
state. There is almost no information on private for-profit diagnostic facilities, especially
the extent to which these facilities may diagnose, prescribe, and treat patients.
3.
Some Current Knowledge on the Number, Distribution, and
Characteristics of Private Providers in A.P.
A5.9 There are several potential sources of information that could be used to describe
the private provision sector in A.P. The Indian Medical Association, A.P. Branch
maintains a list of members, which account for about one-third of the physicians in the
state. However, this is not updated regularly and also does not include information on
practice types and location. It is likely that at the district level this information could be
developed further.
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A5.10 The Institute of Health Systems (IHS) has created the A.P. Health Institutions
Database (APHIDB), which includes both government and private providers3. The
APHIDB was established between 1992-94, based on a private hospital survey (1992)
which was then followed up with several additional data collection efforts such as
reviewing government registration data and a mail survey. HIS has tried to update the
database when it can, using information compiled in other surveys it has done. The
APHIDB mainly covers private hospitals, but has some information on private clinics as
well.
A5.ll In 2000 IHS conducted a of study private providers sampling three areas of A.P.:
Hyderabad city and surrounding Ranga Reddy District, Warangal District, and
Visakhapatnam District4. This study collected information on private hospitals, clinics
and practices, and free-standing diagnostic facilities. It also developed an opportunistic
sample of “alternative private practicioners”, ambulatory care providers of ISM,
homeopathy, allopathy, and combinations, including some less than fully qualified
providers. This dataset is one of the most detailed on private health care provision in
India. Due to the lack of any comprehensive database on private providers, it is difficult
to gauge the representativeness of this study.
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■’ Mahapatra. P. “An Overview of Private Hospitals in Andhra Pradesh: Data from the AP Health Institutions Database (APHIDB),
2001.” Institute of Health Systems, Hyderabad, 2001.
4 Mahapatra. P. “Structure and Dynamics of Private Health Sector: Implications for India’s Health Policy”, Institute of Health
Systems. Hyderabad. 2002.
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Hospitals and beds
A5.12 The IHS5 database recorded about 95,000 hospitals beds in A.P. in 2001. 32
percent are in government institutions, 63 percent are in private for-profit institutions, and
only 5 percent are in private not-for-profit institutions. Data from the IHS survey show
that almost all of the private for-profit facilities are proprietary, i.e. owned by individuals,
rather than corporate, including the large private hospitals.
A5.13 Over 85 percent of total beds are located in the Coastal and Telengana regions of
the state. In Rayalaseema, the share of private hospital beds is well below the level in the
other two regions and public and private beds are approximately equal in share in that
region.
A5.14 Private for-profit hospitals includes the category “nursing homes” which are
typically smaller institutions6. 86 percent of for-profit hospitals and nursing homes are
under 30 beds, and 38 percent are between 10-20 beds. The database includes even
smaller institutions, and 32 percent were reported as having 1-10 beds.
A5.15 The location of these facilities reflects their small size. 71 percent are located in
Mandal headquarters and 5 percent in village headquarters. In other words, three-quarters
of these institutions are located at the same level of PHCs or below. It is not possible to
assess what is the capacity of these institutions with the data as currently reported, but
this would be an important issue to investigate further if there was interest in involving
these providers more in public health activities.
A5.16 Some data are available on the distribution of private hospitals across the state.
Figure 1 shows that private for-profit beds are dominant in Coast and Telengana regions,
but that government beds are the largest share in Rayalaseema. The Institute of Health
Systems has also analyzed the distribution of beds by district against the CMIE index of
development for each district. These distributions are shown in Figure 2, for all districts
in A.P. and then again for all districts with Hyderabad removed, since there is a large
concentration of beds in Hyderabad. There is clearly a strong correlation between general
development at the district level and the intensity of private bed provision.
A5.17 The IHS survey of private providers collected information on the date of
established of these providers and whether they have grown in size. The data suggest that
significant growth of formal institutions began during the 1970s and has continued up to
today.
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’ This section draws on data reponed in Mahapatra. 2001 cited above.
Many nursing homes would probably not meet strict catena for definition as “hospitals”, since they may lack specialist services or
capacity to carry out some clinical tasks typically associated with hospitals. India defines "hospital” to include institutions of 10 beds
or more, which is a low threshold by international standards
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Figure 1: Distribution of Hospital Beds in A.P. by Ownership and Region
V
Coastal Andhra
6.3%
Government
32.6%
■ Private for-profit
Private not-for-profit
61.1%
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Rayalaseema
8.8%
41.1%
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Government
Private for Profit
Private not-for-profit
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50.1%
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t
Telangana
2.4%
Government
36.7%
Private for-profit
Private not-for-profit
60.9%
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Source: Institute of Health Systems, APHIDB, 2002. Note, numbers differ slightly between APHIDB 2001
and 2002 reports.
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Figure 2:Private Hospital Beds per 1000 Population in A>P. Districts, According to
Index of Socio-economic Development
a) All A.P., b) A.P. without Hyderabad
(a)
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PKM
GUN
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RRD
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MBN
SKIADB
.25 “
ANT
VZM
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50
150
1OO
75
300
250
200
CMIE - Index of Socioeco. Dev.
(b)
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125
Source: Mahapatra, Sridhar, and Rajshree, Structure and Dynamics of Private Health Sector: Implications
for India’s Health Policy, Institute of Health Systems, Hyderabad, 2002, pp. 36-37.
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Clinics and Practices
A5.18 Much less information is available on ambulatory care facilities than on hospitals.
The APHIDB does compile data on ambulatory care institutions, but this data is probably
not complete and comprehensive. At present there is not a well-functioning registration
system for ambulatory care facilities even of qualified practicioners.
A5.19 Figure 3 presents some of the distributions available from the APHIDB, according
to regions of the state. This distribution suggests that most of the private ambulatory care
facilities are located in the Telangana region, but it is likely that this is an artifact of the
data available.
Figure 3: Distribution of Non-hospital and Non-nursing-home Facilities by Region
36.1
■ Coastal Andhra
B Rayalseema
H Telangana
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61.5%
2.4%
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Source: Institute of Health Systems, APHIDB, 2002.
A5.20 The IHS survey provides some further detail on the types of services offered by
ambulatory care clinics. The range of services overall is quite broad, with the three most
common categories general medicine, general surgery, and pediatrics. A minority of
private clinics (ranging from 10-18 %) also provide public health services, including
family planning, immunization, antenatal care, and treatment of communicable disease.
c.
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Diagnostic facilities
A5.21 The only data available on these are from the IHS surveys. The surveys
distinguish between “extramural” facilities, i.e. those that provide only diagnostic and
laboratory services, and “intramural” facilities, those that provide these services as part of
a health care institution, such as a hospital. Intramural facilities may still sell diagnostic
services in the market to those coming from outside the institution.
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A5.22 Extramural diagnostic facilities provide a wide range of tests including pathology,
biochemistry, imaging, cardiology, and microbiology. For the first four of these
categories, 70-80 percent of freestanding facilities provide at least some tests. 69% offer
ECG, 38% offer ultrasound, 65% X-ray, and 70-80% various types of laboratory testing
of pathology and biochemistry.
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The Role of Private Providers in Health Care Expenditures and
Utilization
A5.23 Over the last decade, several major national studies have developed and
strengthened the evidence base on the role of private health care providers in India’s
health system. The National Sample Survey (42nd and 52nd Rounds, 1986-87 and 199596 respectively) provides national and state-level estimates on utilization of inpatient and
outpatient services and household out-of-pocket spending. NSS data is very
comprehensive, but may under-report overall health care use and does not allow much
discrimination between different types of private providers other than hospitals and
“doctors”7. National market and economic surveys by the National Council for Applied
Economic Research complement these data. The India Family Welfare Surveys I and II
provide utilization information on personal preventive services and population-based
public health interventions, also measuring private provider outputs for these services.
These national surveys are complemented by many smaller state and local studies which
provide much richer detail, but less coverage and representativeness.
A5.24 These data sources have been summarized and reported in detail in several recent
national policy studies, especially World Bank (1995), World Bank (2001), and Misra,
Chatterjee, and Rao (2001). Some of the key findings are reproduced here for reference,
wherever possible highlighting the position of A.P. in the national picture.
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Private Financing
A5.25 Health financing in India is dominated by household out-of-pocket spending,
estimated to account for 75-80 percent of total spending during the 1990s. Comparison of
the NSS 42nd and 52nd rounds suggests that the share of household in total spending may
be rising.
A5.26 Table 2 and Figure 4 present two recent estimates for government and private
spending at state level that allow comparison of A.P. with other states. The two estimates
are for different years, use different data, and show highly different figures in terms of
rupees per capita. Nonethess, both show that A.P. spends below the national average in
terms of government spending and above the average in terms of private spending. The
first table shows only Kerala with a higher per capita private spending level than A.P.
7 Use of the term “doctor” in national surveys should not be assumed to mean qualified allopathic or ISM
physicians. One cannot distinguish from these data qualified and unqualified “doctors.”
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Table 2: Health Spending for Major States in India, 1993
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State
T
J
Per
Capita
Annual Government Household
Total
Health Exp.
Health
Health Exp. as Health
Govt Household Total Expenditure as %
of] Exp. as ®/.
%
of Household
of
NSDP/NNP __ Income
NSDP/NNP
& 238
325
563
4.5
NE
10.7
Jammu
Kashmir*
Kerala
111
Himachal Pradesh 209
Bihar__________ 51
Orissa_________
74
Andhra Pradesh
66
Karnataka______
93
Rajasthan_______ 83
Uttar Pradesh
55
Gujarat________
78
Madhya Pradesh
63
Tamil Nadu
100
West Bengal
73
Haryana________ 83
Punjab_________ 110
Maharashtra_____ 85
Assam_________ 66
All-In dia
84
482
370
223
276
421
360
593
579
274
350
487
453
279
196
175
259
168
202
154
267
282
259
392
344
96
162
250
334
230
337
231
302
227
350
1.8
3.2
1.4
1.6
1.0
1.3
1.6
1.2
1.0
1.2
1.4
1.2
0.8
4,5
0.8
1.1
1.4
11.9
" 6.7
' 6.1
' 8.2
p7.8
' 8.8
4.2
4.5
4.7
9.5
' 8.9
' 7.5
' 7.4
I 7.4
6.5
5.4
4.9
4.4
6.9
4.3
4.2
3.8
3.4
3.2
3.2
6.5
3.4
4.1
6.2
5.4
2.4
2.8
6.0
5.5
I
r
i
Note: f
Estimates for Jammu & Kashmir are based on the previous NCAER survey of 1990.
NSDP - Net State Domestic Product, NNP - Net Nationafproduct
Source: Pearson, 2002, citing Shariff et al. (1999:56).
L
■
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11
Figure 4: Public and Private Per Capita Health Expenditure Across the Different
States, 1995-96
3|
a>
140
or
120 -
Q.
yj
Median Private Spending
RJ^ KA
y/B ♦ AP
♦ OR
80 -
■c
60 -
S
□
40 -
O)
20 -
Median Public Spendi ig
♦ HA
♦ MH
------
100
—
<3
re .'S
o cl
X re
*PJ
♦ th
O)
.E
■o
c
o>
cn 3
♦ KE
♦ UP
MP
♦ Bl
o °
CL
re
a>
>
<
0 4-------------------------------------- ------------------------------0.0
100.0
200.0
300.0
400.0
500.0
Average Private Health Spending (Rs. per capita/year)
fj
Source: World Bank, 2001
ri
A5.27 Almost all out-of-pocket spending goes to private providers, since user fees in
public institutions are not universal and are generally low. This is shown in Figure 5
below. This may be somewhat misleading, if households are purchasing medical goods
and services privately in conjunction with treatment delivered in public hospitals.
A5.28 It is not clear from the available national data the shares of out-of-pocket
spending going to the different types of providers, since the national surveys don’t
measure this carefully. But it is likely that a very large share of the total goes to
unqualified providers, pharmacies, and sources of retail drugs and commodities, and a
much lower share to qualified allopathic and ISM physicians.
■
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A5.29 All-India data, reported in World Bank (2001) and its background papers, shed
some light on the impact of this out-of-pocket spending burden on different groups in the
population. Analyses like this can be done for A.P. with the available household survey
data, although I was not able to produce these tables for this report. General results from
the all-India analysis probably apply to A.P.
A5.30 Out-of-pocket spending rises as a share of total household consumption
expenditure from lower to higher expenditure households (3.8% of total spending for the
poorest quintile, 6. 6% for the richest.) The line is flatter when only non-food
ri
-
12
I)
expenditure is considered, since this is a smaller share of total spending for poor
households.
A5.31 More telling is the evidence from national surveys on the impact of significant
out-of-pocket spending on the poor. Figure 6 shows one result reported in World Bank
2001 which suggests that the impact on the poor in A.P. of spending related to
hospitalization is relatively high, compared with other states.
I]
Figure 5: Out-of-pocket spending to Public and Private Facilities
u
RAJASTHAN
BIHAR
KARNATAKA
0 R IS S A
NORTH EAST
GUJARAT
TAM IL NADU
MADHYA PRADESH
WEST BENGAL
ALL IN D IA
ANDHRA PRADESH
MAHARASHTRA
UTTAR PRADESH
i
HARYANA
PUNJAB
KERALA
0
100
[□Out of Pocket to Public Facilities
200
300
400
500
j
k
MO u t of Pocket to Private Facilities [
u
Source: World Bank, 2001
r
tn
r
i
I
Ik
*1
1
13
A
Figure 6: Hospitalized People below the Poverty Line Who Financed Their Care in
Public and Private Hospitals from Borrowing or Sale of Assets by State,
1995-96 (percent)
II
north east
ANDHRA PRADESH
TAMIL NADU
KARNATAKA
BIHAR
KERALA
MAHARASHTRA
ALL INDIA
HARYANA
UTTAR PRADESH
WEST BENGAL
GUJARAT
I
1
MADHYA PRADESH
RAJASTHAN
EW
0
10
20
1
30
40
50
60
70
80
Percent
[■Public ■Private |
Source: World Bank, 2001.
A5.32 Health care utilization data from recent national surveys provide further evidence
of where this high out-of-pocket burden comes from As shown in Figures 7 and 8 below,
there is considerable use of private hospital and ambulatory treatment services in A.P., in
comparison with other Indian states. Table 3 compares some relevant indicators between
A.P. and all-India estimates. In general, A.P. shows higher levels of private service use
than the all-India average and a high out-of-pocket burden related to that use.
A5.33 The two recent rounds of the National Health and Family Welfare Survey provide
further evidence on the role of non-govemment providers in personal preventive services.
I was not able yet to produce these tables for A.P., but Figure 9 below shows the all-in a
breakdown for a range of services. With the exception of immunization, private providers
are a significant source of several other preventive services which are typically seen as
almost entirely the province of public providers.
14
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Table 3: Select Health Care Utilization Indicators
Indicators
Andhra
/India
Inpatient Care
Rural
1986- 199587___ 96___
30.8
22.2
59.7
43.8
I21.9
33.3
60.7
41.6
% Used Govt.
Andhra
Facility
India
°/o Received Free Andhra
Hospital
India
Bed/Medicine
Cost of Treatment Andhra 686
(Rs.)___________ India
853
Andhra [2.2
Treatment Cost
Ratio between
India
1.6
Private and Govt.
Facility
6428
3202
3.8
2.1
Urban
198687___
41.7
60.3
41.3
55.2
199596___
35.4
41.9
36.8
38.2
Outpatient Care
Rural
Urban
1986- 1995- 198687
96___ 87___
21.6
22.0
22.6
27.2
25.6
19.0
20.1
20.8
24,2
7.7
19.7
17.5
781
1183
5.2
2.4
4886
3921
5.4
2.4
67
75
1.8
0.7
199596___
19.0
20.0
8.5__
9.3
165
176
4.1
1.4
172
194
2.3
1.2
63
81
4.2
0.9
Source: Pearson, M. Impact and Expenditure Review, cited from:
1986-87: Sarvekshana, Vol. 15(4), Issue No. 51, Apnl-June 1992.
1995-96: NSS Report No. 441, August 1998.
I
Figure 7
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Utilisation of Hospital Services
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8.000
7.000
6.000
i
5.000
4,000
3.000
2,000
1,000
a®
K,
<i
I
Source: Pearson, M. Impact and Expenditure Review, Part II, Policy Issues, Draft, DflD, New Delhi,
2002.
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5.
Current Efforts to Involve Private Providers in A.P.’s Health
Programs
a.
Examples of innovative approaches
During a brief visit to Hyderabad, I learned something about several efforts to link
government health programs with private providers.
A5.34 Sukhibhava. This program provides cash subsidies to help low income women
offset the costs of institutional deliveries. It provides them with Rs. 300 when they
deliver in a a public facility. The objective is to increase the share of institutional
deliveries by low income women. I am not sure whether this subsidy can be obtained if a
private facility is used?
in
i
A5.35 Arrogyaraksha. This program provides health insurance coverage for the whole
family when couples with two children agree to sterilization. Families pay Rs. 75 for the
coverage and are entitled to 5 years coverage totaling a possible Rs. 20.000 in benefits
with a limit of Rs. 4000 per year. The benefits can be used in either public or private
providers. Approximately 200,000 beneficiaries per year participate in this scheme.
n
A5.36 Social marketing of contraceptives and other family welfare related commodities.
The Family Welfare program uses commercial distribution points to increase access to
contraceptives and other commodities, such as oral rehydration solution. (ORS still true
in A.P.?)
n
A5.37 Assistance to private providers delivering immunizations. Private providers can
receive vaccines from government supplies. (Still true in A.P.?)
h
A5.38 Provision of Directly-Observed Therapy Short-course (DOTS) by private
physicians. The Mahavir Trust and Mahavir Hospital in Hyderabad have for several years
run an innovative program to enroll private physicians in case-finding, diagnosis, and
treatment using DOTS. The program enables private physicians to refer suspected TB
cases for proper diagnosis. Patients diagnosed positive are then referred back to their
physicians for supervised treatment. Physicians “retain” their patients, but are assisted by
the program in assuring observation of patients taking medication. This program is felt to
be quite successful, but has not been expanded beyond its current site. The state TB
control society reported that the program requires a lot of effort from the Mahavir
Hospital and depends a lot on the leadership of Dr. K.G.R. Murthy, which may not be
forthcoming easily from other sites.
t
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A5.39 Other innovations in TB control
a) Collaboration with NGOs (about 14)
b) Experimentation in Medak town with RMPs who are willing to refer
patients to DOTS program.
17
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c) New Gol guidelines on involving private providers in DOTS, for referral,
as DOTS providers, and in microscopy, and
I
d) State society has “public-private mix” consultant, has proposed full-time
staff for Hyderabad, and there may be other posts in budget.
A5.40 New state act on regulation of private providers. The state government has just
passed an act providing for the regulation of private providers throughout the state. The
specific rules are still being drafted by the DoH in consultation with stakeholders such as
the IMA. This could provide the legal basis for development of a state-level database o
private providers and steps towards registration and accreditation.
I
A5.41 In order to fill vacant medical officer posts, the state has created a mechanism for
hiring doctors on contract. However, few doctors have taken up this offer, reportedly
because the compensation levels are too low.
b.
Views of the Indian Medical Association
A5.42 I was able to meet with the state office of the IMA during my visit. IMA-A.P. has
14 000 members, about one third of all physicians in A.P. Most of these are pnva e
doctors in general practice, since most government doctors would not join and there are
separate or|amzations for the specialties. The state IMA is involved m several wajjw.*
government health programs, including connnumg medical education eff .
participation in the RNTCP with DfID support, and participation in expanding Hepatitis
B immunization in collaboration with the Bill and Melinda Gates Foundation.
U
tl
A5.43 The IMA representatives voiced some clear views about certain issues.
•
d
Regarding the new regulation act, there was concern that the rules recognize the
different circumstances of physicians’ practices in cities, smaller towns, an
villages and not impose to rigorous uniform standards that cannot be met m th
more remote areas.
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6.
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•
There was concern that ISM doctors also practice allopathy and that they are
trained in ISM colleges to do so by allopathic doctors.
•
The policy of contracting doctors to fill vacant medical officer posts in
government was condemned as being a “bogus policy”, since these P°sts
adequate supplies and other inputs and the payment rates were too low to attract
doctors to this service.
Suggestions on Short and Medium Term Strategies to Enhance
the Contribution of Private Providers
a.
Short term strategies
18
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A5.44 These relate to things that the state government and especially the Department of
Health and the Commissioner of Family Welfare could do now, with only modest
additional investigation or analysis. It is noted where these activities could be contracted
out. The main thrust of these recommendations is to expand efforts by DoH, CoFW, and
state-level disease control societies working at state, district, and local levels to involve
private providers in health promotion, case finding and diagnosis, treatment and other
clinical services related to priority health conditions for which control programs have a
significant “primary treatment” component. This includes TB (also linked to HIV/AIDS),
malaria, sexually-transmitted diseases (also linked to HIV/AIDS), diarrheas, acute
respiratory infections in children. Private providers could also play a much larger role in
health promotion and education efforts addressing emerging chronic disease epidemics
such as diabetes, cardio-vascular disease and cancers and their related risk factors in
tobacco use, diet, etc.
A5.45 I would recommend that the state government envisage a large “crash program” to
involve private providers, since these people currently see and treat the vast majority of
cases even for priority public health problems. However, we may not have sufficient
information at this time to know exactly what to do. It would also not be desirable to load
an addition set of major work tasks onto disease control officers who are already dealing
with large national programs. Thus, the short-term recommendations balance some new
actions with developing more capacity for action and assessments of current activities.
•
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Create senior post at state level for an officer who would have as primary
responsibility the development of government-private provider collaboration in
relation to public health program priorities
6
•
•
•
Create state-level committee/commission to review current efforts at government
private provider collaboration and to make specific recommendations on new
initiatives. Committee should include senior DoH and CoFW officers, new state
level officer (see previous), disease control socieities’ directors, and private sector
stakeholders including representatives of ISM and allopathy (e.g. IMA), RMPs,
and voluntary sector. Committee should have some resources to engage
consultants and contract for review papers and case studies.
Assess accomplishments of Sukhibhava program. Is it reaching the poor? Is it
reaching high risk pregnancies and births? Are mothers reaching facilities who are
capable of providing the necessary clinical inputs. This could be done as an
epidemiological case-control study covering villages where Sukhibhava has been
made available and comparing women and births who accessed Sukhibhava with
those who didn’t. A cost-effectiveness assessment should also be done. [Could
contract out]
Implement changes in Sukhibhava program as per evaluation. Expand coverage if
program proves effective and efficient.
19
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r.
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I
If
•
Assess current efforts to integrate private providers in disease control programs
and health promotion efforts. These efforts may be hampered by the lack of
specific initiatives or programs to develop such integration as well as by the lack
of staff at district level to devote significant time to such efforts. For example, the
RNTCP (TB control) reported that there are many efforts to involve private
providers in the districts and the Gol has now issued formal guidelines for doing
so in terms of case-finding/referral, microscopy, and treatment observation. These
include working with qualified and alternative private providers. But efforts in the
districts are constrained by the many demands on the district TB control officer.
Working with private providers in very time intensive, requiring visits,
discussions, supervision, etc. [Could contract out.]
•
Require major disease control programs (TB, Malaria, HIV/AIDS, STDs) to
develop action plans for government-private provider collaboration
•
Launch new initiatives for government-private provider collaboration in pilot
districts, with additional finance for district level staff, transport, training,
supervision, etc.
•
Launch new initiatives in health information and promotion to reach private
providers with up-to-date information about government disease control
strategies, recommended case-finding and treatment practices, etc.
•
Develop training materials for private providers, for example short, focused (half
day, 2-3 hours?) Continuing Medical Education (CME) type sessions. [Could
contract out.]
M
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b.
Fl
Medium-term strategies
A5.46 These are strategies which require significant further investigation and analysis,
or experimentation/piloting before larger scale implementation.
A5.47 There are three basic goals to the medium-term strategies: expanding successful
government-private provider collaborations to state-wide implementation; experimenting
with new initiatives to engage private providers through changes in health care
organization, incentives, and regulation; and creating the infrastructure of people,
capacity, and information to develop, sustain, and monitor these efforts.
i.
Expanding government-private provider collaborations.
A5.48 The prerequisite for making progress in expanding collaborations is being able to
identify successful collaborations, understand what makes them work, and provide the
inputs needed to implement them over a wider area.
A5.49 Current programs must be inventoried and assessed for their contributions to
higher coverage and improved health outcomes
20
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A530 Resources for wider implementation of collaborations must be allocated and
organized effectively. The development of a state-level officer charged with this task is
one step in this direction. State government also needs to determine what resources are
needed at district and mandal level and how these can be made available. Funds could be
budgeted from the annual increases in primary health care expenditure to which GoAP is
committed. Should these be organized as programs within the state budget? Should they
be funded through the societies? Could a new society for government-private
collaboration be developed?
ii.
Experimenting with new initiatives.
A5.51 This area of work is potentially quite broad. We should analyze strategies in terms
of their impact on the determinants of increasing health benefits/outcomes, especially of
the poor, and improving financial protection of the poor. These determinants are:
1
L
A5.52 Access and coverage of the services that address the priority health problems.
This is related both to physical access, but also to financial access and the perceptions of
the population about quality of different types of providers.
A5.53 Technical (clinical) quality of services.
J
A5.54 Efficiency in resource use, in the sense that inefficient services waste resources
that could be used more productively.
A5.55 Reducing the out-of-pocket burden of the poor for essential services.
A5.56 There are several areas where development of new initiatives could be launched:
•
Developing an accreditation and quality assurance scheme for private
providers and diagnostic facilities, especially in relation to the priority
health programs. This would:
•
Call on state government to establish basic quality standards for primary
care providers, certify or accredite providers who meet these standards,
and provide mechanisms through which providers can improve their
quality to meet accreditation standards or attain higher standards.
•
Create a scheme of for allowing private providers to publicly advertise
their accreditation. This might include agreement on standard (and
modest) charges for patients related to priority health programs.
•
Support public notice of accreditation with public information efforts to
encourage patients to use accredited providers.
21
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There are some recent international experiences, for example, Indonesia s
creation of accredited private family planning providers. This type of
effort would help address quality issues, but may have little impact on
access/coverage or financial protection, unless it is tied to reforms in
patient charges of some type of public subsidy for patients.
A5.57 Developing new financing and organization strategies for primary care coverage.
In its study on the private sector, IHS proposed that A.P. could develop a new approach
to primary care coverage based on a “family doctor” model. In this model, each patient or
family would be affiliated with a primary care provider. These providers could be in
government facilities or private providers. They would be paid by capitation. Low
income families would have their capitation paid for or subsidized by the government. A
pilot project along these lines is now being developed under the poverty alleviation
program, with some funding through a World Bank loan. This type of initiative could
address all of the determinants of poor outcomes listed above, but will require significant
investment. It could be linked to experiments with new financing approaches, such as a
District Health Fund, with funding from government and households.
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A5.58 Involving LTFQ providers (such as RMPs and village doctors) in priority health
programs. This is a controversial area. Some efforts are already being implemented
through the disease control programs in the districts (e.g. TB), but there are legal issues
and opposition from the IMA. Nonetheless, these providers are the main source of initial
treatment for most of the priority health problems. Achieving significant increases in
coverage without involving them may be difficult. The types of involvement include
training, providing supplies and other inputs, referral linkages, accreditation to participate
in disease control programs, and government financing (subsidies) for their work in these
programs. Some of this is already being done, but there is no documentation or evaluation
of these efforts.
Creating Capacity to Implement Innovation and Essential
Information/Evidence on Private Provision
iii.
d
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A5.59 Development of state database on private providers. The APHIDB developed by
the Institute of Health Systems is a valuable resource. The state government should either
take on the responsibility for enumerating and registering all private providers or contract
that task out to voluntary organization. Registration should cover all hospitals, nursing
homes, private clinics and practices of qualified allopathic and ISM providers, fixed
practices of LTFQ providers such as RMPs and not-fully-qualified ISM providers,
pharmacies, and free-standing diagnostic facilities. In other words, all health
establishments. Part-time and itinerant practicioners can be excluded. The database
should include information on address, ownership, qualifications, main types of services
offered, availability of ancillary services (diagnostics, drugs), etc. This database should
be updated periodically.
•
The database could be used to develop an information and outreach
program to at least inform private providers about priority public
22
programs, referral and clinical guidelines and practices, and
opportunities for collaboration. It could be used by district officers
to develop new initiatives.
There are risks in developing such a database. If providers feel that
this, will be used to take legal action against them, they will not be
willing to provide information. The state must find ways to address
this concern in its outreach to providers.
A5.60 Providing human and financial resources. The activities discussed above (and
others that might be forthcoming in discussions) essentially comprise a major new
initiative for the state in government-private provider collaboration. This initiative has
major potential for improving health outcomes, given the large role played by private
providers in A.P.’s health system and their significant role treating most major priority
problems and even reaching poor populations. But to achieve this potential, development
ot government-private provider collaboration must be evidence-based in planning and
evaluation. The capacity to implement new strategies in pilot areas and the state as whole
must be provided.
A5.61 Can this activity be accomplished by adding tasks onto the work of the existing
disease control program staff? Without having done a specific analysis of their workload,
it is difficult to say. But state authorities should expect that a serious effort to build up
government-private provider collaboration will require a major new initiative, with staff,
funding, and other inputs. To my knowledge, no other state in India has launched a
serious state-level cross-cutting program of this kind. Can A.P. make a commitment in
this area, allocating significant additional resources over the next 3-5 years? This would
require at least the following:
Significant financial commitment to a new program for
government-private provider collaboration, cutting across the
current major vertical lines of disease control and family welfare.
1
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Creating posts and allocating staff at state and district levels to
work on this program.
Setting up the capacity to design, monitor, and evaluate innovative
projects. This could be contracted out to one or several of A.P.’s
very competent non-governmental organizations.
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References
Berman, P. and R. Rannan-Eliya. “Factors Affecting the Development of Private Health
Care Provision in Developing Countries. Phase I: Review of Concepts and Literature, and
Preliminary Field Design,” Major Applied Research Paper No. 9, Health Financing and
Sustainability Project, Abt Associates, Inc., Bethesda, MD, October 1993.
Berman, P. “Rethinking Health Care Systems: Private Health Care Provision in India”
World Development. 26(8): 1463-1479, 1998
fl
Institute of Health Systems, Andhra Pradesh, Health Institutions Database (APHIDB),
results from 2001 and 2002.
Mahapatra, P. “An Overview of Private Hospitals in Andhra Pradesh: Data from the AP
Health Institutions Database (APHIDB), 2001.” Institute of Health Systems, Hyderabad,
■I
h
I '
Mahapatra, P, Sridhar, and Rajshree. Structure and Dynamics of Private Health Sector:
Implications for India’s Health Policy, Institute of Health Systems, Hyderabad, 2002.
Misra, R.L., Chatterjee, R. and S. Rao, Changing the Indian Health System: Current
.Issues,—Future Directions, Indian Council for Research on International Economic
Relations, New Delhi, 2001.
Pearson, M. Impact and Expenditure Review, Part I, Financing and Part II, Policy Issues,
Draft, DUD, New Delhi, 2002.
World Bank. 1995 India: Policy and Finance Strategies for Strengthening Primary
Health Care Services. Washington: World Bank, Report No. 13042-IN.
World Bank, 2001, Raising the Sights for India’s Health System, Washington, World
Bank, Report No. 22304.
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DRAFT
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Annex 6
Support for Development of a Medium Term
Health Strategy for Andhra Pradesh:
■W
The State of Health and Burden of Disease
in Andhra Pradesh, about 2000 AD
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Prasanta Mahapatra and C.K. George
1
4
Annex 6
The state of health and burden of disease in Andhra Pradesh, about
2000 AD
Prasanta Mahapatra and C.K. George
4
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1.
Introduction
A6.1 The Vision 2020 document of the Government of Andhra Pradesh (GoAP) sets out
ambitious goals to achieve improved population health status and access to responsive basic
health services. The Department of Health, Medical and Family Welfare of GoAP has initiated a
number of exercises to define and operationalize the objectives set in Vision 2020. The GoAP is
in the process of developing a Medium Term Financing Strategy for Health intended to serve the
State for a minimum period of five years. Such a strategy would set out the framework within
which the GoAP will operate in the health sector.
A6.2 Taking stock of the population health status, it’s past trends, and measurements of disease
burden of various population subgroups of the State are essential inputs for setting of priorities
for the reform process. This will enable the development of targeted interventions that will
provide these groups the necessary support for their survival, growth, development and
sustenance. In this paper, we first review the population health status in Andhra Pradesh using
conventional indicators and then present an estimate of disease burden in the State using the
Disability Adjusted Life Year (DALY) as a summary measure.
2. Conventional Indicators of population health status
A6.3 The World Health Organization (1981) identified five broad indicators to measure health
status of a population. These include; (a) nutritional status of children, (b) infant mortality rate
(IMR) (c) under five child mortality, i.e. mortality below five years age, (d) life expectancy, and
(e) maternal mortality rate (MMR). IMR, under five child mortality, and life expectancy
represent various aspects of general mortality. If we group these together, the health status
indicators listed above reduce to three sets, namely; (a) nutritional status, (b) general mortality,
and (c) maternal mortality. These three groups of indicators are used here to describe the health
status of the State. In addition we have included Total Fertility Rate (TFR), since fertility is an
indicator of the level of reproductive activity which has important implications on reproductive
health. TFR is also an indicator of the State’s population policy goals, which are intricately
linked with the health sector.
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1
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Nutritional status
a.
A6.4 Nutritional status is a positive health indicator (WHO, 1981 p32). There are many ways
to measure nutritional status. Among these, the weight-for-age status of the preschool children is
considered to be the most sensitive indicator of community nutrition. For adults the body mass
index (BMI) is considered more appropriate.
A6.5 The National Nutrition Monitoring Bureau (NNMB) measures nutrition status in 10 states
including Andhra Pradesh on a continuous basis. The NNMB has so far conducted one reference
and two repeat surveys to assess changes in nutritional status of population in the study states.
The reference survey took place in 1975-79 and the two repeat surveys took place during 198890 and 1996-97. Figure-1 shows time trend of moderate to severe malnutrition prevalence among
preschool children in different states, based on weight-for-age. In AP, as in most other NNMB
states, there has been an improvement in nutritional status over the years. However still 50% of
children in AP are suffering the burden of moderate to severe malnutrition.
c
o 80
c 70
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60
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CD
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o
40
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Figure 1. Malnutrition among preschool children in AP and other states.
■ 1975
X
B 1988
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TN
KA
AP
MH
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OR
BL
IRih
ALL
ft
1 Source: The figure is based on Weight-for-age data from NNMB Repeat Surveys 1975-79, 88-90, and 96-97,
reproduced from Mahapatra and Reddy, Health Status in AP, IHS Working Paper WP- 43/2001 (1-28).
A6.6 The National Family and Health Surveys (NFHS) provides estimate of prevalence of
malnutrition among preschool children. The figure-2 compares the prevalence of moderate to
severe under nourishment in AP and other states according to the two NFHS surveys. The first
NFHS survey (left chart) show that Kerala had the lowest prevalence of under nutrition and all
other NNMB states including AP had a higher but similar prevalence of malnutrition. The
second NFHS survey shows that the states have somewhat differentiated probably on account of
differences in interventions and programme implementation.
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to
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Figure 2. Under nourishment in preschool children according to NFHS^
□ NFHS-2(1998-99): 0-3 year children
□ NFHS-1(1992-93): 0-4 year children
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1 Source: The figure is based on data from NFHS-1 and NFHS-2 (India) p-286, table- 10.10 NFHS-2 p-270
table- 7.17, reproduced from Mahapatra and Reddy, Health Status in AP, MS Working Paper WP- 43/2001 (128)._____________________________
4
A6.7 Overall, under nutrition among preschool children is still an important problem in AP.
About 40 to 50% of preschool children suffer from under nutrition. Poor nutrition is a risk factor
for many infectious diseases like ARI, Diarrhoea etc.
A6.8 Body mass index (BMI) is an indicator of energy deficiency or obesity in adults. pereons
with BMI less than 18.5 kg/m2 are considered to suffer from chronic energy deficiency (CED)
and those with BMI greater than 25 kg/m2 are the obese. Figure-3 shows that chronic energy
deficiency among adults of AP was comparatively higher than the average for all NNMB states.
Figure 3. Chronic Energy Deficiency (CED) in adults of AP and
other states, 96-97,98-99_______________ __________
70
60
Q
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□ NNMB-1996-97
0UNFHS-2(1998-99J3 gg
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26.84
18.7
3?
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Id
id
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KE______ TN_______ KA_______ AP______ MH_______GJ_______ QR
AL------------
Source: Figure is based on Body mass index (BMI) data from NNMB Repeat Survey 1996-97 and NFHS-2 ,
reproduced from Mahapatra and Reddy, Health Status in AP, MS Working Paper WP- 43/2001 (1-2^-----------
4
A
I
b.
General mortality level (IMR and Life Expectancy):
L
Infant mortality Rate
1)
A6.9 The Infant Mortality Rate (IMR) is a sensitive indicator of population health as well as
socio-economic development. In addition, IMR is a sensitive indicator of the availability,
utilization and effectiveness of health care, particularly perinatal care (WHO, 1981)
A6.10 The IMR of the state registered a consistent decline from 110-120 in 1970s to 66-70 in
1990s (Figure-4). The reduction of IMR in AP (red line in fig-4) has been keeping pace with the
national trend. However performance of the state has been much less than that of the neighboring
states. Kerala started with a lower level of IMR during the 1970s and has experienced consistent
improvements over time. Tamil Nadu started with a level of IMR similar to AP. The decline of
IMR in Tamil Nadu is higher than in AP. Both states started with similar levels of IMR in 1970s
and improved the same more or less similarly during the 1980s. During 1990s, Tamil Nadu
continued its improvements in IMR but Andhra Pradesh appears to have slowed down, resulting
in a gap of about 10 infant deaths per 1000 live births between the two states.
Figure 4. Infant mortality trend in AP and other neighbouring states
AP
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1971
1975
1979
1983
1987
1991
1995
&
A
------- 0
1999
1 Source: SRS Annual Reports, 1971 - 1999, reproduced from Mahapatra and Reddy, Health Status in AP, IHS
Working Paper WP- 43/2001 (1-28).
A6.ll Though AP has performed reasonably well in reducing IMR, it has definitely not been
able to exploit the full potential available to it. Of particular concern is the slow down in
reduction of IMR in the state, during the 1990s.Despite the overall decline in infant and child
mortality, 1 in every 15 children bom in Andhra Pradesh during the mid 1990s died within the
first year of life.
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Life Expectancy:
2)
A6.12 Life expectancy is an indicator of socioeconomic development in general and long-term
survival (WHO, 1981). Life expectancy of a population at a given age is the average years of life
lived by those reaching that age. For example life expectancy at birth of 60 years means that all
children taking birth in the population can on an average expect to live for 60 years. Life
expectancy at birth is highly influenced by the IMR, particularly if it is at a high level.
4
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A6.13 Table-1 shows estimates of life expectancy for Andhra Pradesh, Kerala and India at
different points of time. Though expectation of life at birth was low in the state during 50s, by
70s it was slightly better than the national average, suggesting a significant improvement in the
health status of people. There after life expectancy at birth in AP has remained slightly above the
national average.
Table 1. Life Expectancy at Birth of Andhra Pradesh,
India and Kerala
India
Kerala
AP
Period
41.2
36.9
48.3
1951-61
47.7
44.4
48.8
1961-71
54.4
55.7
65
1971-81
59.4
72
60.6
1989-92
60.7
62
73
1992-96
Source: Table based on SRS mortality data, reproduced frojn Mahapatra and Reddy,
Health Status in AP, HIS Working Paper WP- 43/2001 (1-28).
N
Figure 5. Life expectancy at birth in AP and other states, 1992-96
80
co
Females
Males
in
75
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70
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55
50
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IN
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MP
Source: Figure based on SRS mortality statistics, reproduced from Mahapatra and Reddy, Health Status in AP,
IHS Working Paper WP- 43/2001 (1-28).*
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6
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A6.14 Figure- 5 shows female and male life expectancy estimates for AP and other states, for
the period 1992-96. Life expectancy in AP is slightly better than the all India average, but is the
lowest among the south Indian states. Life expectancy at birth is the best in Kerala, and better
than AP in Tamil Nadu, Karnataka, and Maharashtra.
I
Total Fertility Rate
3)
A6.15 Total Fertility Rate is mostly used by demographers to analyze trends of fertility.
Reduction in fertility levels is viewed as an indicator of improvements in reproductive health.
Figure-6 shows total fertility rate of Andhra Pradesh and other states. There is a constant decline
of TFR from 1970s to 1998. All India TFR was 5 in 1971-73 and declined to 3.2 in 1998. The
TFR of AP was 4.5 in 1971-73 and it has decreased to 2.4 in 1998.There is ample scope for
further decline of TFR in AP considering the much lower fertility levels attained by the southern
states in India like Kerala and Tamil Nadu (1.8 and 2 respectively).
Figure 6. Total fertility rate (TFR) in Andhra Pradesh and
other states 1971-1998
6
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KA
KE
TN
5
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OR
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IN
MP
AP
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1971
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1974
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1980
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1983
i
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1986
i
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1989
i
i
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1992
i
i
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1995
i
i
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1998
Source: Figure based on SRS Annual Reports for the period 1971-1998, reproduced from IHS (2002),
Reproductive health services and sector reform : Draft Action Plan
4)
Maternal Mortality
1
6
A6.16 Maternal Mortality ratio (MMR) reflects the risk to mothers during pregnancy and
childbirth. It is influenced by general socioeconomic conditions, nutrition and sanitation, as well
as by maternal health care.
A6.17 Precise estimates of maternal mortality rate (MMR) in Andhra Pradesh are not available.
The NFHS did collect data to estimate maternal mortality rates. Both NFHS- 1&2 give MMR
estimates at the national level. All India estimates of MMR ranges from 400 to 500 deaths per
100000 live births (UPS, 2000 pl96). Mahapatra and others (2002) have computed MMR using
7
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1
estimates of matemai deaths in AP during the 1990s by Mahapatra (2000) and an estimate of live
births in AP on 1991 census population and SRS estimates of CBR. This would imply that MMR
in AP might be around 260 per 100000 live births.
■I
A6.18 A more interesting aspect of the cause of death estimates shown in table-2 is the large
number of deaths of young and adult women due to non-matemal causes. About 4400 woman die
of matemai causes. But 8500 women commit suicide every year. This is about twice the number
of matemai deaths. Another 3000 women die on account of fire accident or violence. These
deaths have intricate relationship with status of women, socioeconomic vulnerability and poor
power equation of women.
Table 2. Major causes of death among women in reproductive age
________ group of 15-44 years, for the year 1991 in AP._________
Number of female deaths_______
Cause of death
Rural_____ Urban______ Total
44109
8049
52158
All causes_____________________
Maternal Causes
544
82
462
Matemai Hemorrhage
580
118
462
Matemai sepsis
603
4
599
Hypertensive disorders of pregnancy
315
7
308
Obstructed labour
1100
56
1044
Abortion
1279
389
890
Other matemai conditions________
Other major causes_____________
8638
94
8544
Self-inflicted injury (suicides)
3408
1645
1763
Fire accidents
1564
349
1215
Violence
4421
656
3765
Estimated matemai deaths
1729208
436446
1288453
Estimated births in 1991
100000
292/100000150/
100000256/
Matemai Mortality Ratio
___________________________________ live births live births live births
j
Source: Mahapatra. Estimating National Burden of Disease. 2000, Appendix: 3-7.1 and 3-8.1.______
M
H
3.
Summary measures of population health and the burden of disease in Andhra
Pradesh
A6.19 With epidemiological transition from communicable diseases to non-communicable and
degenerative disease, measurement of non fatal outcomes assumes importance. Summary
measures of population health are designed to incorporate mortality experience of a population
with the level of morbidity in a single number. These can either be measures of healthy life
expectancy like the ‘disability adjusted life expectancy’ (DALE) or health gaps like the
‘disability adjusted life years’ (DALY) lost due to disease. The World Bank’s World
Development Report, 1993 titled “Investing in health” used the disability adjusted life years
(DALY) measure to estimate burden of disease in different parts of the world. The World Health
Organization started using summary measures like the DALY and DALE starting with the World
Health Report 1999. In Andhra Pradesh, Mahapatra (2000) has estimated the burden of disease in
8
1>
the state dunng the 1990s using similar methodology. An overview of the burden of disease in
AP during the 1990s, is presented here, using estimates from the AP Burden of disease studv
based on expert rated disability weights (Mahapatra, 2000).
3
™erT:ra11 burden of disease in Andhra Pradesh in terms of DALYs lost is estimated to
be 277 DALYs per 1000 population in Andhra Pradesh. The rate of loss is 293 DALYs/1000 for
males and 269 DALYs/1000 for females (Mahapatra 2000). The break up of burden of disease
into crude YLL and YLD rates by region is shown in Figure 7. It is seen that the variance of
burden of disease rates among the regions is mainly on account of the premature mortality
component m their disease burden. In EME, burden is equally attributable to premature death
and disability, while in SSA over three quarters of the burden of disease is due to premature
mortahty. In India and Andhra Pradesh, close to 70% of the disease burden due to premature
mortality.
Figure 7: Disability(YLD) and Mortality (YLL) rates in AP and other regions, 1990’s
I
i
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(
r
700 --------------------------------------------------------------------------------------------------------------
□ YLL/1000
■ YLDflOOO
600
500
§ 400
i
d 300
>
■g
ra' 200
9
>
100
0
B1E
FSE
CHhM
AP
INOA
SSA
Region
I
Source : Estimates for AP taken from Mahapatra (2001) The burden of disease in Andhra Pradesh 1990s;
estimates for other regions from Murray and Lopez ; 1996 Annex tables 7 and 8
A6.21 Table 3 shows age sex distribution of disease burden in terms of YLL: YLD ratios. In
contrast to developed regions, premature mortality is the predominant cause of disease burden in
a age groups in India. The YLL: YLD ratios for Andhra Pradesh are comparable with overall
estimates or India. In Andhra Pradesh, infants and children in the 0-4 age group are particularly
more vulnerable to death (YLL: YLD ratio = 4.14 in females and 4.65 in males).
—Igble 3
: YLD ratios by age and sex for different demographic regions, 1990s
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9
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Region
Age Groups by sex
Sex
5-14
0.54
M
EME
F
0.46
0.98
M
2.57
FSE
F
2.07
0.76
2.89
M
SSA
8.32
7.44
F
3.11
CHINA
M
2.27
1.01
F
2.56
0.88
1.07
5.29
INDIA
M
5.84
1.64
F
0.62
AP
M
4.65
_________________
F
414____________
0.73
0-4
1.62
1.37
$
■I
15-44
0.61
0.28
0.82
0.36
1.54
1.2
0.79
0.57
1.08
0.79
1.65
1.13
45-59
1.54
0.81
2.39
1.06
1.66
1.51
1.68
1.16
1.98
1.6
2.73
2.13
+60
2.68
1.99
3.72
2.75
2.52
2.43
2.67
2.35
3.18
3.01
6.38
5.35
Source : Estimates for AP taken from Mahapatra (2001) The burden of disease in Andhra Pradesh 1990s;
estimates for other regions from Murray and Lopez ; 1996 Annex tables 7 and 8
Note: Table 9.8 in Mahapatra, (2000), page 251, shows YLL : YLD ratios for 0-4 year males in Andhra
Pradesh as
0.83. We have recomputed the figures using YLL and YLD estimates given in Appendices 9-3.2 and 9-3.3 of
Mahapatra ((2000). The ratio shown in Table 9.8 of Mahapatra (2000), page 251, was a result of computation
error.
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A6.22 Table- 4 shows ten leading causes of burden in rural and urban areas of the state. Six
leading causes are common to both the areas. These are (a) lower respiratory infections, (b)
diarrhoea, (c) low birth weight, (d) ischaemic heart disease, and (e) falls and (f) tuberculosis.
Poor nutrition, lack of safe drinking water and sanitation are common risk factors for three of
these, namely lower respiratory infection, diarrhoea, and low birth weight. Four of these (a, b, c,
and f) are already included in various public health and disease control programs of the state.
The results obtained here reinforce the desirability of those programs.
Table-4 Leading causes of disease burden (DALY) in rural and urban AP,1990s
%_____
Urban: Cause_____________
%_____
Rural: Cause______________
6.91
8.4
Falls
Lower respiratory infections
6.32
6.94
Low birth weight
Diarrhoeal diseases
5.98
Lower respiratory infections
6.8
Low birth weight
5.34
6.09
Tuberculosis
Ischaemic heart disease
4.00
5.45
Diarrhoeal diseases
Falls
3.77
4.24
Ischaemic heart disease
Self-inflicted injury
3.47
4.1
Fires
Tuberculosis
3.21
Birth asphyxia or trauma
Cerebrovascular disease
2.56
2.96
Road accidents
Bacterial meningitis
2.39
2.91
Unipolar major depression
2.24
Epilepsy
Road accidents_______________________________________________
2.15
Source: Reproduced from Mahapatra, 2000; The Burden of Disease in Andhra Pradesh. 1990s. Table-6.1
10
ata*.<
.... -T”
A6.23 Table 5 shows the leading causes of burden due to premature mortality. Most of the
leading causes of overall disease burden, for example, lower respiratory infections, diarrhoeal
diseases, low birth weight, tuberculosis, etc are repeated here. In addition, malaria appears as a
leading cause of mortality in rural areas.
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=4
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Table 5 Leading causes of premature mortality (YLL) in AP, 1990s
Rural: Cause
Lower respiratory infections
Diarrhoeal diseases
Low birth weight
Ischaemic heart disease
Self-inflicted injury
Tuberculosis
Cerebrovascular disease
Bacterial meningitis
Cirrhosis )f the liver
Malaria
Road traffic accidents
%
11.43
9.26
9.01
8.49
6.00
5.12
3.25
3.22
2.63
Urban: Cause
Low birth weight
Lower respiratory infections
Tuberculosis
Ischaemic heart disease
Diarrhoeal diseases
Birth asphyxia or trauma
Road accidents
Fires
Cerebrovascular disease
%
9.74
9.4
7.86
6.18
5.84
4.17
3.59
3.58
3
2.47
2.22
Source: Reproduced from Mahapatra, 2000; The Burden of Disease in
i Andhra Pradesh, 1990s. Table-6.2
A6.24 Table 6 shows leading causes of disability in the state. Falls and fires are among the
leading causes of disability. This reflects the fact that falls and fires not only cause loss of life,
but also produce a lot of disability. Protein energy malnutrition is a major cause of disability. The
burden is on account of developmental disability suffered by children due to poor nutrition.
Unipolar major depression is yet another leading cause of disability to be viewed along with the
fact that suicide is a leading cause of premature mortality. Cataract blindness, for which a control
program is under implementation, is also among the leading causes of disability.
Table-6; Leading causes of disability (YLD) in Andhra Pradesh, 1990s
%
Urban: Cause
%
Rural: Cause
16.22
Falls
16.43
Falls
7.14
Unipolar major depression
6.66
Unipolar major depression
5.85
Epilepsy
5.64
Epilepsy
3.37
Schizophrenia
3.65
Cataracts
3.32
Fires
3.26
Fires
2.98
Cataracts
3.00
Schizophrenia
2.53
Lymphatic
filariasis
2.66
Protein-energy malnutrition
2.45
Protein-energy malnutrition
2.39
Lymphatic filariasis
2.4
Obsessive-compulsive
2.23
Obsessive-compulsive
disorders
disorders
2.37
Chlamydia
2.16
Chlamydia
2.32
Abortion
_________
2.11
Abortion___________________________________________________
I
Source: Reproduced from Mahapatra, 2000; The Burden of Disease in Andhra Pradesh, 1990s. Table-6.3
r
12
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n
4.
Vision 2020 goals and current health status
A6.25 The Vision 2020 document has set specific targets for four health indicators, namely (a)
Infant Mortality Rate (b) Child Mortality Rate (c) Total Fertility Rate and (d) Life Expectancy. In
Table 7, we compare the Vision 2020 goals for the year 2020 with corresponding status in 1990’s.
To achieve the Vision 2020 goals for reduction of infant mortality the State has to reduce infant
mortality by about 46 infant deaths per 1000 live births over about a twenty-year period. During
the 1970’s IMR in the State was about 110 to 120 per 1000 live births. Thus it took three decades
for the State’s IMR to reduce by about 40 to 50 infant deaths per 1000 live births. If we assume
that the decline in IMR is linear, as has been the case in AP so far, it will take another two decades
to realize reduction in IMR to about 20 infant deaths per 1000 live births. As the mortality level
declines, further decline in mortality becomes difficult to achieve. Hence the Vision 2020 goals
regarding reduction of IMR appears achievable, but will require a more streamlined and
efficacious approach.
Pn
i
*
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r
Table 7 Comparison of current levels and Vision 2020 goals for selected Indicators
Indicator
Current
Goals for year 2020
level (1990s)________________________
Infant Mortality Rate(per 1000 live birth) (1999)1 66
20
Child Mortality (per 1000 ) (1999)1
21
10
Total Fertility Rate (1998)2
2.4
1.5
Life Expectancy (Male) (1998)2
60.8
68.1
Life Expectancy (Female) (1998) 2____________ 63_____________ 70.6_______________
I
Source:1 NFHS data from UPS (2000); 2 SRS Annual Report (1999);3 GoAP, Andhra Pradesh: Vision 2020
Note: The Vision 2020 document reads; “This vision will translate into the following key health and
development indicators by 2020: infant and child mortality rates of 10 per 1000 (live births) and 20 per 1000
respectively;”(GoAP, Vision 2020, pg. 92). Mortality experience world over shows that IMR is usually higher
than Child mortality rate even in low mortality developed countnes. Hence IMR of 10 per 1000 live births and
Child mortality rate of 20 per 1000 appears implausible. We assume that the figures have been switched in the
Vision 2020 document by a typographical error. Hence we work with the assumption that the Vision 2020 goal
is for an IMR of 20 per 1000 live births and Child mortality rate of 10 per 1000.__________________ ________
5.
Summary and Conclusion
A6.26 A significant proportion of the disease burden in Andhra Pradesh is on account of
premature mortality. The top causes of disease burden in AP, during the 1990s include (a) lower
respiratory tract infections (LRI), (b) diarrhoeal diseases, (c) low birth weight (LBW), (d)
tuberculosis and (e) falls were. Three out of these five, namely: LRI, diarrhoea, and LBW, are
public health problems for infants and children. They should serve as stark reminders to the
persisting problems of poor nutrition, water supply and sanitation. Tuberculosis, another
infectious disease, continues to be a major problem. Currently there are many programmes
seeking prevention and treatment of these problems. For example: the reproductive and child
health programmes, programme to build awareness about usefulness of oral rehydration therapy,
tuberculosis control programmes. Obviously, the agenda to control diseases due to infection malnutrition - poor hygiene complex remains unfinished.
I
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A6.27 Demographic changes in age profile of the population due to rising life expectancy, and
urbanization with accompanying lifestyle changes have led to an epidemiological transition in
the State. Non communicable diseases contribute significantly to the disease burden in Andhra
Pradesh. Ischaemic heart disease, cerebrovascular disease and cirrhosis of the liver are leading
causes of premature mortality in the State. Neuro-psychiatric conditions like unipolar major
depression, schizophrenia, obsessive-compulsive disorders, and epilepsy are a major cause of
disability in the state. The implications of such a health transition does not bode well for Andhra
Pradesh. On one hand the State has to deal with the unfinished agenda of diseases of poverty
and on the other it has to gear up to meet the challenges posed by the increasing prevalence of
risk factors for non communicable diseases like smoking, excessive drinking and sedentary life
styles.
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A6.28 Injuries, unintentional and intentional, contribute significantly to the burden of disease in
Andhra Pradesh. There is hardly any discussion about falls as a major public health problem.
Lack of attention on falls as a major cause of disease burden, we believe, is largely due
ignorance about the size of problem attributable to falls. Self-inflicted injury and fire accidents
emerged as major causes of disease burden in the state. Suicides, mostly among adolescents and
young adults are largely due to problems of adjustment due to many factors during the transition
phase of a person's life. The high burden on account of fire accidents, particularly among
women, is consistent with widespread social ill of bridal harassment, dowry etc. A large
proportion of suicides among young women is probably due to the same factors. The high level
of disease burden due to road accidents is a cause for concern. Unless appropriate preventive
measures are taken urgently, the burden is bound to increase on account of the lack of adequate
infrastructure to meet the needs of a rapidly increasing automobile population and the laxity in
enforcement of mandatory traffic regulations.
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References
i
Brundtland. Women’s health in South East Asia, Director General, WHO, Chapter-3 ,2000.
Downloaded from http:/7www.whosea.org/women/chap3 4f.htm, in the month of November
2001)
Government of Andhra Pradesh (1999), Andhra Pradesh: Vision 2020
International Institute for Population Sciences (UPS), Roy TK et al. National Family Health
Survey 1998-99 (NFHS-2). India. Mumbai (Bombay): International Institute for Population
Sciences (UPS), 2000.
r
International Institute for Population Sciences (UPS), Ramesh BM, Arnold Fred et al. National
Family Health Survey 1992-93. India. Mumbai (Bombay): International Institute for
Population Sciences (UPS), 1995.
Mahapatra. Estimating National Burden of Disease. The burden of disease in Andhra Pradesh
1990s, IHS, 2001.
Mahapatra, Reddy. State of Health and Nutrition in Andhra Pradesh, IHS, 2001. Working Paper
WP 43/2001(1-28).
Murray Christopher J.L. and Lopez Alan D; The global burden of disease. A comprehensive
assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and
projected to 2020. Boston: Harvard School of Public Health; 1996.
National Nutrition Monitoring Bureau (NNMB), Repeat surveys, 1975-79, 1988-90, 1996-97.
National Institute of Nutrition, Hyderabad.
SRS Annual Reports, Registrar general, India, New Delhi.
World Health Organization (WHO). Development of indicators for monitoring progress towards
health for all by the year 2000. Geneva: 1981.
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DRAFT
Annex 7
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Support for Development of a Medium Term
Health Strategy for Andhra Pradesh:
Financing Health in Andhra Pradesh
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Ajay Mahal
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Annex 7
Financing Health in Andhra Pradesh
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Ajay Mahai
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A7.1 The note has three main objectives. The first is to bring together information on the
overall magnitude of funds, public and private, likely to flow into the health sector in
Andhra Pradesh over the course of the five-year period 2002-7. We are concerned not
only with funds available for spending on activities usually referred to as health care ,
preventive and curative, but also with activities that likely have a significant impact on
the population’s health, such as improvements in water and sanitation, nuttition, and
pollution control. Of special interest is the magnitude of funds available to the
Department of Health, Medical and Family Welfare, other state government departments,
and various local governments for activities that impact on health, which will be a key
input for developing a medium term health strategy and expenditure framework. A
second set of objectives is to evaluate the use of these funds - including the degree of
flexibility that these different public sector entities possess with regard to the disposal ot
funds available to them, and the rules used to distribute the funds across the different
districts/regions of Andhra Pradesh. Both of the above goals will be useful as a means to
assess ways in which financial planning can be undertaken to support a vanety of shortand medium-run strategies to improve the health of the people of Andhra Pradesh. Many
of these strategies have been discussed in the other background papers that form part o
this Annexe. In addition, this paper has a third objective - to provide the basis for and
suggesting the introduction of new strategies that lead to a more equitable and effective
use of existing funds for health care, as well as helping raise additional funds.
A7.2 In addressing these goals, the author had the benefit of access to a recent^and
comprehensive impact and expenditure review of the health sector in Andhra a es , as
well as additional preliminary work on the costing of health sector strategies and the
development of a “resource envelope” for the Andhra Pradesh health sector supported by
the Department for International Development (DfID 2001, Pearson 2000a,b).
recen
fiscal reforms strategy paper prepared by the Department of Finance of the ovemmen
of Andhra Pradesh also proved very useful in developing the arguments of this paper
(GoAP 2002a). This background paper takes advantage of the several excellent ideas
presented in this earlier work, and builds on it in areas that could do wit
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discussion and analysis, such as health sector financial resources available to districts an
local bodies.
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Introduction
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a.
The Economic Setting
A7.3 It is a tautology to state that much of the private and public spending on health (and
related activities) in Andhra Pradesh is closely tied to its overall economic performance,
and indeed, to the economic performance of India as a whole. Higher incomes make
health care more affordable to individuals and households, and are also more likely to be
associated with increased tax revenues, so critical for improvements in the fiscal
situation. Prudent fiscal management, however, does require more than just increased
revenues. How and where public monies are spent is also crucial, so that the fiscal
circumstances can act as an independent barrier to health spending by the public sector.
A7.4 We begin with an overview of the economic and fiscal situation in Andhra Pradesh.
The post-reform period in India, the 1990s, has been characterized by an annual average
rate of growth of real gross domestic product (GDP) that is somewhat higher relative to
its magnitude in the 1980s - 5.7 percent in the latter period, and 6.3 percent in the 1990s,
with a slowdown in the last few years.1 This fact, coupled with declines in the average
annual rate of growth of population during the 1990s, implies that the rate of growth of
real GDP per capita has speeded up as well in the post-reform period, from 3.1 percent in
the 1980s to 4.2 percent in the 1990s. Relative to India taken as a whole, Andhra Pradesh
did rather well in the 1980s, with its real SGDP (State Gross Domestic Product) per
capita growing at an annual average rate of 4.1 percent. Post-1993, the annual average
rate of growth of real SGDP per capita in Andhra Pradesh has been about 4.3 percent
(roughly similar to India as a whole), and its rate of growth of real SGDP, higher than the
rate of growth of real GDP (all India). One net consequence of these trends is that the per
capita income of Andhra Pradesh is about equal to the all India average. The latter half
of the 1990s (1997-2001) has seen Andhra Pradesh perform better economically than the
rest of India, with its real SGDP growing at 7.7 percent per year, higher than the 5.9
percent average annual rate of growth for India. These trends clearly indicate that over
the last two decades, AP is keeping pace with all India performance, and if anything, has
surpassed the latter in recent years.
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A7.5 Andhra s relatively good economic performance is also reflected in the lower than
average proportion of its population that lives below the national poverty line. According
to estimates based on National Sample Survey (NSS) data for 1999-2000, nearly 11.1
percent of the rural population of Andhra Pradesh, and 26.6 percent of its urban
population, lived below the poverty line, defined as the minimum amount of expenditure
needed to purchase a basket of commodities providing a desirable level of calorie intake.
In sum, 11.9 million people lived below the poverty line (5.8 million in rural areas and
6.1 million in urban areas) in Andhra Pradesh in 1999-2000, amounting to about 15.8
percent of its total population (GoAP 2002a, pp.1-2). By contrast, the proportion of
population living below the poverty line in India as a whole was 26.1 percent in 19992000.
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'Calculations based on data in GoAP (2002b, Annexture 2.9).
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i.
Intra Andhra Pradesh Patterns of Economic Performance
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A7.6 Within Andhra Pradesh, there are significant differences in economic achievements
across districts. These relate both to differences in the levels of per capita income, as
well as differences in the rates of growth of real income per capita, across districts.
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A7.7 While district-level GDP data for the most recent years are not yet available, data
for the late 1990s indicate per capita income levels in Medak, Hyderabad and Ranga
Reddy to be the highest, with others such as Mahbubnagar, Warangal and Srikakulam
being the poorest. The richest district, measured in terms of per capita income, as of
1998 was Medak and it had a per capita income that was more than double that in the two
poorest districts, Mahbubnagar and Warangal.
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A7.8 The differences in per capita incomes across districts may be increasing over time.
Data for the period 1993-98 indicate a correlation coefficient of +0.20 between the rate of
growth of real per capita income in a district during 1993-98 and its level of per capita
income in 1993. As one example, Hyderabad and Medak, two of the richer districts in
1993, experienced the highest annual average rates of growth of real income per capita,
7.3 percent and 6.5 percent, respectively during the period 1993-98, whereas Warangal
and Vizianagaram, two of the poorer districts experienced annual average rates of growth
that were 1.5 percent and 0.9 percent, respectively, over the same period.
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Fiscal Situation
A7.9 The economic trends highlighted above suggest that at least on the revenues front,
governments at the central and state levels in India are likely to have enjoyed some
buoyancy, even if the situation at the district level is more complicated. Given, however,
that the budgetary circumstances of governments depend on a host of factors on the
expenditure side, further analysis is in order.
A7.10 In fact, the overall budgetary situation of the central and state governments in
India has been rather bleak during the recently completed five-year plan period. The
fiscal deficit of the central government alone averaged 5 percent of GDP during the
period 1996-2001 (Planning Commission 2002). The major reasons for this include the
implementation of the recommendations of the Fifth Pay Commission that have led to a
high wage and salary burden of government employees, high interest payments on public
debt, and the failure of revenues to keep up with expenditures owing particularly to the
slowdown of GDP growth in recent years. The interest burden on public debt has
worsened on account of government efforts to partly bridge the fiscal deficit by
borrowing from the high interest bearing small savings deposits. According to estimates
provided by the Planning Commission, the debt service burden of the central government
has risen from 30 percent of its own tax revenues in the early 1980s to nearly 70 percent
of its own tax revenues at the present time (Planning Commission 2002, p. 12).
A7.ll The tight fiscal situation of the central government has meant the active
consideration of a number of strategies to address it. The approach paper to the tenth five
4
year plan, for example, refers to a planned reduction in the number of government
employees, with no new recruitment, over the plan period. Other suggested strategies
include holding steady certain non-pian expenditures of the central government by means
of reductions in subsidies on “non-merit” goods and user charges, and an acceleration of
the disinvestments process of public sector undertakings (Planning Commission 2002,
p.13). Moreover, the plan document also refers to promoting a linkage between states’
performance on fiscal reform and at least some of the central government funding to
states, with a view to ensuring more effective use of central government funds by the
states.
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A7.12 The fiscal situation at the center and the overall economic environment has
obvious consequences for the fiscal health of the Government of Andhra Pradesh. This is
so because central government grants and shared taxes account for nearly one-third of all
receipts of the Andhra Pradesh government (GoAP 2002a, pp.5-6). A significant chunk
of central funds take the form of shared revenues on the basis of the recommendations of
the Finance Commission of India/ Moreover, central grants, which typically occur in
three ways - centrally sponsored schemes, grants under article 275 of the constitution
under the auspices of EFC for especially needy states/regions and “plan” grants (normal
external aid projects, structural adjustment grants by donors) — also make a significant
financial contribution to states. With the recent slowdown of the national economy, some
squeeze in tax revenues that are to be shared between the center and the states, as well as
other devolutions suggested by the EFC can be expected. Indeed, during the fiscal year
2001-2, Andhra Pradesh’s receipts in centrally devolved taxes were lower than their
budgeted estimates by nearly 9 percent (GoAP 2002a, p.5). More generally, transfers
from the central government to Andhra Pradesh have declined in importance - from 5.2
percent of SGDP in 1995-6 to 4.6 percent of SGDP in 2000-1. Conversely, the role of
own revenues (tax and non-tax) in total state revenues has increased from 54.9 percent in
1995-6 to 68.3 percent in 2000-1 (from 6.3 percent of SGDP in 1995-6 to 9.8 percent of
SGDP in 2000-1). It is also unlikely that international donor funding will increase
beyond existing commitments given the concern among central policymakers that funds
for externally aided projects are focused on only a few selected states, with obvious
consequences for inter-state resource inequity (Planning Commission 2002, p. 14).
A7.13 Apart from the revenue crunch that it faces, the government of Andhra Pradesh is
also faced with challenges on the expenditure side, as highlighted by the strategy paper
on fiscal reforms published by the department of finance (GoAP 2002a). Its expenditures
on revenue account less total revenues — that is, the revenue deficit — have increased in
recent years, from 1.0 percent of SGDP in 1995-6 to 2.7 percent of SGDP in 2000-1. The
fiscal deficit (all expenditures on revenue and capital account less total revenues) has also
been increasing - from 3.1 percent of SGDP in 1995-6 to 5.4 percent of SGDP in 2000-1.
As in the case of the central government, interest payments on state debt have increased
sharply, from 1.9 percent of SGDP in 1995-6 to 2.8 percent of SGDP in 2000-1,
reflecting an increasingly worsening public debt burden. Total state debt amounted to
28.6 percent of SGDP at the end of 2001, with loans guaranteed by the state government
forming an additional 12.6 percent of SGDP. Pay revisions, natural calamities and
The Eleventh Finance Commission (EFC) was the most recent of these constitutionally mandated bodies.
5
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budgetary support to the power sector have also played a major role in the increased
magnitude of revenue expenditures, which have gone up from 12.5 percent of SGDP in
1995-6 to 17.1 percent of SGDP in 2000-1.
iii.
Fiscal situation of local governments
A7.14 Even if the financial situation at the level of the central and state governments is
somewhat grim, local governments can provide services with their own revenues. This
sub-section takes a preliminary look at the financial situation of urban and rural local
governments in Andhra Pradesh.
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A7.15 As of 1991, nearly 13 percent of Andhra Pradesh’s population resided in its 117
municipalities and municipal corporations. Together, these urban local bodies had an
estimated Rs. 1,100 crore in receipts in 2000-1, a miniscule amount when compared to the
resources of state government departments (about 5.5 percent of state government
receipts and 0.9 percent of SGDP) in that fiscal year.3 About 25 percent of these receipts
took the form of plan and non-plan grants from the central and state governments, with
the remainder raised through taxes and fees (including taxes collected by the state but
“assigned” to local bodies) (GoAP 2001; Communication with Y. Srilakshmi, Municipal
Commisioner). The share of plan and non-plan grants in total revenues of urban local
bodies has been virtually constant during the period 1995-2000 (State Finance
Commission 1997, pp. 167-9). Three points are noteworthy with respect to the finances
of urban bodies. First, they cover a significant portion of their current expenditures from
their own revenues, whether collected or assigned. Second, the relatively small size of
their own funding may reflect an inability on the part of urban local bodies to raise extra
revenues locally, whether on account to a lack of access to remunerative sources of
revenue, or lack of political will. Finally, the reliance on own sources of revenue
suggests that the economically better off urban areas are likely to have local governments
that are placed better in terms of resources, so that the existing pattern of financing local
governments is likely to be inequitable. Preliminary analysis of municipality-level data
provides some support to this hypothesis. The correlation between own revenues (per
capita) in a municipality and the level of per capita in the district where the municipality
was located was +0.33. On the other hand, there is some weak evidence to suggest that
the central and state grants provided to urban bodies act to equalize inter-municipality
equality - with the correlation between grants per capita and district-level per capita
income being of the order of -0.21.
A7.16 Financial data on the more than 21 thousand panchayats (Gram, Mandal and
Zilla) in Andhra Pradesh is not readily available for years after 1996 (State Finance
Commission 1997). However, available evidence suggests that panchayats are dependent
on central and state government grants to a much greater degree than urban local bodies.
As per data for 1996, the year prior to the submission of the report of the First State
Finance Commission of AP, 75 percent of all panchayat expenditures were funded by
various central and state grants. The greater reliance on central and state government
funding would suggest a more equitable allocation of resources among rural local
3There are 110 municipalities and 7 municipal corporations in AP.
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governments than urban local governments. On the other hand, it may also signal a lack
of flexibility in the use of funds if they are allocated to specific uses and dependence on
the vagaries of the fiscal situation of the central government and the government of
Andhra Pradesh.
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A7.17 While past data is useful in obtaining insights about the financial situation of local
bodies, it may not be as accurate an indicator of the situation in more recent years in light
of the constitutional amendments requiring a transfer of functions and financing to local
governments, or of future prospects. An analysis of the recommendations of the state
finance commissions is useful for this purpose, only one of which has submitted its report
thus far. The First State Finance Commission (SFC), which submitted its report in 1997
for the period 1997 through 2000, suggested a variety of increases in funds to local
governments, including by increasing the magnitude of general grants allocated on a per
capita basis, after adjusting for interregional and inter-local body inequities, specific
grants for maintenance of assets and the like. Overall, the magnitude of such increased
transfers relative to total expenditures/revenues of the local governments was roughly 40
percent of their existing receipts in 1996-7, a not insubstantial sum. But as the SFC itself
acknowledged, continuation of added grant money to local bodies from the state
government was dependent on its fiscal situation.
5
c.
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The Medium-Term Fiscal Framework of the Government of Andhra
Pradesh
A7.18 With local body own revenues comprising only a small portion of public spending
in Andhra Pradesh, the medium-term fiscal outlook for its state government is the key
indicator of the resource constraints faced by sectoral strategy in the health sector. This
section reviews the government of Andhra Pradesh’s own assessment of its fiscal outlook
in the medium run and the strategies it proposes to adopt as part of this exercise (GoAP
2002a).
A7.19 Over the five-year period from 2002 to 2007, the GoAP seeks to reduce its fiscal
deficit from 5 percent of SGDP to 2 percent of SGDP. There are additional five-year
targets with respect to the size of the revenue deficit, public debt, and contingent
liabilities and these are indicated in its strategy document (GoAP 2002a, p. 18). It
proposes to achieve these targets by addressing several of the key elements that underlie
its adverse budgetary situation without imposing too much of a constraint on social sector
expenditures. Indeed, “The overriding objective of Andhra Pradesh’s fiscal restructuring
program is to augment state revenues and redirect government expenditure away from
less productive schemes towards investments in people to improve their quality of life
and strengthen their social and economic assets through improved health, education and
other social services.” (GoAP 2002a, p.12).
A7.20 A major challenge in trying to achieve these objectives is the control of
“establishment costs” (salaries plus pensions) that increased from 73.4 percent of the
state’s own revenue in 1998-99 to 78.7 percent of own revenues in 2001-2. This is
proposed to be addressed by restrictions on hiring in the government that apply to all
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sectors except for law and order, and essential health and education services, coupled
with attrition via retirement and selective application of voluntary retirement packages.
As a consequence, the share of establishment costs in the state’s revenues is expected to
fall from its current high levels to 61 percent by the year 2006-7. The government has
placed an emphasis on human resource development and skill upgradation of employees
rather than any radical downsizing of civil services. Thus, its strategy calls for
reorientation, retraining and redeployment of existing staff.
A7.21 Another key factor influencing the budget is subsidies - the power subsidy for
2001-2 was “fixed” at Rs. 1,561 crores, but a drought situation in the state meant that
there would have been an added burden f Rs. 876 crores during the year 2001-2 on
account of additional power purchases. In the short-run the state intends to meet this
shortfall by the securitization of outstanding dues to the creditors of the AP Power
Finance Corporation by way of bonds guaranteed by the state government, although this
will increase interest payments in the future. Over time, the government expects the
power subsidy to fall to 0.5 percent of SGDP by 2006-7 from its current level of 2.1
percent of SGDP. Similarly, the subsidy on rice is expected to fall from its current level
of 0.3 percent of SGDP to 0.2 percent of SGDP by 2006-7.
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A7.22 Another key pillar of the government’s strategy is its plan to privatize public
enterprises and putting a cap on loan guarantees as a means to curtail its stock of public
debt. The government has also allowed for plans to support voluntary retirement
packages to employees in some of the public enterprises, such as the provision of loans to
the concerned enterprises for this purpose - Rs. 180 crore for the fiscal year 2002-3, and
additional amounts in each subsequent year until 2006-7.
A7.23 These declines in spending and the promotion of fiscal prudence are, apart from
their expected impact on the fiscal deficit, expected to lead to additional funds becoming
available for infrastructure development, especially in the transport and communication
sectors. They are also expected to lead to increases in operational and maintenance
expenditures form 1.7 percent of SGDP in 2001-2 to 1.8 percent of SGDP in 2002-3, and
ultimately to 2.2 percent of SGDP by 2006-7.
A7.24 The government has also committed itself to increased spending on primary
health and primary education, which comprised 2.1 percent of SGDP in 2000-1. As per
its strategy document, “The government will aim to provide 1 percent of SGDP for
primary health and 2 percent of SGDP for primary education to translate the policies laid
down in the strategy papers on health and education.” (GoAP 2002a, p.26). Objectives of
poverty reduction, expansion of core social services to the poor and under-privileged
communities are also emphasized, along with the amelioration of geographical disparities
in development (GoAP 2002a, p.26).
8
iv.
In sum
A7.25 The tight budgetary situation at the central and state levels limits the extent to
which the central and state governments can spend significantly more on the health
sector. There is a clear commitment though, on the part of the government to spend more
on primary health care which, in a regime of reasonably fast growth of SGDP - say at
6.5 percent or more per year, the assumptions implicit in the department of finance
calculations for its medium term fiscal strategy - also has implications for increased
private spending for health, whether provided in the public or private sectors.
2.
Total Resource Flows to the Health Sector
a.
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Some Observations on Data
A7.26 According to one recent estimate, current spending on health care (excluding
water and sanitation, nutrition and pollution control expenditures) by the government of
Andhra Pradesh accounts for only about 13-14 percent of all health spending (DfID
2001). Total spending, public and private, amounts to roughly 6.6 percent of SGDP.
These estimates rely on data from a recent household level survey of consumer spending
undertaken by the National Sample Survey Organization (NSSO), together with
information from the demand for grants of the government of Andhra Pradesh, and
ignores other types of spending, such as insurance premiums, spending by private firms
on health and the like.
A7.27 Information on health expenditures, whether private or public, at the district level
is even more difficult to obtain. Household expenditure surveys carried out by
organizations such as the NSSO do not provide statistically robust results at the district
level. At best, regional level estimates may be arrived at. Government expenditure data
at the district levels, while technically in existence, is not readily accessible. Our
discussions with the officials of the department of health, medical and family welfare
suggest that obtaining this data might require field visits to all 23 districts in the state.
Another concern is the need for better management and consolidation of financial data on
health in the public sector, currently under the control of several different departments,
with some not being recorded in budget documents at all - as in the case of the AIDS
society. At the aggregate level, much greater effort is needed to collect information on
the activities of private health insurers many of whom are already operating in the health
sector. In general, such information is best collected in a systematic way by following a
national/state/district health accounts framework. The recently crafted National Health
Policy of India explicitly states the need to develop a national and state level health
accounts for India.
b.
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Implications for Health Planning
A7.28 The much larger out-of-pocket health spending of households, relative to that of
the government, much of it on curative care, has at least three implications for policy.
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development of insurance mechanisms, within the public sector or wit out, a p
financial risk pooling. Second, to the extent that a s.gntficant amount of pnyate
household spending is directed towards pnvate health providers, who therefore impact on
health outcomes, it calls for more pro-active policymaking towards the pnvate sector,
including regulatory strategies, as also co-opting it m efforts to *mP™ve
5^
services that are particularly desirable, such as TB treatment. Fina y, e sma
the public sector spending suggests using public resources more effectively in ways that
readdy enhance major policy priorities of the government - such as better targeting
expenditures to the poor and backwards groups, public health and the like.
3.
Public Financing for Health in Andhra Pradesh
A7.29 This section carries out a situation analysis and assesses the nature of government
financing available for health over the medium-run - from 2002 to 2007. Two sets of
health-related activities are emphasized. The first is simply public resources use
health care as commonly understood in the literature, whether preventive or cura ye.
Curative care at the primary, secondary and tertiary levels, immunization and health
promotion activities belong to this category. This second refers to items that hkely have
a major influence on health - such as improved nutrition, water and sanitation, PO1^10
control and the like - but which do not always enter into standard calculations of health
spending.
a.
Recent Trends and Prospects
government in connection with its annual budgetary exercise, and a recent overvie
the health sector undertaken by the department of health, medical and fami y we are.
A7.31 Table 1 provides information on recent trends in-public sector health spending.
These estimates exclude expenditures incurred by local bodies on preventive an cura ye
care from their own resources. Nor do they include health spending directed through
district level societies that circumvent the stole government’s budgetary process (such
the AIDS control society), or in-kind grants, as for example under the Fami y e
program. Previous work suggests that these are still small relative to the overall size ot
the health budget (DfID 2001). The data clearly show that the overall size of the^he
budget has been keeping pace with GDP growth, and constitutes about 0.
SGDP as of now. As a proportion of total public sector spending, healt sp
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fallen a bit compared to the mid-1990s, but is still hovering around the 5 -percent 1
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On two points, however, there can be no doubt. Total health spending has increased m
real terms over time. Moreover, on a per capita basis, real public health spending
increased by nearly 40 percent over the period 1996-2002.
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A7.32 Table 2 takes a closer look at three major components of public sector spending medical education, medical and health, and primary health and family welfare. Broadly
speaking, the first two can be thought to signify secondary and tertiary care, whereas the
latter category includes most (but not all) elements of primary care. The table also
provides estimates of the wage and salary burden under each of the main expenditure
categories. The numbers in the tables and additional calculations based on the demand
for grants by the health, medical and family welfare department suggest that the share of
primary care in total public health spending has increased in recent years, from 57
percent in 2000-1, to 59 percent in 2001-2, and to 66 percent as per the budget of 20023.4 Indeed, in the budget of 2002-3, an amount of nearly Rs. 1,000 crores is allotted to
activities that could be reasonably be classified as primary care. This would amount to
about 0.6 percent of SGDP in 2002-3, assuming that the state’s domestic product grows
at about 6.6 percent per annum next year, the assumption used by the department of
finance for its medium term fiscal framework calculations.
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A7.33 Table 2 highlights another key feature of the expenditures incurred by the
department of health, medical and family welfare. Wages and salaries account for about
70 percent of the spending of this department, and even higher of its non-plan spending
(80 percent). Previous work has already noted the considerable variation in the share of
wages and salaries across expenditure line items. According to the impact and
expenditure review undertaken by DfID (DflD 2001) salaries accounted for somewhat
more than half of all non-plan spending of tertiary hospitals, whereas the salary
component for APWP hospitals was considerably greater at about 80 percent of all nonplan spending. The salary component of non-plan primary spending is even higher, at
nearly 90 percent for each of the three financial years for which we were able to obtain
estimates in Table 2. The large share of salaries in total public health spending,
particularly at the primary care level, could have negative implications for utilization
rates and the efficiency with which public sector financial resources on health are being
currently utilized in Andhra Pradesh.
A7.34 Previous authors, policymakers and policy researchers have raised a number of
legitimate concerns about the way in which public resources on health in Andhra Pradesh
are being spent. One is the relatively fast growth of plan expenditures in the secondary
care sector (under the AP First Referral Health Project), which although it has now come
to an end, would impose a large recurrent non-plan expenditure burden on the
government. This added burden appears not to have occurred in the budget for 2002-3
however. A second, related concern has to do with the disproportionately large share of
the secondary and tertiary sectors in government spending. There is a clear effort on the
part of the GoAP to address this concern in the 2002-3 budget, which raises the share of
primary care spending to nearly two-thirds of the department of health, medical and
family welfare spending on health from its previous year’s share of 59 percent. A third
concern is the small magnitude of resources committed to health care in AP (see, for
example, DflD 2001, p.7). The large share of private financing of health care (some 87
4Pnmary care is taken to include expenditures undertaken under the heading of primary health and family
welfare, plus additional amounts spent on prevention, on non-allopathic systems of medicine that are
included under expenditure heads other than primary health and family welfare.
11
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percent of all health spending in AP) is also indicative of the failure of the public sector
to provide an insurance cover for needed expensive care to poor rural households
especially when recent evidence suggests much greater utilization of public hospitals by
urban households and better off groups among the rural population (Mahal et al. 2001).
Fourth, the resource crunch in the public sector is a bottleneck in promoting better use of
public sector funded primary care facilities (as well as hospitals) given that most of the
allocations go for salary payments with not much left over for drugs, medical supplies
and maintenance. A final issue of concern is the distribution of public funding on health
in ways that address regional/district inequities in health status and service provision,
cited as one of the goals of the Vision 2020 document.
A7.35 In addressing the concerns of the previous paragraph over the medium run, the
first matter at hand is to assess the overall level of funding for health available to the
government of Andhra Pradesh. What are the likely future trends in funds available for
public health spending in Andhra Pradesh in the medium run? We disregard, for the
aoment, the own resources of local bodies, and donor and central government funds that
circumvent the state budget, because they are relatively small in magnitude thus far
(DfID 2001). In this setting, the three key determinants of expenditures in the future
would be the budgetary constraints that face the government of Andhra Pradesh, the
economic environment that underlies them and the priority it places on health.
A7.36 As to the overall budgetary constraint faced by the GoAP, this will be very tight
as the government intends to sharply reduce its fiscal and revenue deficits as well as its
debts over the medium run, as highlighted in the introductory section. However, an
improvement in the economic situation, that is a growth in SGDP, would help ease the
economic burden on the government, both my making its fiscal targets (all expressed as a
proportion of SGDP) more manageable, as well as providing some boost to its tax and
non-tax revenues that typically depend on economic performance (for example, sales tax
revenues). The department of finance in its strategy paper presents forecasts of nominal
SGDP up to the year 2006-7. Assuming that the inflation rate during 2002-7 continues to
be the same as in the year 2000-1 (the most recent year for which such data are
available), these nominal SGDP forecasts amount to assuming annual rates of growth of
real SGDP increasing from 6.6 percent in 2002-3 in constant 0.2 percentage point
increments to 7.4 percent by the year 2006-7. We assume these rates of growth of SGDP
for the calculations that follow. As to the third determinant, the GoAP’s recent fiscal
reforms strategy paper envisages “primary health care” expenditures to increase to 1
percent of SGDP by the end of the mid-term plan period 2006-7.
A7.37 Provided that “primary care” is precisely defined, a rough estimate of the
magnitude of government resources available to primary health care can be arrived at
under the above assumptions. For our purposes, we take it that the magnitude of primary
health care expenditures will be roughly Rs. 1,000 crores in 2002-3, slightly above the
total amount budgeted under the primary health and family welfare head in the demand
for grants of the department of health, medical and family welfare.
12
A7.38 Table 3 presents the resource profile for supporting public spending on primary
health care under three different scenarios. Under scenario I, spending on primary health
care as a proportion of SGDP is taken to increase from its 2002-3 level of 0.6 percent by
0.1 percent points each year so as to be 1.0 percent of SGDP during 2006-7. Under
scenario II, a “pessimistic” counterpart of I, expenditure on primary health care as a
proportion of SGDP is taken to remain at 0.6 percent for all subsequent years except
2006-7, when it jumps up to 1.0 percent of SGDP to meet the desired goals of the
department of finance strategy paper. Scenario III is based on a conversation with the
principal secretary (finance department) which suggested the possibility that a 0.04
percent point annual increase, starting from an initial level of 0.6 percent of SGDP, was a
more realistic option. Scenario I offers the possibility of a fairly large increase in
allocations to primary health care, averaging nearly Rs. 700 crore (at 2002-3 prices)
annually during 2003-7. Under scenarios II and III, the increase is somewhat smaller, but
still significant, averaging about Rs.400 crore (at 2002-3 prices) over the period 2003-7.
In sum, if the assumptions and commitments outlined in the strategy paper of the
department of finance were to come true, a fairly substantial increase will occur in
financial resources allocated to primary health care, ranging from 40 percent to 70
percent of the budgeted amount in 2002-3.
A7.39 How about amounts to be allocated to secondary and tertiary care? Little is said
on this issue in the fiscal strategy report, but the discussion with the secretary of finance
appeared to point towards leaving unchanged the total amounts allocated to the health
sector (taken as a proportion of SGDP). Under these circumstances, in the most
optimistic scenario one could imagine total secondary and tertiary care spending
remaining unchanged at their 2002-3 level of about Rs.550 crore annually during the plan
period. If, however, the overall public sector health spending were to remain unchanged
as a proportion of SGDP even as the share of primary health care is increasing, fairly
drastic cuts in the amounts allocated to secondary and tertiary care may result, as
indicated in table 4. Given that salaries are more or less protected scenarios I, and II,
may imply unrealistic outcomes, and therefore may not be credible. In fact APWP
grants are not under threat (communication with principal secretary, finance). But if any
squeezes do occur, one consequence may be increased reliance on user charges. If there
is any movement towards raising resources in this manner, a careful assessment of the
potential implications of user charges for equity in the financial burden of health care is
called for. Another possibility is to look into raising resources by charging students
higher fees in teaching institutions, since such education is typically heavily subsidized.
This needs to be evaluated as well, in light of its potential political ramifications.
A7.40 As to user fees, receipts from user fees at APWP hospitals are currently rather
small - amounting to barely one percent of receipts from various sources in 1999-2000
(DtID 2001). There is also a “recent” directive from the department of health, medical
and family welfare that request spending departments to attempt to collect user fees to at
least the value of non-salary recurrent expenditure. In the case of teaching hospitals, this
would imply the cost recovery of 40-50 percent of total expenditures, and for secondary
hospitals, just under 20 percent. Given the possible equity issues involved, the Impact
and Expenditure Review by DflD (2001) suggested that an even more modest set of user
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fee rates than those underlying the above calculations could also do reasonably well - and
potentially cover 15 percent of total costs (p.22). Little knowledge exists, however, of
the impact of user charges on the utilization of health care by poor households in AP.
4
SS
A7.41 A financial squeeze on public hospitals, particularly in the tertiary sector, could be
thought of as further adversely affecting the chances of the poor to obtain subsidized
treatment for catastrophic illnesses. Development of insurance schemes across large
numbers of self-group groups (or a fund set with contributions at the district level) with
possible subsidization of the premium contributions of the poor could be a way around
this. The pooling of large sums of money could be used to help purchase such care on
competitive terms from private/autonomous tertiary hospitals, and is also a way to bring
in private resources to work with public contributions. But resources for the poor will
have to be found. If the insurance scheme is voluntary, participants will have to be
assured of the quality of care they will receive in return for their contributions to it. This
might require pre-assessment via pilot projects before large-scale schemes are put in
place. An interim measure could be to move towards implementing more effectively the
requirement that private hospitals provide care to a pre-specified number of poor patients,
in return for having previously received land and equipment subsidies from the
government.
A7.42 Will the increased amounts to be allocated to primary care over the next few years
be gobbled up by increased wage and salary costs of existing employees, leaving little for
new initiatives? All else the same, there are two counteracting forces that influence the
answer to this question. The first are standard increases in salary over time, as employees
move into higher income brackets. The second is attrition on account of retirement,
which would reduce the salary burden. To derive the net effect of the two would
necessitate an analysis of the age-composition and earnings profiles of existing
employees, an analysis that could potentially be undertaken once the data on the census
of government employees in Andhra Pradesh becomes available. If we assume that the
two effects will neutralize each other, the new resource allocation policy will leave open
a lot of financial space for initiatives in the arena of primary care. Conversely, it would
imply a sharp tightening of the secondary, and especially the tertiary care sectors. It is
worth noting that additional financial flexibility could also be made possible by means of
redeployment and retraining of existing staff, although early evidence suggests this to be
a difficult option to exercise (DfID 2001).
b.
A Note on Water and Sanitation, Nutrition and Anti-Poverty
Programs of the Government of Andhra Pradesh
A7.43 Apart from “health care” as usually understood, the government also contributes
to good health through a variety of programs to improve water and sanitation facilities in
rural and urban areas, nutrition, occupational health and the environment. More
generally, by the promotion of anti-poverty programs (and various employment and
infrastructure development schemes) it helps contribute to the ability of individuals and
households to afford improved nutrition and other inputs to promoting good health.
14
’Wil*
they include expenditures that miaht he ‘
as/°restry and ligation. Nor do
their own funds on any of these activities '"to do Y
bodieS’ rural and ,urban’ fro™
of the expenditures independent!v i
a r S° Wou.^ re^uire a careful disentangling
expenditures from state and central 00^™
municipalities and panchayats versus
purposes, the latter having central government grants specifically directed towards such
preliminary estimates presented in Table ‘s th^.eStlrnautes Prov,ded in Table 5. The
spending that directly impacts health but dn lnd.‘Ctte 11131 there 15 S1gnificant public
medical and family welfare departrnrat
“
Sh°W UP
budget °f the health’
bX'al,h ren"”en‘effons Mwar"
employment creation social welfare and '
3 WI e range of Programs addressing
that their execution makes better nuXn
^elopment that are relevant in
households. Rough estimates bv the nnth preVentI0n and heaith care more affordable to
department of urban development and na^’h31118
’"J116 demand for ^nts of the
public expenditures (or budgeted amounts) in excess 0/^000^ deVelOpme,nt- suggest
during the year 200? 1
1
,
cxcess 01 Ks-d000 crores on such programs
ptaui of iTeX,“SST W<,“ld be
activities.
c.
» ™«reP3eC:
P^^^ms incurred by the government of Andhra Pradesh on those
Health-related expenditures of local governments and districts
body spends on healthTlsol^ ^mplfcation^fb'1-613^ aCtivities- How much each local
government health allocations anart fr
°r lnterTeglonai
inter-district equity in
resources available for health. ForPthat °» lts imPact on the overall magnitude of
departments allocate budgeted funds across di
m WhlCb health 3nd Other state
allocation.
stncts also impact on equity in resource
the most recent year for which such da^
type of spending by urba^ govemmenR
sometimes in conjunction with a limited
eTd,,
“r“by
SeCt°r
p b e’
in the year 200°-1’
11 comes t0 ^alth, the main
i
163nd sanitation services,
I
administration suggests that neariv 40
P ( ! by the dePanment of municipal
providing water and sanitation services inTh^munl^i^1111101^1 bUd8et goes towards
Pradesh. This would amount to rourrhlvRc"1Uniclpalities and corporations of Andhra
total amounts devoted to water and sanitaf
annually ln 20°0-l- Given that the
St3te’leVel dePartments of
the government of Andhra Pradesh were Tbouf
uuesn were about Rs.500 crore as reported in tale 5, it
15
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appears that municipalities and municipal corporations play a crucial role in providing a
key public health input.
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A7.48 Data for health expenditures by rural local governments is not readily available,
but it appears that the main role of these bodies, in so far as health is concerned, is to
provide for water and sanitation. In the case of rural local bodies, though, it is likely that
most of the funds for water and sanitation are obtained as grants from the state
government. The paucity of own resources is possibly one of the major reasons
underlying line items (in the demand for grants) requesting assistance for panachayats in
the maintenance of water and sanitation facilities.
A7.49 What can one expect in the future? Own resources of local bodies will obviously
increase as SGDP increases (along with district-level economic activity) lead to increases
in revenues from income-elastic taxes - for example, surcharge on stamp duty, property
tax, and the like. Increasing devolution of funds from the state could be another
possibility, although likely to be constrained by GoAP’s tight fiscal situation. Another
concern has to do with the possibility of inequitable allocation of resources across regions
and local bodies. The main argument for this view is that assigned (and locally collected
taxes) are likely to be buoyant with respect to the economic environment in which the
panchayat (or the municipality) exists. The introductory provided some evidence
suggesting that municipalities that were economically better off (in per capita income
terms) were also likely to be better placed with respect to own or assigned revenues.
Although corresponding data for panchayats is not readily available, there is no reason to
believe that the relationship between economic status and revenue position would be any
different for rural local bodies. On the other hand, grants from the state government to
urban governments were negatively correlated with economic position, suggesting a
movement in the direction towards greater equality.
A7.50 While additional analysis is clearly needed to verify the robustness of these
findings, there are some reasons to believe that allocations/grants to local bodies (other
than assigned taxes) made by the central and state governments at least tend towards
greater equity. First, untied grants made under the recommendations of the state finance
commission (SFC 1997) are allocated on the basis of a formula that favors poorer local
bodies. For instance, the formula used by the first SFC to allocate funds used the ratio
3:2:5:8 to distribute funds (on a weighted per capita basis) across four categories of
panchayats - ordinary, advanced, backward and tribal. A similar type of weighting
system is used for untied grants to urban local bodies as well, classified as municipal
corporations, first grade municipalities, second grade municipalities, third grade
municipalities and nagar panchayats. Second, there are special efforts to address the
needs of poorer villages (as in rural water supply projects) and areas with significant
populations of scheduled castes and tribes residents. Whether these allocation methods
and the funds involved are sufficient to address the regional and district-level inequities
in socio-economic and health conditions is an issue that obviously merits further analysis.
A7.51 A similar set of issues arises when the concern is with allocations to district level
counterparts of the department of health, medical and family welfare. Data on public
i
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health spending at the district level is not readily available, owing to the nature of the
process by which financial data are put together in the first place. While no obvious
formula is apparent in the allocation of funds, the government policy of using population
based norms for setting up CHCs, PHCs and sub-centers suggests the de facto application
of a per capita allocation rule that does little to address regional inequities. Given the
further possibility that medical personnel positions in the poorer and far-flung regions are
likely to be disproportionately vacant, the logical outcome would be regional inequity in
departmental resource allocation, even when the government sets lower population norms
for health facilities in tribal areas (for example), or if the enhanced malaria initiative is
launched in tribal districts.
A7.52 In thinking about potential areas for added financial support to local bodies,
particularly in rural areas, one way to potentially promote greater use and accountability
of medical facilities and personnel at primary health centers is to devolve the financing of
such centers to panchayats. An alternative approach that has been suggested is to work
with a UK type GP-fund-holding model (with contributions on behalf of the poor being
made by the government) and private practitioners competing with primary health center
personnel for government (and private funds). An evaluation of these alternative
approaches in rural areas of AP could be potentially worthwhile.
4.
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Summary and Recommendations
A7.53 In light of the above, the government strategy will have to be a mix of information
generation, some experimentation with new strategies to finance health care, and ways to
address any regional/district inequities through the possible development of allocation
rules to districts and local governments.
a.
Short Term
i.
Information for decision-making: Health Accounts
State and district health accounts on an annual/bi-annual
basis including the creation of local capacity to undertake
them
Computerization of Financial Accounts
ii.
Information for decision-making: Costing
•
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Defining and costing an appropriate benefits package for
purposes of insurance
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iii.
Information for decision-making: Evaluating User Charges
•
1
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iv.
b.
Possible reduction in public subsidies on medical education
Medium Term
i.
Experiments with Insurance mechanisms
•
ii.
iii.
Assess existing patterns of resource allocation to local
bodies and districts; development and evaluate new
allocation formulae
Improving primary care in rural areas (Experiment)
•
•
iv.
District Health Funds, Community Financing via Self-Help
Groups
Allocation of primary health care funds across districts
•
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Evaluation of user charges imposed at APWP and tertiary
hospitals, regarding impact on revenues, and utilization of
facilities by the poor.
GP fund-holding (DPIP)
Mandal panchayat oversight of primary health centers
Stricter enforcement of rules on care for the poor in private
hospitals
II
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Table 1. Trends in Public Spending on Health (Plan + Non-Plan)
Indicator/Year
1996-7
1997-8
1998-9
1999-0
2000-1
2001-2
2002-3
Public Health Spending
! per capita (1993-94 Rs.)
83.0
83.8
93.2
106.7
105.3
110.4
112.7
[ Public Health Spending
782
862
1,039
1,240
1.294
1,435
1,549
597
610
688
798
797
847
876
0.87
0.89
0.90
1.00
0.94
0.94
0.92
5.6
5.3
5.2
5.7
4.8
4.8
5.0
! (Rs. Crores)
Public Health Spending
(in 1993-94 Rs. Crores)
Public Health
Spending/SGDP
(percent)____________
Public Health
Spending/Budget
, (percent)
Vote’. Estimates for 2001-2 and 2002-3 are based on projected rates of real GDP growth and projected
inflation rates. The rate of growth of SGDP was taken to be 6 percent per year, whereas the rate of
inflation (based on the SGDP deflator) was taken to be equal that of the latest year (2000-1) for which data
were available. We do not include expenditures by local governments and by district level societies, which
are small relative to the overall size of the health budget of the department of health, medical and family
welfare.
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Table 2. Public Health Spending in Andhra Pradesh: Salary,
non-Salary Distribution
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2002-3
2001-2
2000-1
Category
Plan
Non-Plan
Plan
Non-Plan
Plan
Non-Plan
Medical Education
(Rs. Crores)_____
17.78
(11.98)
199.63
(150.94)
30.95
(11-55)
222.45
(149.63)
24.49
(14.41)
258.17
(171.04)
Medical and Health
(Rs. Crores)______
122.72
(>4.99)
246.53
(195.34)
148.46
(>4.12)
236.89
(194.38)
46.40
(40.51)
249.66
(204,37)
Primary Health and
Family Welfare
(Rs. Crores)_______
323.87
(186.50)
383.75
(345.40)
408.91
(183.40)
407.77
(367.01)
459.43
(214.42)
511.44
(454.68)
TOTAL
464.37
(>203.5)
829.91
(691.7)
588.32
(>1991.)
867.11
(711.0)
530.32
(269.32)
1,019.27
(830.11)
'W
Plan + Non-Plan
1,435.4
(>910.1)
1,294.3
(>895.2)
1,549.6
(1,099.4)
Note: Based on data provided in the demand for grants of the government of Andhra Pradesh. Numbers in
parentheses indicate amounts allocated to wages and salaries.
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Table 3. Forecasting Public Sector Resources for Primary Health Care,
2002-3 to 2006-7
I
Variable
2002-3
2003-4
2004-5
2005-6
SGDP
(In 2002-3 Rs. Crores)_____
Scenario I
Primary Health Care/SGDP
(percent)________________
Scenario I
Primary Health Care
(In 2002-3 Rs. Crores)_____
Scenario II
Primary Health Care/SGDP
(percent)________________
Scenario II
Primary Health Care
(In 2002-3 Rs. Crores)_____
Scenario III
Primary Health Care/SGDP
(percent)________________
Scenario III
Primary Health Care
(In 2002-3 Rs. Crores)
165,784
177,129
189,607
203,345
218,487
0.60
0.70
0.80
0.90
1.00
1,000
1,240
1,517
1,830
2,185
0.60
0.60
0.60
0.60
1.00
1,000
1,068
1,144
1,227
2,185
0.60
0.64
0.68
0.72
0.76
1,000
1,134
1,289
1,464
1,661
I
;
0
2006-7
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Table 4. Forecasting Public Sector Resources for
Secondary/Tertiary Care, 2002-3 to 2006-7
2
r.
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Variable
2002-3
2003-4
2004-5
2005-6
2006-7
SGDP
(In 2002-3 Rs. Crores)_____
Scenario I
Primary Health Care/SGDP
(percent)________________
Scenario I
Secondary/Tertiary Care
(In 2002-3 Rs. Crores)_____
Scenario II
Primary Health Care/SGDP
(percent)________________
Scenario II
Secondary/Tertiary Care
(In 2002-3 Rs. Crores)_____
Scenario III
Primary Health Care/SGDP
(percent)________________
Scenario HI
Secondary/Tertiary Care
(In 2002-3 Rs. Crores)_____
165,784
177,129
189,607
203,345
218,487
0.60
0.70
0.80
0.90
1.00
550
416
256
71
-142
0.60
0.60
0.60
0.60
1.00
550
587
629
675
-142
0.60
0.64
0.68
0.72
0.76
550
522
483
437
383
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Table 5. Expenditures on Water and Sanitation and Nutrition
in Three Departments
(Rs. Crores)
I
2000-1
j Category
I
2001-2
2002-3
Non-Plan
Plan
Non-Plan
Plan
Non-Plan
Plan
Nutrition
10.1
140.9
9.8
238.3
10.7
289.1
Water and
Sanitation
133.7
367.5
137.7
611.1
147.3
640.2
p
Other
11.6
0.7
12.6
1.9
11.7
1.3
I_______
f
Total
155.4
509.1
160.1
851.3
169.7
930.6
!
I
Grand
Total
5.
664.5
1,011.4
1,100.3
p
People met
1. S.K. Arora, Principal Secretary (Finance)
2. Veena Ish, Secretary (Planning and Finance)
3. R.K. Panda, Secretary (Planning)
4. Rachel Chatteiji, Principal Secretary (Health, Medical and Family Welfare)
5. N. Srinivas Rao (Officer on Special Duty, Finance)
6. LY.R. Knshna Rao, Principal Secretary (Panchayati Raj and Rural Development)
7. Harinarayan, Principal Secretary (Irrigation)
8. Anil Punetha (Commissioner for Rural Development)
9. Neelam Sawhney (Commissioner for Family Welfare)
10. Ms. Damayanthi (SPACS)
11. Lipika Nanda (Independent Consultant)
12. Dr. Ranga Rao (Independent Consultant)
13. Joint Director, National Malaria Programme
14. Lalit Dandona Director, Health Policy Unit (ASCI)
15. Y. Srilakshmi (Commissioner, Municipal Administration)
16. Dr. G. Hariprasad (Joint Director, National Blindness Control Programme)
17. Dr. R. Puroshottam Reddy (Joint Director, National Leprosy Control Programme)
18. Dr. Venkateshwarlu (Joint Director, National TB Control Programme)
19. Saroja Rama Rao, Director (Economics and Statistics)
20. Dr. Prakasamma (AP Nursing Academy)
21. Dr. K. Narayana (CESS)
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References
DfID (Department for International Development). 2002. “Towards a resource
envelope for the health sector.” Draft. New Delhi: Department for International
Development.
R
3
. 2001. “Impact and Expenditure Review: Health Sector.” Draft. New
Delhi: Department for International Development.
GoAP(Govemment of Andhra Pradesh). 2002a. “Fiscal reforms strategy paper.”
Hyderabad, AP: Finance Department.
2002b.
Economic Survey 2001-2. Hyderabad, AP: Planning
Department.
2001. Statistical Abstract of Andhra Pradesh. Hyderabad, AP:
Directorate of Economics and Statistics.
Pearson, Mark. 2000. “Assistance to the Government of Andhra Pradesh in Costing
Health Plan.” London, UK: Institute for Health Sector Development and the
Department for International Development.
Planning Commission. 2002. “Approach Paper to the Tenth Five Year Plan 2002-7.”
New Delhi: Government of India, Planning Commission.
SFC(State Finance Commission).
1997. Report of the First State Finance
Commission Andhra Pradesh, 1997-2000. Hyderabad, AP.
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DRAFT
Annex 8
Support for Development of a Medium Term
Health Strategy for Andhra Pradesh:
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Reading Materials and Background Papers
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Annex 8
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Reading Materials and Background Papers
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Andhra Pradesh: Vision 2020.
Andhra Pradesh Economic Restructuring Project Health Component - January
2002.
Bajpai, N. 2002. “A Decade of Economic Reforms in India: Unfinished
Agenda.” Center for International Development at Harvard University,
Working paper No.89.
Functioning of Panchayat Raj Institutions in Andhra Pradesh, A Note.
Chatterjee, R. 2002. Health Systems in Andhra Pradesh, Current Issues:
Future Directions. Presentation to the Chief Minister.
AP Medium Term Health Strategy (The View from DflD).
DFID, Briefing Notes:
a. Medium Term Expenditure Frameworks
b. Towards a Resource Envelope for the Health Sector
c. Recent changes in Public Expenditure management in the UK.
d. The Medium Term Expenditure Framework; A case study of Ghana
e. The Budget and Medium Term Expenditure Framework in Uganda
Government of Andhra Pradesh, Department of Health, Medical & Family
Welfare. 2002. “Development Indicators under Vision 2020”.
“INDIA: Andhra Pradesh - Sector Support for Health & Education” - internal
memo proposing general funding strategy for DflD (Project Concept Note),
April 2001.
DFID Strategy paper: Evaluation of the Orissa Drugs system (Study
undertaken by Delhi Society for Promotion of Rational Use of Drugs, New
Delhi).
DFID Strategy paper. 2002. Presentation to the State Level Strategic
Committee, 18 April, Park Hotel, Kolkata.
DFID Health Systems Resource Center. 2002. General Support to Health
Economics, Orissa Phase II.
DflD. 2002. “Health Financing in Orissa.” A Background paper to assist the
Development of a Health financing strategy.
Duraisamy P. 2000. “Health Status and Curative Health Care in Rural India.”
New Delhi: National Council of Applied Economic Research.
Government Orders on Regulation of the Private Health Sector
G. O.Rt.No.217 Dated 26.02.2001
G.O.Rt.No.802 dated 25.07.2001
G.O.Rt.No.1344 dated 24.12.2001
Memo No.34049/J2/2000 dated 20.04.2002
Government ofAP Bill on regulating private medical care
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27.
28.
29.
30.
31.
32.
Government of Andhra Pradesh, Department of Health, Medical and
Family Welfare. 2001. “Strategy Paper on Health and Family Welfare in
Andhra Pradesh”.
“Strategy Document on Health Policy” Health Medical and Family
Welfare Department, GoAP, (no date, transmitted January 2001 by letter
from Mr. C. Arjuna Rao to Dinesh Nair, DfID, New Delhi).
Foster M., Thornton P., Brown A. 2000. “Andhra Pradesh: Sector
Approaches for Human Development.” Report to DfID.
Health & Family Welfare Sector Programme in India: Model Terms of
Reference for Policy Reviews, Government of India, Department of
Family Welfare, and the European Commission, August 1999.
Government of Andhra Pradesh, Health Medical & Family Welfare
Department. 2002. “Performance Indicators.”
“Health Strategy Meeting with DfID, March 13, 2001”.
Health Watch Trust. 1999. “The Community Needs-Based Reproductive
and Child Health in India: Progress and Constraints”, Jaipur, India.
The Indian Law Institute. 2000. “Legal Framework for Health Care in
India: Experience and Future Directions”. New Delhi: The World Bank.
Institute of Health Systems. 2002. “AP Vaidya Vidhana Parishad:
Periodic analysis of hospital performance: Dec. 2001.” Hyderabad,
Andhra Pradesh.
Mahal, A., et al. 2001. “Who Benefits from Public Health Spending in
India? New Delhi: National Council of Applied Economic Research.
Mahapatra P., Kumar Dhanaraj, V.B. Sai. 2001. “A Manual on Control of
Malaria with special reference to Andhra Pradesh, India.” Hyderabad,
AP: Institute of Health Systems.
Mahapatra P., Reddy S. 2001. “A Manual on Control of Gastroenteriris
with special reference to Andhra Pradesh, India.” Hyderabad, AP: Institute
of Health Systems.
Mahapatra P., Sridhar P., Rajshree K.T. 2000. “Structure and Dynamics
of Private Health Sector in India: A Study of Andhra Pradesh 2000.”
Report Series - RP 13/2001 (1-208). Hyderabad, AP: Institute of Health
Systems.
Mahapatra P. 2001. Estimating National Burden of Disease: The burden
of disease in Andhra Pradesh 1990s.” Hyderabad, AP: Institute of Health
Systems.
Mahapatra P., Kumar V.B. Sai, Pushpalatha K.M., Reddy P.R., Rambabu
J., Kumar B.S. 2001. “Proceedings of the Strategy Development
Workshop for Health Sector in Andhra Pradesh.” Report Series - RP
12/2001 (1-71). Hyderabad, AP: Institute of Health Systems.
Indian Institute of Population Sciences. 2000. National Family Health
Survey (NFHS — 2), Health and Family Welfare, India 1998-1999.
Mumbai, India.
Pearson, M., Gupta D.B., Cumber A., Purohit B., Rao V., George A.
2001. “Impact and Expenditure Review: Health Sector” (Phase 1 Draft
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36.
37.
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42.
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44.
45.
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Final Report: Health Strategy Development and Policy Analysis),
prepared for the Government of Andhra Pradesh, Part I.
Pearson, M., Gupta D.B., Gumber A., Purohit B., Rao V., George A.
2001. “Impact and Expenditure Review: Health Sector.” Prepared for the
Government of Andhra Pradesh, Part II.
Pearson M. 2000. “Assistance to the Government of Andhra Pradesh in
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Costing Health Plan”, Institute for Health Sector Development.
Nandraj, S. 2000. “Private Health Sector: Concerns, Challenges &
Options.” Paper submitted to the Ministry of Health & Family Welfare,
Government of India, New Delhi.
V. Ramachandran. 2002. “Beyond Numbers: A Symposium on
Population Planning and Advocacy.” Health Watch, Jaipur.
Indira Rajaraman. 2001. “Growth Accelerating Fiscal Devolution to the
Third Tier.” Draft. New Delhi: National Institute of Public Finance and
Policy.
The World Bank. 1997. “India: New Directions in Health Sector
Development at the State Level: An Operational Perspective.” Report No.
15753-IN. Washington, D.C.: Population and Human Resources
Division.
Sahu, B.K. Shri. Undated. “ESI Scheme - Total Social Security Cover for
the Workmen.”
The World Bank. 2001. “Raising the Sights: Better Health Systems for
India’s Poor.” Draft Report. Washington, D.C.: Health, Nutrition, and
Population Unit.
SFC(State Finance Commission). 1997. Report of the First State Finance
Commission Andhra Pradesh, 1997-2000. Hyderabad, AP.
Planning Commission. 2002. “Approach Paper to the Tenth Five Year
Plan 2002-7.” New Delhi: Government of India, Planning Commission.
Government of Andhra Pradesh. 2001. Statistical Abstract of Andhra
Pradesh. Hyderabad, AP: Directorate of Economics and Statistics.
Government of Andhra Pradesh. 2002. Economic Survey 2001-2.
Hyderabad, AP: Planning Department.
GoAP,(Government of Andhra Pradesh). 2002. “Fiscal reforms strategy
paper. Hyderabad, AP: Finance Department.
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DRAFT
Annex 9
V
Support for Development of a Medium Term
Health Strategy for Andhra Pradesh:
Terms of Reference/Scope of Work
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Annex 9
Terms of Reference/ Scope of Work
Support for Development of Andhra Pradesh Medium Term
Health Strategy (APMTHS)
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Introduction
1.
The Department of Health, Medical and Family Welfare (DoHM&FW) of
Government of Andhra Pradesh (GoAP) is in the process of developing a
Medium Term Health Strategy intended to serve the State for a minimum
period of five years. The objective of this strategy is to operationalise the
principles set out in the Vision 2020 document to meet the health needs of the
population. In the context of possible sector support, DFID is interested in
supporting the GoAP to define this Strategy for the Health Sector. These
Terms of Reference broadly set out the nature of support to be provided to
GoAP in carrying out this exercise.
Background
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2.
In January 1999, the GoAP released its Vision 2020 document, which sets out
ambitious goals for the sector. A ‘Strategy Paper’ released earlier this year,
and an earlier action plan, attempted to define and operationalise the
objectives set in Vision 2020 but this remained a largely incomplete effort.
GoAP has also initiated a number of very useful exercises, which began
planning, and monitoring for the sector as a whole. These include the
development of monitoring indicators, proposal and strategy development
exercises, and impact expenditure studies.
3.
The DoHM&FW with support from the European Commission (EC) is
carrying out policy reviews (with Administrative Staff College of India,
Hyderabad) in four key programmatic areas: Workforce management,
Rational use of infrastructure, Decentralisation and Delineation and
Performance based funding options. As part of the same programme the
DoFW is coordinating the development of a State Action Plan (with Institute
of Health Systems, Hyderabad) and will include the preparation of a basic
package of services and designing interventions for the Family Welfare sector.
The reports of these studies are due in March 2002. Similarly, the World Bank
in their support to the State to operationalise the priority health outcomes
within Vision 2020, are looking at undertaking focussed studies on utilisation
of the private sector in AP. A diagnostic workshop has also been tentatively
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planned for the end of March 02. At the macro level the State Government is
in the final stages of negotiation with The World Bank and DFID for agreeing
a S200 million programme for economic and public sector reform in 2002-03.
As a milestone to be reached, GoAP have agreed to develop a medium term
expenditure framework (MTEF) for the primary health and education
segments by the middle of financial year 2002-03.
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To summarise, the key steps that have been taken in the process leading to the
development of the medium term health strategy and expenditure frame work
are
Activity
Date
AP Vision 2020___________________________ __
GoAP Strategy Document________________________
AP: Sector Approaches for Human Development
(CAPE, GDI)__________________________________
GoAP Strategy Paper on H&FW___________________
Impact & Expenditure Review of the Health Sector PE Analysis and Health Strategy Development and
Policy Analysis________________________________
Health Strategy Development Workshop____________
EC Policy Reviews and State Action Plan____________
The World Bank support:
Studies for operationalising Vision 2020
S Diagnostic workshop
January 1999
2000_________
September 2000
January 2001
March 2001
April 2001_______
Due in March 2002
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Ongoing
March - April 2002
The World Bank and DFID funded programme for
public and economic sector reform:
End February 2002
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GoAP DOHFW led activities
monitoring indicators etc.
e.g.
identifying Ongoing
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Note: Documentation relating to the above activities are available with DFID and will be
provided to the consultants.
1.
It will be seen that in the period since the initial terms of reference for
development of APMTHS were drafted, many enabling developments have
taken place, the most significant one being the progress of discussions on the
S200 million World Bank-DFID funded programme for public and economic
sector reform. These processes have created an acceptance in GoAP of the
need to plan sectorally. A draft state budget for 2002-03 has also been
released for public debate. The stage therefore is set to synthesise current
knowledge to arrive at a holistic and costed Health sector strategy. Such a
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strategy would set out the framework within which GoAP will operate in the
sector, and also provide a context within which donor partners and others can
programme their assistance.
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GoAP Institutional Mechanisms
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A Health Strategy Team has been constituted by the GoAP to coordinate and
guide the Strategy development process. A Sector Reform Cell has also been
set up as part of the EC Sector Investment Programme. To avoid duplication
of efforts there has been broad agreement to combine these into a single
functional body to guide the strategy development exercise. Go I has also
agreed to input into the deliberations.
Objective
3.
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The overall objective of this consultancy is to help GoAP’s DoHM&FW
develop and document a medium term strategy and expenditure framework,
which meets key objectives laid down in the Vision 2020, and addresses
issues raised at the Strategy Development Workshop (Annex). This will
require generation of different policy options that can be considered by
DoHM&FW and taken forward in the medium term strategy.
Scope of Work, Output and Payment
4.
The strategy development exercise will be done in two phases:
J Phase 1 - The team, after agreeing a Strategy outline, will
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Set milestones for the development of the Strategy,
Specify clear components and activities to be included in the Strategy
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The resources needed to implement them, and the resources available
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Highlight critical information gaps
J Phase 2 - will involve taking the work from the Phase 1 forward and filling in the
information gaps
At this stage the consultancy will be restricted to Phase 1.
1.
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To arrive at the content of the strategy, the process should include a careful
analysis of
The stakeholders who are affected by and influence the strategy
The context within which the strategy will be implemented;
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The process, by which the strategy will be formulated, implemented and
evaluated
Capacity building requirements in the longer term.
1.
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The output from this consultancy will be an agreed Medium Term Health
Strategy, which spells out the critical components within the medium term
expenditure framework, the availability and requirement of resources, and
highlights information gaps to be taken up as part of phase 2. The process and
the outcome should have the full support and commitment of GoAP and
should take account of the views and contributions of other stakeholders,
particularly other donors like The World Bank and the EC.
2.
Preparatory activities will include briefing by DFID India in New Delhi, and
study of relevant literature. After consultation with key stakeholders the
consultant team will arrive at the Strategy outline and a Plan of Work to
complete the strategy development exercise. The Plan of Work should be
agreed with GoAP and DFID latest by the end of the first week of the
consultancy.
3.
In Phase 2, the successful bidder will lead the process of filling in the
information gaps identified in Phase 1 subject to successful completion of
Phase 1 and subsequent negotiations.
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Competency and Expertise requirement
4.
The successful bidder will be able to demonstrate a wide range of skills,
particularly the following:
•
Experience in supporting and facilitating Governments in the development of
health strategies/plan, particularly health systems management and
development.
•
Experience of working with Sector approaches in the developing country
context.
•
Competence in public health management and planning, health economics,
and institutional and social development.
•
Experience in managing and coordinating large programmes involving a range
of partners like governments, civil society, communities etc.
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Conduct of the Work
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The consultant team will provide technical, process, and management inputs
and will work under the overall guidance of the Health Sector Strategy team.
A number of key institutions exist within the State like Centre for Governance
Reform, Institute for Health Systems, Administrative Staff College of India
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and the Indian Institute of Health and Family Welfare. The consultant team
will consider developing strategic links with these and other relevant
institutions.
2.
As noted above, this consultancy will need to be undertaken on a highly
participative and interactive basis with the personnel of DHM&FW, under the
guidance of the Health Strategy Team. However, the consultants will be
expected to work with a great degree of autonomy and independence.
3.
All travel and administrative arrangements will be the responsibility of the
consultants, keeping the Health Strategy Team informed of plans and
movements. The Secretary (Health) will provide initial letters of introduction
for the consultants to meet with key personnel in the GoAP/GOI/other
stakeholders.
The consultants will provide the DHM&FW/GoAP with the Plan of Work in
hard copy (10 copies) and electronically (1 copy) using Word 2000.
4.
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